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For further information, see CMDT Part 18-11: Female Sexual Dysfunction

Key Features

General Considerations

  • Dyspareunia is defined as recurrent or persistent genital pain that is provoked by sexual contact

  • Vulvodynia

    • Frequent cause of dyspareunia in premenopausal women

    • It is defined as vulvar pain of at least 3 months duration without an identifiable cause

  • Vaginismus is defined as recurrent or persistent involuntary spasm of the musculature of the lower third of the vagina that interferes with sexual intercourse, causing marked distress or interpersonal difficulty

Clinical Findings

Symptoms and Signs

  • The discomfort may be experienced as either constant or intermittent, focal or diffuse, and spontaneous or provoked

  • There are generally no physical findings except; a subset of patients may have vulvar erythema

Differential Diagnosis

  • Vulvodynia or vulvar vestibulitis

  • Vaginismus

  • Insufficient vaginal lubrication

  • Vulvovaginitis

  • Vulvar disease, including lichen planus, lichen sclerosus, and lichen simplex chronicus

  • Pelvic disease, such as endometriosis or chronic pelvic inflammatory disease

  • Vaginal atrophy

  • Ovarian tumor

  • Pelvic adhesions


  • Colposcopy to evaluate vulvovaginitis: areas of marked tenderness in the vulvar vestibule without visible inflammation occasionally show lesions resembling small condylomas



  • Warty lesions on colposcopy or biopsy should be treated appropriately (see Vaginitis)

Vulvar disease


  • Sexual counseling and education may be useful

  • Self-dilation, using a lubricated finger or dilators of graduated sizes, may help. Before coitus (with adequate lubrication) is attempted, the patient and her partner should be able to painlessly introduce two fingers into the vagina

Insufficient lubrication of the vagina

  • See Menopausal Syndrome

  • For inadequate sexual arousal, sexual counseling is helpful

  • Lubricants during sexual foreplay may be of use

  • If lubrication remains inadequate, use estradiol vaginal ring worn continuously and replaced every 3 months. Concomitant progestin therapy is not needed with the ring

  • Estrogen vaginal cream

Infection, endometriosis, tumors, or other pathologic conditions

  • Temporarily abstain from coitus during treatment

  • Consider hormonal or surgical treatment of endometriosis

  • Dyspareunia from chronic pelvic inflammatory disease or extensive adhesions is difficult to treat without extirpative surgery. Couples can be advised to try coital positions that limit deep thrusting and to use manual and oral sexual techniques


  • Difficult management since etiology unclear

  • Surgical vestibulectomy has had success

  • Antiviral, antifungal, corticosteroid, or anesthetic agents have varied success

  • Pain control through behavioral therapy, biofeedback, or acupuncture has varied ...

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