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General Considerations
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”Dyspareunia” refers to women who experience persistent or recurrent pain with sexual intercourse, including pain with vaginal penetration
Vulvovaginal or pelvic pain during genital contact (vulvodynia)
Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of genital contact
Marked hypertonicity or overactivity of pelvic floor muscles with or without genital contact (ie, vaginismus)
It has a host of potential causes, including
Vulvovaginitis
Vulvar disease, including lichen planus, lichen sclerosus, and lichen simplex chronicus
Pelvic disease, such as endometriosis, chronic pelvic inflammatory disease
Vaginal atrophy
Vaginismus
Insufficient vaginal lubrication
Vulvodynia or vulvar vestibulitis
Postmenopausal vaginal atrophy
Pelvic adhesions
Ovarian tumor
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May be treated initially with
Warty lesions on colposcopy or biopsy should be treated appropriately (see Vaginitis)
Lichen sclerosus is treated with clobetasol propionate 0.05% ointment, applied twice daily for 2–3 months
Vaginismus is treated with sexual counseling, education on anatomy and sexual functioning, and pelvic floor physical therapy by a specialized provider
Self-dilation, using a lubricated finger or dilators of graduated sizes, may help. Before coitus (with adequate lubrication) is attempted, the patient—and then her partner—should be able to painlessly introduce two fingers into the vagina
Injection of botulinum toxin has been successfully used in women with refractory vaginismus
Insufficient lubrication of the vagina
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
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
Vulvodynia
Difficult management since etiology unclear
Surgical vestibulectomy has had success
Topical anesthetics (eg, estrogen cream and a compounded mixture of topical amitriptyline 2% and baclofen 2% in a water washable base) are useful
Useful oral medications include
Amitriptyline in gradually increasing doses from 10 mg/d to 75–100 mg/day
Gabapentin, starting at 300 mg three times daily and increasing to 1200 mg three times daily
Various selective serotonin reuptake inhibitors
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