Dyspareunia
Dyspareunia is triaged by pain timing and location, not treated as one disease: superficial pain at the introitus on entry points to vulvovaginal atrophy, infection, vulvodynia, or vaginismus, while deep pain with penetration points to endometriosis, pelvic inflammatory disease, or a pelvic mass, and each branch has its own diagnostic and treatment pathway.
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What this article covers
- Overview
Dyspareunia is triaged by timing and location: superficial/introital pain (at entry) versus deep pain (with full penetration) sorts every case, each branch with its own differential and workup.
- Epidemiology
Genitourinary syndrome of menopause is the most common cause of dyspareunia among menopausal women.
- Risk factors
Menopause and hypoestrogenic states (surgical menopause, breastfeeding, antiestrogen therapy): drive genitourinary syndrome of menopause.
- Pathophysiology
Estrogen deficiency thins and dries the vaginal epithelium: loss of estrogen reduces secretions, glycogen, and lactobacilli, raising pH and producing atrophic, friable mucosa that tears with penetration.
- Clinical features
Timing and location are the dominant clues: pain at initial penetration is superficial; pain with deep thrusting or maximal penetration is deep.
- Differential diagnosis
Genitourinary syndrome of menopause: most common cause in menopausal patients; discriminated by pale, thin, atrophic mucosa with little or no rugae in a hypoestrogenic patient.
- Diagnosis
This is a triage algorithm, not a single-test diagnosis: superficial versus deep pain sets the pathway (inspection, cotton swab test, and vaginal secretions for superficial; pelvic exam and…
- Management
Treat the identified cause; do not treat dyspareunia as a single entity.
- Complications
Sexual avoidance and relationship strain from untreated pain.
- Prognosis
Genitourinary syndrome of menopause responds well to low-dose vaginal estrogen, though therapy must continue indefinitely.
- Prevention
Menopausal patients with vaginal dryness: start lubricants and moisturizers early, and offer low-dose vaginal estrogen when nonhormonal measures are insufficient.
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Related articles
- Genitourinary syndrome of menopause
Genitourinary syndrome of menopause is the chronic, progressive constellation of vulvovaginal and lower urinary tract symptoms caused by estrogen deficiency, presenting with vaginal dryness, dyspareunia, and recurrent urinary symptoms in menopausal women. It is a clinical diagnosis treated first with nonhormonal moisturizers and lubricants, then low-dose vaginal estrogen, with ospemifene or vaginal prasterone reserved as second-line options.
- Endometriosis
Endometrial-like glands and stroma implanted outside the uterus drive cyclic pelvic pain, dyspareunia, dyschezia, and infertility. Diagnosis is presumed clinically and confirmed by laparoscopic visualization with biopsy; treatment is staged from NSAIDs and hormonal suppression through conservative or definitive surgery.
- Vulvovaginal candidiasis
Candida vulvovaginitis presents with vulvar itching, burning, and thick curdy white discharge at a normal vaginal pH; uncomplicated disease clears with a single 150 mg oral fluconazole dose or a short topical azole course, while complicated or recurrent disease needs a longer induction course followed by suppressive therapy.
- Bacterial vaginosis
Bacterial vaginosis is a polymicrobial dysbiosis of the vagina caused by loss of lactobacilli and anaerobic overgrowth, diagnosed clinically by the Amsel criteria and treated with oral or intravaginal metronidazole or clindamycin.
- Trichomonas vaginalis infection
Trichomonas vaginalis is a flagellated protozoan sexually transmitted infection that presents with malodorous frothy yellow-green discharge and a strawberry cervix but is frequently asymptomatic, especially in men. Diagnosis rests on nucleic acid amplification testing of vaginal secretions, and treatment is a single 2 g oral dose of metronidazole or tinidazole with partner treatment and retesting in 3 months for high reinfection rates.
- Pelvic inflammatory disease
Pelvic inflammatory disease is an ascending polymicrobial infection of the upper female genital tract, most often caused by Neisseria gonorrhoeae, Chlamydia trachomatis, or Mycoplasma genitalium, diagnosed clinically on uterine, adnexal, or cervical motion tenderness. Most women are treated as outpatients with a single dose of ceftriaxone plus 14 days of doxycycline, while parenteral cefotetan or cefoxitin plus doxycycline, or clindamycin plus gentamicin, is reserved for hospitalized patients, with tubo-ovarian abscess and infertility among the major complications of delayed treatment.
- Vulvar lichen sclerosus
Vulvar lichen sclerosus is a chronic inflammatory dermatosis causing porcelain-white atrophic plaques, itching, and scarring of the vulva, confirmed by biopsy and treated with an ultrapotent topical corticosteroid to relieve symptoms and reduce the lifelong risk of vulvar squamous cell carcinoma.
- Sexual dysfunction
Sexual dysfunction spans desire, arousal, orgasmic, and pain disorders in men and women, most often from a mix of vascular, neurologic, hormonal, medication, and psychological causes. Diagnosis rests on a structured sexual history plus screening for diabetes, cardiovascular disease, and androgen deficiency. First-line treatment is an oral phosphodiesterase type 5 inhibitor for erectile dysfunction, an SSRI for premature ejaculation, and flibanserin or bremelanotide for female sexual interest and arousal disorder, alongside treatment of the underlying cause.
- Menopause
Menopause is the permanent cessation of menses from ovarian follicular depletion, confirmed retrospectively after 12 months of amenorrhea around a mean age of 51 years. Management centers on treating moderate to severe vasomotor symptoms with the lowest effective dose of hormone therapy in appropriately selected candidates, alongside bone and cardiovascular risk assessment.
- Evaluation of vaginal discharge
Abnormal vaginal discharge is triaged at the bedside with vaginal pH, the amine whiff test, and saline/KOH microscopy, and treated with metronidazole for bacterial vaginosis or trichomoniasis, fluconazole or clotrimazole for candidiasis, and ceftriaxone plus doxycycline for cervicitis.