April 2003 · Vol. 15, No. 4Dyspareunia: 5 overlooked causes
Disorders ranging from a simple anatomic problem to a complex psychosocial/biologic phenomenon can cause difficult or painful coitus. An expert outlines diagnosis and treatment strategies for 5 common causes and offers guidance on how to conduct the physical exam and elicit information from the patient.
ELIZABETH
G.
STEWART,
MDDr. Stewart is Director, Stewart-Forbes Vulvovaginal Specialty Service, Harvard Vanguard Medical Associates, Boston, Mass; assistant professor of obstetrics and gynecology, Harvard Medical School, Boston, Mass; and OBG attending physician, Brigham and Women’s Hospital,
Boston, Mass.
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KEY POINTS
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The leading cause of dyspareunia for women under age 50 is vulvar vestibulitis; for women over age 50, it is vulvovaginal atrophy.
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The skin conditions dermatitis, lichen sclerosus, and lichen planus are a significant cause of dyspareunia complaints.
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Candida can be difficult to diagnose; the fissuring experienced by patients with this infection is often attributed to other causes.
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Desquamative inflammatory vaginitis leads to the loss of the lactobacillus, with bacterial overgrowth and clue cells similar to bacterial vaginosis.
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Generalized vulvar dysesthesia involves constant or episodic unprovoked stinging, burning, irritation, rawness, or pain anywhere on the vulva. In contrast, localized vulvar dysesthesia is provoked pain in the vestibule.
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Identifying the cause of a patient’s dyspareunia can be just as challenging as getting her to admit to the problem.
Due in part to underreporting of the condition, the incidence and prevalence of dyspareunia—defined as genital pain experienced just before, during, or after sexual intercourse1—is uncertain.2
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