News for Your Practice

Postmenopausal dyspareunia— a problem for the 21st century

OBG Manag. 2009 March;21(3):37-44

With one third of the female population already past the age of 50, the primary complaints of menopause—including vulvovaginal atrophy and sexual pain—are becoming alarmingly prevalent.

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IN THIS ARTICLE

Questions to ask when the complaint is dyspareunia
What kind of sexual problems trouble older Americans?
Why patients are reluctant to discuss vulvovaginal atrophy

References

1. US Census Bureau. 2006 American community survey. S0101. Age and sex. Available at: http://fact-finder.census.gov/servlet/DatasetMainPageServlet?_program=ACS&_submenuId=&_lang=en&_ts.

2. National Center for Health Statistics. Health, United States, 2007, with Chartbook on Trends in the Health of Americans. Hyattsville, Md: NCHS; 2007. Available at: http://www.cdc.gov/nchs/fastats/lifexpec.htm. Accessed February 2, 2009.

3. Sarrel PM, Whitehead MI. Sex and menopause: defining the issues. Maturitas. 1985;7:217-224.

4. Dennerstein L, Hayes RD. Confronting the challenges: epidemiological study of female sexual dysfunction and the menopause. J Sex Med. 2005;2(suppl 3):118-132.

5. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288:321-333.

6. Lindau ST, Schumm LP, Laumann EO, Levinson W, O’Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the United States. N Engl J Med. 2007;357:762-774.

7. Dennerstein L, Alexander JL, Kotz K. The menopause and sexual functioning: a review of the population-based studies. Annu Rev Sex Res. 2003;14:64-82.

8. Basson R, Berman J, Burnett A, et al. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol. 2000;163:888-993.

9. Simon JA, Komi J. Vulvovaginal atrophy (VVA) negatively impacts sexual function, psychosocial well-being, and partner relationships. Poster presented at North American Menopause Association Annual Meeting; October 3-6, 2007; Dallas, Texas.

10. Heim LJ. Evaluation and differential diagnosis of dyspareunia. Am Fam Physician. 2001;63:1535-1552.

11. Marwick C. Survey says patients expect little physician help on sex. JAMA. 1999;281:2173-2174.

12. Basson R, Althof S, Davis S, et al. Summary of the recommendations on sexual dysfunctions in women. J Sex Med. 2004;1:24-34.

13. Basson R. Female sexual response: the role of drugs in the management of sexual dysfunction. Obstet Gynecol. 2001;98:350-353.

14. Walsh KE, Berman JR. Sexual dysfunction in the older woman: an overview of the current understanding and management. Drugs Aging. 2004;21:655-675.

15. Bachmann GA, Komi J, Hanley R. A new SERM, Ophena (ospemifene), effectively treats vulvovaginal atrophy in postmenopausal women: results from a pivotal phase 3 study. Presented at the Endocrine Society annual meeting, San Francisco, Calif, June 2008.

Fast Track

During intercourse, the brain’s awareness of vaginal pain may trigger a physiologic response that can cause the muscles of the vagina to tighten and lubrication to decrease

Ask patients about sexual function in general and dyspareunia in particular as part of the routine annual visit

The author reports that he serves on the speaker’s bureau for Novogyne, TherRx, Warner-Chilcott, and Solvay, and on the advisory board for Upsher-Smith, Novogyne, QuatRx, and Wyeth.

CASE: History of dyspareunia

At her latest visit, a 56-year-old woman who is 7 years postmenopausal relates that she has been experiencing worsening pain with intercourse to the point that she now has very little sex drive at all. This problem began approximately 1 year after she discontinued hormone therapy in the wake of reports that it causes cancer and heart attack. She has been offered both local vaginal and systemic hormone therapy, but is too frightened to use any hormones at all. Sexual lubricants no longer seem to work.

How do you counsel her about these symptoms? And what therapy do you offer?

Physicians and other health-care practitioners are seeing a large and growing number of genitourinary and sexual-related complaints among menopausal women—so much so that it has reached epidemic proportions. Yet dyspareunia is underreported and undertreated, and quality of life suffers for these women.

In this article, I focus on two interrelated causes of this epidemic:

vaginal dryness and vulvovaginal atrophy (VVA) and the impact of these conditions on women’s sexual function and psychosocial well-being
barriers to optimal treatment.

I also explore how ObGyns’ role in this area of care is evolving—as a way to understand how you can better serve this expanding segment of our patient population.

Dyspareunia can have many causes, including endometriosis, interstitial cystitis, surgical scarring, injury that occurs during childbirth, and psychosocial origin (such as a history of sexual abuse). Our focus here is on dyspareunia due to VVA.

A postmenopausal woman reports a problem with pain
during sex. What should you do?

Sexual pain as a category of female sexual dysfunction is relevant at any age; for postmenopausal women dealing with vaginal dryness as a result of estrogen deficiency, it may well be the dominant issue. When determining the cause of a sexual problem in a postmenopausal woman, put dyspareunia caused by vaginal dryness (as well as its psychosocial consequences) at the top of the list of possibilities.
Bring up the topic of vaginal dryness and sexual pain with postmenopausal patients as part of the routine yearly exam, and explain the therapeutic capabilities of all available options.
Estrogen therapy, either local or systemic, remains the standard when lubricants are inadequate. Make every effort to counsel the patient about the real risk:benefit ratio of estrogen use.
If the patient is reluctant to use estrogen therapy, discuss with her the option of short-term local estrogen use, with the understanding that more acceptable options may become available in the near future. This may facilitate acceptance of short-term hormonal treatment and allow the patient to maintain her vaginal health and much of her vaginal sexual function.
Keep abreast of both present and future options for therapy.

Just how sizable is the postmenopausal population?

About 32% of the female population is older than 50 years.¹ That means that around 48 million women are currently menopausal, or will become so over the next few years.

Because average life expectancy approaches 80 years in the United States and other countries of the industrialized world,² many women will live approximately 40 years beyond menopause or their final menstrual period. Their quality of life during the second half of their life is dependent on both physical and psychosocial health.

Postmenopausal dyspareunia isn’t new

Sexual issues arising from physical causes—dyspareunia among them—have long accounted for a large share of medical concerns reported by postmenopausal women. In a 1985 survey, for example, dyspareunia accounted for 42.5% of their complaints.³

But epidemiologic studies to determine the prevalence of female sexual dysfunction in postmenopausal women are difficult to carry out. Why? Because researchers would need to 1) address changes over time and 2) distinguish problems of sexual function from those brought on by aging.⁴

The techniques and methodology for researching female sexual dysfunction continue to evolve, creating new definitions of the stages of menopause and new diagnostic approaches to female sexual dysfunction.

However, based on available studies, Dennerstein and Hayes concluded that:

postmenopausal women report a high rate of sexual dysfunction (higher than men)
psychosocial factors can ameliorate a decline in sexual function
“vaginal dryness and dyspareunia seem to be driven primarily by declining estradiol.”⁴