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Surgical Technique

Postmenopausal dyspareunia— a problem for the 21st century

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.

March 2009 · Vol. 21, No. 03


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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

The WHI and its domino effect

Millions of postmenopausal women stopped taking estrogen-based therapy in the wake of widespread media coverage after 2002 publication of data from the estrogen–progestin arm of the Women’s Health Initiative (WHI), which purported to show, among other things, an increased risk of breast cancer.5

For decades, many postmenopausal women achieved medical management of VVA through long-term use of systemic hormone replacement therapy (HRT), which they used primarily to control other chronic symptoms of menopause, such as hot flashes.

After the WHI data were published (and misrepresented), reduced usage of estrogen-based HRT “unmasked” vaginal symptoms, including sexual pain, due to the effects of estrogen deficiency on the vaginal epithelium and vaginal blood flow. Since then, we have been forced to examine anew the natural history of menopause.

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Within days or weeks of discontinuing HRT, women may reexperience the acute vasomotor symptoms that accompany estrogen withdrawal—most commonly hot flashes, night sweats, sleeplessness, palpitations, and headaches. Over time—anywhere from 6 months to several years—the body adjusts to the loss or withdrawal of estrogen, and these vasomotor symptoms eventually diminish or resolve. Not so for the longer-term physical effects of chronic low serum levels of estrogen, which worsen over time.

Approximately 6 months after discontinuing estrogen therapy, postmenopausal women may begin to experience vaginal dryness and VVA. As the years pass, other side effects of estrogen deficiency arise: bone loss, joint pain, mood alteration (including depression), change in skin tone, hair loss, and cardiac and central nervous system changes. These side effects do not resolve spontaneously; in fact, they grow worse as a woman ages. They may have deleterious psychosocial as well as physical impacts on her life—especially on the quality of her intimate relationship.

Here’s what to ask a postmenopausal patient when she complains of dyspareunia

Clarify the report (adjust appropriately for same-sex partner)

  • Where does it hurt? Describe the pain.
  • When does it hurt? Does the pain occur 1) with penile contact at the opening of the vagina, 2) once the penis is partially in, 3) with full entry, 4) after some thrusting, 5) after deep thrusting, 6) with the partner’s ejaculation, 7) after withdrawal, or 8) with subsequent micturition?
  • Does your body tense when your partner is attempting, or you are attempting, to insert his penis? What are your thoughts and feelings at this time?
  • How long does the pain last?
  • Does touching cause pain? Does it hurt when you ride a bicycle or wear tight clothes? Does penetration by tampons or fingers hurt?

Assess the pelvic floor

  • Do you recognize the feeling of pelvic floor muscle tension during sexual contact?
  • Do you recognize the feeling of pelvic floor muscle tension in other (nonsexual) situations?

Evaluate arousal

  • Do you feel subjectively excited when you attempt intercourse?
  • Does your vagina become sufficiently moist? Do you recognize the feeling of drying up?

Determine the consequences of the complaint

  • What do you do when you experience pain during sexual contact? Do you continue? Or do you stop whatever is causing the pain?
  • Do you continue to include intercourse or attempts at intercourse in your lovemaking, or do you use other methods of achieving sexual fulfillment? If you use other ways to make love, do you and your partner clearly understand that intercourse will not be attempted?
  • What other effect does the pain have on your sexual relationship?

Explore biomedical antecedents

  • When and how did the pain start?
  • What tests have you undergone?
  • What treatment have you received?

Source: Adapted from Basson R, et al.12

Is 60 the new 40?

Many women and men in the large cohort known as the Baby Boomer generation continue to be sexually active into their 60s, 70s, and 80s, as demonstrated by a 2007 study of sexuality and health in older adults.6 In the 57- to 64-year-old age group, 61.6% of women and 83.7% of men were sexually active (defined as sexual activity with a partner within the past 12 months). In the 65- to 74-year-old group, 39.5% of women and 67% of men were sexually active; and in the 75- to 85-year-old group, 16.7% of women and 38.5% of men were sexually active (TABLE).

These findings indicate that fewer women than men remain sexually active during their later years. One reason may be the epidemic of sexual-related symptoms among postmenopausal women. In the same survey, 34.3% of women 57 to 64 years old reported avoiding sex because of:

  • pain during intercourse (17.8%)
  • difficulty with lubrication (35.9%).

Across all groups, the most prevalent sexual problem was low desire (43%).6 Around 40% of postmenopausal women reported no sexual activity in the past 12 months, as well as lack of interest in sex. This number may include women who have ceased to have sex because of vaginal dryness and dyspareunia, thereby reducing the percentage reporting these symptoms (TABLE).


Older adults are having sex—and experiencing sexual problems

Activity or problem by gender

Number of respondents

Report, by age group (95% confidence interval*)

57–64 yr (%)

65–74 yr (%)

75–85 yr (%)

Sexually active in previous 12 months



83.7 (77.6–89.8)

67.0 (62.1–72.0)

38.5 (33.6–43.5)



61.6 (56.7–66.4)

39.5 (34.6–44.4)

16.7 (12.5–21.0)

Difficulty with lubrication



35.9 (29.6–42.2)

43.2 (34.8–51.5)

43.6 (27.0–60.2)

Pain during intercourse



3.0 (1.1–4.8)

3.2 (1.2–5.3)

1.0 (0–2.5)



17.8 (13.3–22.2)

18.6 (10.8–26.3)

11.8 (4.3–19.4)

Avoidance of sex due to sexual problems**



22.1 (17.3–26.9)

30.1 (23.2–37.0)

25.7 (14.9–36.4)



34.3 (25.0–43.7)

30.5 (21.5–39.4)

22.7 (9.4–35.9)

Source: Adapted from Lindau ST, et al.6

Adjusted odds ratios are based on a logistic regression including the age group and self-rated health status as covariates, estimated separately for men and women. The confidence interval is based on the inversion of the Wald tests constructed with the use of design-based standard errors.

These data exclude 107 respondents who reported at least one sexual problem.

** This question was asked only of respondents who reported at least one sexual problem.

Assessing menopause-related sexual function is a challenge

Although the transition phases of menopause have been well studied and reported for decades, few of these studies have included questions about the impact of menopause on sexual function.7 When longitudinal studies that included the classification of female sexual dysfunction began to appear, they provided evidence of the important role that VVA and psychosocial factors play in female sexual dysfunction.8

In the fourth year of the Melbourne Women’s Midlife Health Project longitudinal study, six variables related to sexual function were identified. Three were determinate of sexual function:

  • feelings for the partner
  • problems related to the partner
  • vaginal dryness/dyspareunia.

The other three variables—sexual responsiveness, frequency of sexual activity, and libido—were dependent or outcome variables.

By the sixth year of this study, two variables had increased in significance: vaginal dryness/dyspareunia and partner problems.7

Sexual pain and relationship problems can create a vicious cycle

The interrelationship of vaginal dryness, sexual pain, flagging desire, and psychosocial parameters can produce a vicious cycle. A woman experiencing or anticipating pain may have diminished sexual desire or avoid sex altogether. 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. The result? Greater vaginal pain.

This vicious cycle can contribute to relationship issues with the sexual partner and harm a woman’s psychosocial well-being. Resentment, anger, and misunderstanding may arise when a couple is dealing with problems of sexual function, and these stressors can damage many aspects of the relationship, further exacerbating sexual difficulties.

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