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Clinical Reviews


Dyspareunia: 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.

April 2003 · Vol. 15, No. 4

KEY POINTS

  • The leading cause of dyspareunia for women under age 50 is vulvar vestibulitis; for women over age 50, it is vulvovaginal atrophy.
  • The skin conditions dermatitis, lichen sclerosus, and lichen planus are a significant cause of dyspareunia complaints.
  • Candida can be difficult to diagnose; the fissuring experienced by patients with this infection is often attributed to other causes.
  • Desquamative inflammatory vaginitis leads to the loss of the lactobacillus, with bacterial overgrowth and clue cells similar to bacterial vaginosis.
  • 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.

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

Because it is easy to miss subtle physical findings such as small fissures, periclitoral scarring, or a focus of tender vestibulitis under a hymenal remnant, getting to the root of dyspareunia can present a significant challenge to clinicians. Adding to the difficulty is the fact that intermittent conditions such as cyclical Candida albicans are hard to diagnose.

This review of 5 common but often overlooked causes describes what is known about dyspareunia and how to conduct a complete evaluation, including physical examination, diagnostic tests, and questions to ask the patient.

CAUSE 1Inadequate estrogenization

Vulvovaginal atrophy is the leading cause of sexual dysfunction, affecting up to 50% of women over age 50. It contributes to a lack of vaginal lubrication with sexual arousal and, consequently, dyspareunia and postcoital bleeding.3 Even when a woman is taking oral hormone replacement therapy, the vagina can lack sufficient estrogen.

Younger women also may experience atrophy and lowered estrogen levels. For example, a 34-year-old woman with premature ovarian failure may experience slight burning, dryness, and pain on penetration.

Tamoxifen can be a source of dyspareunia: It can cause vaginal atrophy in the premenopausal woman or estrogenization with Candidal invasion in postmenopausal patients.

Atrophy also can occur:

  • with hypothalamic amenorrhea caused by excessive exercise or marked weight loss
  • during the postpartum period and breast-feeding
  • with the use of some low-estrogen (20 μg) contraceptives and medroxyprogesterone acetate
  • after radiation or chemotherapy

Resolve the problem with local estrogen.

Fortunately, atrophy is easily reversed with local estrogen in the form of cream, tablets, or the vaginal ring. Because the latter does not elevate circulating estradiol levels after the first 24 hours of use, many oncologists are willing to allow this therapy for breast cancer patients.4

When dyspareunia persists despite local estrogen use, we must seek out other causes.

CAUSE 2A skin disease

Dermatitis. There are 2 types of dermatitis: eczematous, in which the irritant is essentially unknown, and contactant, which arises from known irritants or allergens. In some cases, the exposure to an irritant may be fairly recent. In others, the continuing combination of irritants and tight clothing or abrasive activity eventually leads to symptoms.

Physical findings of dermatitis include erythema (with or without scaling) and fissuring—especially of the perineum. A biopsy is diagnostic.

Recommended treatment includes meticulous vulvar hygiene and the use of 2.5% hydrocortisone cream twice daily for 14 to 30 days, followed by twice-weekly “maintenance” applications. For moderate or severe cases, a medium-potency steroid (betamethasone valerate 0.1%) or an ultrapotent steroid (clobetasol 0.05%) may be used in the same manner. In addition, physicians should educate patients with dermatitis about the chronicity of the condition and the importance of eliminating the cause, if possible.

Poorly treated eczema leads to lichen simplex chronicus. One clue to this condition is a history of atopy or eczema elsewhere on the body.

Lichen sclerosus and lichen planus. These dermatoses cause changes in the color and texture of the epithelium.

Because lichen planus can produce erosion of the vestibule, it often is mistaken for vestibulitis. With this condition, erosions are intensely erythematous and vary from small areas to involvement of the entire vestibule. You will also note a serpiginous white border or subtle white reticules adjacent to erosions.

Both lichen sclerosus and lichen planus can produce intense itching or progress without clinical symptoms.

Lichen sclerosus, meanwhile, causes whitened epithelium with the thinned and wrinkled appearance of cigarette paper; areas of hyperkeratosis also may be present. Changes may occur from the periclitoral area to the anus in a keyhole configuration.

Both lichen sclerosus and lichen planus:

  • can produce intense itching or progress without clinical symptoms
  • can scar extensively and cause bridging synechiae at the fourchette, elimination of the labia minora, and fusion of the prepuce over the glans clitoris
  • can produce anal fissuring and painful defecation

While lichen sclerosus never involves the vagina, vaginal lichen planus produces inflammatory vaginitis that can scar and reduce the size of the vagina—even obliterate it entirely.

Treatment for both diseases consists of ultrapotent topical steroids to arrest the inflammatory process. Vaginal lichen planus is treated with hydrocortisone suppositories (25 mg at bedtime), with the length of treatment dependent on severity.5 More potent steroids may be necessary.

CAUSE 3Candida

This infection can be extremely difficult to diagnose for a variety of reasons. Patients come in partially treated with over-the-counter antifungals. Many have taken a fluconazole tablet with a long half-life of action. Others have a cyclical candidiasis that is seen only in the luteal phase of the cycle. In these cases, fissuring is often attributed to other causes.

Complicating matters further, a wet mount will be negative in the presence of Candida approximately 50% of the time.6 For these reasons, a culture is essential when there is an index of clinical suspicion and white blood cells are present on the wet mount.

Uncomplicated Candida is treated by topical -azole creams for 3 or 7 days or a single fluconazole 150-mg tablet.

Complicated Candida (that is, more than 3 infections in a year or infection in a pregnant or immune-compromised host) will require longer courses of therapy.7

CAUSE 4Desquamative inflammatory vaginitis

Because the intense inflammation produced by the 2 diseases are similar, some people believe desquamative inflammatory vaginitis is a form of lichen planus8—in fact, it is sometimes called lichenoid vaginitis. However, desquamative inflammatory vaginitis does not scar the vagina, suggesting a different cause. Its profusely irritative discharge—microscopically characterized by sheets of white blood cells—resembles Trichomonas and Candida. Sheets of white blood cells and parabasal cells also resemble Trichomonas, Candida, or severe atrophy.

Discussing dyspareunia: Questions crucial to a thorough exam1

Questions such as “Are you sexually active?” and “Do you have any concerns about your sex life?” can begin a discussion of dyspareunia. Other vital questions include the following:

When did the pain begin? Primary complete dys-pareunia may result from a congenital anomaly or psychosocial issues, but the leading cause is vulvar vestibulitis.2 Acquired dyspareunia has many causes.

When and where does the pain or discomfort occur? Ask the patient to describe its severity, character, duration, location, and time during the menstrual cycle. Superficial dyspareunia usually is due to vestibulitis, inadequate lubrication, or an anatomic abnormality of the introitus. 3 Other causes include vulvar atrophy, infection, urethral disorders, and vulvar dermatitis or dermatosis. Pain associated with deep penetration or thrusting may be related to a retroverted uterus or to impaired mobility of the pelvic organs due to scarring from endometriosis or pelvic inflammatory disease.4 Cystitis and interstitial cystitis may cause deep midline dyspareunia, as well as dysuria and other urinary tract symptoms. Deep dyspareunia can also be due to vaginal dryness or atrophy. Consider adnexal or bowel pathology when the pain occurs laterally.

Are there other sexual problems? Pain during intercourse often causes sexual dysfunction, which needs to be addressed before the pain can resolve.

What have you tried to treat or prevent the pain? Successful aids can offer diagnostic clues.

Is there any vaginal discharge, itching, burning, odor, or bleeding? These may be present with vaginitis or a neoplasm. Increased discharge may be due to vestibulitis.

Do you have any gynecologic problems, such as endometriosis, fibroids, or chronic pelvic pain? These conditions have well-known associations with deep dyspareunia. Endometriosis and vulvar vestibulitis occur together.

Have you had vulvovaginal or pelvic infections, such as candidiasis, herpes, gonorrhea, or chlamydia?Recurrent herpes or Candidal infection can be painful and difficult to diagnose; pelvic inflammatory disease can cause scarring and decreased mobility of pelvic organs.

What gynecologic surgery or other procedures have you undergone? Childbirth, radiation or chemotherapy, or incontinence procedures may lead to dyspareunia. Female circumcision is practiced in some cultures and should be considered when appropriate. Scarring and fibrosis can distort anatomy, narrow the vagina/introitus, and decrease tissue mobility, thereby causing pain during thrusting. Chemotherapy and radiation may result in premature ovarian failure (hypoestrogenism). Radiation vulvitis contributes to superficial pain.

What is your natural lubrication like? If it is low, have you tried commercially available lubricants? Natural lubrication may be reduced from hypoestrogenism, certain drugs, or difficulty with arousal.

What do you use for contraception? Latex allergy from condoms or a diaphragm, or an irritant reaction to spermicides may be at the root of the pain. Lowestrogen oral contraceptives or depot medroxyprogesterone acetate contribute to poor lubrication. The intrauterine device is a risk factor for recurrent Candida.

What medical or psychiatric problems are you currently being treated for? Skin disorders such as eczema and lichen planus may be associated with vulvar dermatitis. Inflammatory bowel disease may be related to pelvic adhesions. Interstitial cystitis can cause both dyspareunia and dysuria.

What drugs are you taking? Many medications are associated with dyspareunia due to side effects such as decreased sexual arousal, vaginal lubrication, or serum estrogen levels.

Have you ever been sexually abused or had a traumatic injury involving your genitals? Did you receive counseling or help for this? Many women have worked through their trauma, but unresolved issues can contribute to ongoing pain. Sexual abuse is a risk factor for chronic pelvic pain but is not associated with vestibulitis.5

What do you think may be causing this problem? Often, the patient will provide the answer.

REFERENCES

1. Stewart EG. Approach to the woman with dyspareunia. UpToDate. Available at: www.uptodate.com. In press.

2. Meana M, Binik YM, Khalife S, Cohen DR. Biopsychosocial profile of women with dyspareunia. Obstet Gynecol. 1997;90:583-589.

3. Heim LJ. Evaluation and differential diagnosis of dyspareunia. Am Fam Physician. 2001;63:1535-1544.

4. Steege JF, Ling FW. Dyspareunia: A special type of chronic pelvic pain. Obstet Gynecol Clin North Am. 1993;20:779-793.

5. Edwards L, Mason M, Phillip M, et al. Childhood sexual and physical abuse: incidence in patients with vulvodynia. J Reprod Med. 1997;42:135-139.

The inflammation leads to the loss of the lactobacillus, with bacterial overgrowth and clue cells similar to bacterial vaginosis (though bacterial vaginosis never causes such inflammation).

Vulvodynia consists of unprovoked stinging, burning, irritation, rawness, or pain anywhere on the vulva and can be constant or episodic.

Though antibiotics may yield transient improvement,9 management most often consists of 25-mg hydrocortisone suppositories (or compounded as 100 mg for severe cases) at bedtime for 14 days, then every other day for 14 days. After this course of therapy has been completed, clinicians must reevaluate the patient to determine whether she needs extended therapy (in severe cases) or can begin maintenance with a weekly suppository (for cases that are mild but chronic).

If dyspareunia does not resolve after the inflammation abates, superimposed neuroinflammatory pain (vestibulitis) will need treatment.

CAUSE 5Vulvodynia or vulvar vestibulitis

Vulvodynia (generalized vulvar dysesthesia). This condition—which consists of unprovoked stinging, burning, irritation, rawness, or pain anywhere on the vulva—may be constant or episodic. Dyspareunia in these cases may involve postcoital exacerbation of symptoms.

Continued...
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