Beyond Hormone Therapy

T he clinical presentation of dyspareunia is often perplexing; patients may be difficult to assess, and positive clinical findings are not always observed on standard gynecologic examination. Adding to the confusion, the American Psychiatric Association’s Diagnostic and Statistical Manual defines dyspareunia as a sexual condition rather than a pain disorder, implying a psychogenic origin.1,2 Painful intercourse may correlate with sexual problems (ie, lack of libido, arousal, and orgasm), but it cannot be presumed that concurrent sexual problems are causal as opposed to resultant.3,4 In the premenopausal population, the incidence of dyspareunia is estimated at 15% to 20%,5,6 and the most common cause is vulvar vestibulitis syndrome. Approximately 25% of postmenopausal women have some degree of dyspareunia.5 Although dyspareunia in this population is generally attributed to vaginal dryness and mucosal atrophy secondary to loss of ovarian hormones,7 prevalence studies suggest a decrement in all aspects of female sexual function associated with midlife.8 The reduction in ovarian estrogen results in a decline in vaginal lubrication, atrophic vaginitis, and decreased blood flow and vasocongestion with sexual activity. This leads to genital changes including ischemia, thinning skin, and decline in size of the interoitus, labia, vagina, MANAGING POSTMENOPAUSAL DYSPAREUNIA: Beyond Hormone Therapy