Dyspareunia: clinical approach in the perimenopause

Dyspareunia has long been considered to be psychogenic. Opposite, it has solid biological bases, that need to be addressed in a more integrated and patient-centered perspective. The new International Classification on Female Sexual Disorders allocates the etiologic subtypes of “Organic, Psychogenic, Mixed, Unknown” in the group of Sexual Pain Disorders, that includes Vaginismus, Dyspareunia and Non-coital Sexual Pain Disorders. According to this classification, this review analyzes the many different medical (“organic”) factors that may cause pain and/or sum-up with psychogenic (psychosexual) and relational factors contributing to pain during intercourse, with special attention to perimenopausal patients. Biological factors include hormonal, inflammatories, muscular, iatrogenic, neurologic, vascular, connective and immunitary causes. Psychosexual factors -vaginismus, loss of libido, arousal disorders and sexual pain related disordersmay frequently overlap. Couple problems may finally contribute to dyspareunia when they cause loss of libido and poor arousal, with consequent vaginal dryness. A preliminary clinical approach aiming at integrating different biological and psychosexual etiologies in a comprehensive perspective is discussed. It encourages a clinical update on the psychobiology of the experience of sexual pain, hopefully leading to more satisfying and effective treatment.