FEMALE PAIN DURING SEXUAL INTERCOURSE: PART 1 - CAUSES & EVALUATION

Female sexual pain is a common issue, affecting women worldwide. It includes conditions like dyspareunia (painful intercourse) and vulvodynia (chronic genital pain). The prevalence of these conditions varies depending on the definition used and geographic location. For example, in the United States, dyspareunia affects around 10% to 20% of women, with leading causes varying by age group. The global prevalence of painful intercourse ranges between 8% and 21.1%. In Brazil, dyspareunia's prevalence ranges from 1.2% to 56.1%, while Puerto Rico's rate is 17% to 21%.

Vulvodynia is estimated to affect 10% to 28% of reproductive-aged women. Approximately 8% of women aged 18 to 40 have experienced vulvodynia that limited or prevented intercourse. Studies suggest a higher prevalence of vulvar pain in Hispanic women compared to white women.

Impact on Women's Lives.

Women experiencing chronic genital pain often find it difficult to seek help, leading to social isolation. Dyspareunia can cause sexual dysfunction and decreased sexual frequency in affected women. Those with comorbidities like endometriosis, fibroids, or vaginitis related to dyspareunia experience lower sexual function, leading to relationship distress and decreased quality of life. Moreover, sexual pain has been associated with psychiatric comorbidities such as depression and anxiety.

Economic Burden.

Apart from the personal impact, dealing with pelvic pain also incurs significant healthcare expenses. In Canada, over $100.5 million (with an average of $25 million per year) was spent on treating chronic pelvic pain disorders, with dyspareunia contributing 6.6% of the cost. The national burden cost of vulvodynia in the US is estimated to range from $31 to $72 billion annually.

Causes of Dyspareunia and Vulvodynia.

Dyspareunia and vulvodynia have multiple underlying causes, involving both psychological and biological factors. Superficial dyspareunia can be associated with vaginitis, dermatosis, and vulvovaginitis, while deep dyspareunia can result from conditions such as interstitial cystitis, pelvic inflammatory disease, endometriosis, and fibroids. Pain syndromes like irritable bowel syndrome, fibromyalgia, and musculoskeletal dysfunction can also contribute to dyspareunia and vulvodynia.

Risk factors for dyspareunia and vulvodynia include poor vaginal lubrication, vaginal atrophy, childbirth, and other medical conditions. Vulvodynia can be associated with vulvar/vaginal infections, inflammation, neoplasms, trauma, hormonal deficiencies, neuropathic pain, pelvic floor muscle dysfunction, structural defects, and psychosocial factors.

Clinical Evaluation.

When evaluating patients with sexual pain, it is crucial to acknowledge their pain and establish trust. A detailed medical history is necessary, covering pain characteristics, associated symptoms, sexual behavior, psychological history, comorbid medical problems, previous treatments, and history of abuse.

Physical examination includes a musculoskeletal evaluation and external visual and sensory examination, followed by an internal single-digit palpation of the pelvic floor muscles. A bimanual examination and a speculum exam may be performed if tolerated by the patient. An interactive educational pelvic examination process can help reduce anxiety and discomfort during the evaluation.

Treatment Options.

Treatment for dyspareunia and vulvodynia may involve a multimodal approach, including conservative medical non-invasive therapies. Education about pelvic anatomy, physiology, and lifestyle modifications can be helpful. Medical therapies such as topical anesthetics, hormonal treatments, anti-inflammatory agents, botulinum toxin A, and systemic medications like tricyclic antidepressants and anticonvulsants may be prescribed.

Physical therapy and behavioral therapy, particularly cognitive-behavioral therapy, are effective adjuncts to treatment. In severe cases, surgical options like vulvar vestibulectomy may be considered as a last resort when all other treatments have failed.

Conclusion.

Female sexual pain, encompassing dyspareunia and vulvodynia, can have a significant impact on women's lives. Understanding the causes and evaluating patients thoroughly are crucial in providing effective treatment options. A multimodal approach, tailored to each individual, can help improve symptoms and enhance the overall quality of life for women suffering from sexual pain.