Medication. Medication may be used to treat the underlying contributing conditions or the symptom of pain directly. Some common options are particularly important for patients whose dyspareunia does not have an identifiable cause. These medications include anti-inflammatory agents, topical anesthetics, tricyclic antidepressants, and hormonal treatments.2-4 Since effectiveness varies based on subtypes of pain, select a medication according to the location, timing, and hypothesized mechanism of pain.3,31,32
Medication for deep pain. A meta-analysis and systematic review found that patients with some types of chronic pelvic pain with pain deep in the vagina or pelvis experienced greater than 50% reduction in pain using medroxyprogesterone acetate compared with placebo.33 Other treatments for deep pain depend on physical exam findings.
Medication for superficial pain. Many remedies have been tried, with at least 26 different treatments for vulvodynia pain alone.16 Only some of these treatments have supporting evidence. For patients with vulvar pain, an intent-to-treat RCT found that patients using a topical steroid experienced a 23% reduction in pain from pre-treatment to 6-month follow-up.32
Surgery is also effective for vulvar pain.34,35 For provoked vestibulodynia (in which pain is localized to the vestibule and triggered by contact with the vulva), or vulvar vestibulitis, RCTs have found that vestibulectomy has stronger effects on pain than other treatments,31,35 with a 53% reduction in pain during intercourse and a 70% reduction in vestibular pain overall.35 However, while vestibulectomy is effective for provoked vestibulodynia, it is not recommended for generalized vulvodynia, in which pain is diffuse across the vulva and occurs without vulvar contact.34
Unsupported treatments. A number of other treatments have not yet been found effective. Although lidocaine for vulvar pain is often used, RCTs have not found any significant reduction in symptoms, and a double-blind RCT found that lidocaine ointment actually performed worse than placebo.31,34 Similarly, oral tricyclics have not been found to decrease vulvar pain more than placebo in double-blind studies.31,34 Furthermore, a meta-analysis of RCTs comparing treatments with placebo for vestibular pain found no significant decrease in dyspareunia for topical conjugated estrogen, topical lidocaine, oral desipramine, oral desipramine with topical lidocaine, laser therapy, or transcranial direct current.32
Tx risks to consider. Risks and benefits of dyspareunia treatment options should be thoroughly weighed and discussed with the patient.2-4 Vestibulectomy, despite reducing pain for many patients, has led to increased pain for 9% of patients who underwent the procedure.35 Topical treatments may lead to allergic reactions, inflammation, and worsening of symptoms,4 and hormonal treatments have been found to increase the risk of weight gain and bloating and are not appropriate for patients trying to conceive.33
Coordinate care with other providers
While medications and surgery can reduce pain, they have not been shown to improve other aspects of sexual functioning such as sexual satisfaction, frequency of sexual intercourse, or overall sense of sexual functioning.35 Additionally, pain reduction does not address muscle tension, anxiety, self-esteem, and relationship problems. As a result, a multidisciplinary approach is generally needed.3,4,32,33
Continue to: Physical therapists