News for Your Practice

Postmenopausal dyspareunia— a problem for the 21st century

OBG Manag. 2009 March;21(3):37-44

References

1. US Census Bureau. 2006 American community survey. S0101. Age and sex. Available at: http://fact-finder.census.gov/servlet/DatasetMainPageServlet?_program=ACS&_submenuId=&_lang=en&_ts.

2. National Center for Health Statistics. Health, United States, 2007, with Chartbook on Trends in the Health of Americans. Hyattsville, Md: NCHS; 2007. Available at: http://www.cdc.gov/nchs/fastats/lifexpec.htm. Accessed February 2, 2009.

3. Sarrel PM, Whitehead MI. Sex and menopause: defining the issues. Maturitas. 1985;7:217-224.

4. Dennerstein L, Hayes RD. Confronting the challenges: epidemiological study of female sexual dysfunction and the menopause. J Sex Med. 2005;2(suppl 3):118-132.

5. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288:321-333.

6. Lindau ST, Schumm LP, Laumann EO, Levinson W, O’Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the United States. N Engl J Med. 2007;357:762-774.

7. Dennerstein L, Alexander JL, Kotz K. The menopause and sexual functioning: a review of the population-based studies. Annu Rev Sex Res. 2003;14:64-82.

8. Basson R, Berman J, Burnett A, et al. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol. 2000;163:888-993.

9. Simon JA, Komi J. Vulvovaginal atrophy (VVA) negatively impacts sexual function, psychosocial well-being, and partner relationships. Poster presented at North American Menopause Association Annual Meeting; October 3-6, 2007; Dallas, Texas.

10. Heim LJ. Evaluation and differential diagnosis of dyspareunia. Am Fam Physician. 2001;63:1535-1552.

11. Marwick C. Survey says patients expect little physician help on sex. JAMA. 1999;281:2173-2174.

12. Basson R, Althof S, Davis S, et al. Summary of the recommendations on sexual dysfunctions in women. J Sex Med. 2004;1:24-34.

13. Basson R. Female sexual response: the role of drugs in the management of sexual dysfunction. Obstet Gynecol. 2001;98:350-353.

14. Walsh KE, Berman JR. Sexual dysfunction in the older woman: an overview of the current understanding and management. Drugs Aging. 2004;21:655-675.

15. Bachmann GA, Komi J, Hanley R. A new SERM, Ophena (ospemifene), effectively treats vulvovaginal atrophy in postmenopausal women: results from a pivotal phase 3 study. Presented at the Endocrine Society annual meeting, San Francisco, Calif, June 2008.

The WHI and its domino effect

Millions of postmenopausal women stopped taking estrogen-based therapy in the wake of widespread media coverage after 2002 publication of data from the estrogen–progestin arm of the Women’s Health Initiative (WHI), which purported to show, among other things, an increased risk of breast cancer.⁵

For decades, many postmenopausal women achieved medical management of VVA through long-term use of systemic hormone replacement therapy (HRT), which they used primarily to control other chronic symptoms of menopause, such as hot flashes.

After the WHI data were published (and misrepresented), reduced usage of estrogen-based HRT “unmasked” vaginal symptoms, including sexual pain, due to the effects of estrogen deficiency on the vaginal epithelium and vaginal blood flow. Since then, we have been forced to examine anew the natural history of menopause.

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Within days or weeks of discontinuing HRT, women may reexperience the acute vasomotor symptoms that accompany estrogen withdrawal—most commonly hot flashes, night sweats, sleeplessness, palpitations, and headaches. Over time—anywhere from 6 months to several years—the body adjusts to the loss or withdrawal of estrogen, and these vasomotor symptoms eventually diminish or resolve. Not so for the longer-term physical effects of chronic low serum levels of estrogen, which worsen over time.

Approximately 6 months after discontinuing estrogen therapy, postmenopausal women may begin to experience vaginal dryness and VVA. As the years pass, other side effects of estrogen deficiency arise: bone loss, joint pain, mood alteration (including depression), change in skin tone, hair loss, and cardiac and central nervous system changes. These side effects do not resolve spontaneously; in fact, they grow worse as a woman ages. They may have deleterious psychosocial as well as physical impacts on her life—especially on the quality of her intimate relationship.

Here’s what to ask a postmenopausal patient when she complains of dyspareunia

Clarify the report (adjust appropriately for same-sex partner)

Where does it hurt? Describe the pain.
When does it hurt? Does the pain occur 1) with penile contact at the opening of the vagina, 2) once the penis is partially in, 3) with full entry, 4) after some thrusting, 5) after deep thrusting, 6) with the partner’s ejaculation, 7) after withdrawal, or 8) with subsequent micturition?
Does your body tense when your partner is attempting, or you are attempting, to insert his penis? What are your thoughts and feelings at this time?
How long does the pain last?
Does touching cause pain? Does it hurt when you ride a bicycle or wear tight clothes? Does penetration by tampons or fingers hurt?

Assess the pelvic floor

Do you recognize the feeling of pelvic floor muscle tension during sexual contact?
Do you recognize the feeling of pelvic floor muscle tension in other (nonsexual) situations?

Evaluate arousal

Do you feel subjectively excited when you attempt intercourse?
Does your vagina become sufficiently moist? Do you recognize the feeling of drying up?

Determine the consequences of the complaint

What do you do when you experience pain during sexual contact? Do you continue? Or do you stop whatever is causing the pain?
Do you continue to include intercourse or attempts at intercourse in your lovemaking, or do you use other methods of achieving sexual fulfillment? If you use other ways to make love, do you and your partner clearly understand that intercourse will not be attempted?
What other effect does the pain have on your sexual relationship?

Explore biomedical antecedents

When and how did the pain start?
What tests have you undergone?
What treatment have you received?

Source: Adapted from Basson R, et al.¹²

Is 60 the new 40?

Many women and men in the large cohort known as the Baby Boomer generation continue to be sexually active into their 60s, 70s, and 80s, as demonstrated by a 2007 study of sexuality and health in older adults.⁶ In the 57- to 64-year-old age group, 61.6% of women and 83.7% of men were sexually active (defined as sexual activity with a partner within the past 12 months). In the 65- to 74-year-old group, 39.5% of women and 67% of men were sexually active; and in the 75- to 85-year-old group, 16.7% of women and 38.5% of men were sexually active (TABLE).

These findings indicate that fewer women than men remain sexually active during their later years. One reason may be the epidemic of sexual-related symptoms among postmenopausal women. In the same survey, 34.3% of women 57 to 64 years old reported avoiding sex because of:

pain during intercourse (17.8%)
difficulty with lubrication (35.9%).

Across all groups, the most prevalent sexual problem was low desire (43%).⁶ Around 40% of postmenopausal women reported no sexual activity in the past 12 months, as well as lack of interest in sex. This number may include women who have ceased to have sex because of vaginal dryness and dyspareunia, thereby reducing the percentage reporting these symptoms (TABLE).