Clinical Review

Dyspareunia: 5 overlooked causes

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Disorders ranging from a simple anatomic problem to a complex psychosocial/biologic phenomenon can cause difficult or painful coitus. An expert outlines diagnosis and treatment strategies for 5 common causes and offers guidance on how to conduct the physical exam and elicit information from the patient.



  • The leading cause of dyspareunia for women under age 50 is vulvar vestibulitis; for women over age 50, it is vulvovaginal atrophy.
  • The skin conditions dermatitis, lichen sclerosus, and lichen planus are a significant cause of dyspareunia complaints.
  • Candida can be difficult to diagnose; the fissuring experienced by patients with this infection is often attributed to other causes.
  • Desquamative inflammatory vaginitis leads to the loss of the lactobacillus, with bacterial overgrowth and clue cells similar to bacterial vaginosis.
  • Generalized vulvar dysesthesia involves constant or episodic unprovoked stinging, burning, irritation, rawness, or pain anywhere on the vulva. In contrast, localized vulvar dysesthesia is provoked pain in the vestibule.
Identifying the cause of a patient’s dyspareunia can be just as challenging as getting her to admit to the problem.

Due in part to underreporting of the condition, the incidence and prevalence of dyspareunia—defined as genital pain experienced just before, during, or after sexual intercourse1—is uncertain.2

Because it is easy to miss subtle physical findings such as small fissures, periclitoral scarring, or a focus of tender vestibulitis under a hymenal remnant, getting to the root of dyspareunia can present a significant challenge to clinicians. Adding to the difficulty is the fact that intermittent conditions such as cyclical Candida albicans are hard to diagnose.

This review of 5 common but often overlooked causes describes what is known about dyspareunia and how to conduct a complete evaluation, including physical examination, diagnostic tests, and questions to ask the patient.

CAUSE 1Inadequate estrogenization

Vulvovaginal atrophy is the leading cause of sexual dysfunction, affecting up to 50% of women over age 50. It contributes to a lack of vaginal lubrication with sexual arousal and, consequently, dyspareunia and postcoital bleeding.3 Even when a woman is taking oral hormone replacement therapy, the vagina can lack sufficient estrogen.

Younger women also may experience atrophy and lowered estrogen levels. For example, a 34-year-old woman with premature ovarian failure may experience slight burning, dryness, and pain on penetration.

Tamoxifen can be a source of dyspareunia: It can cause vaginal atrophy in the premenopausal woman or estrogenization with Candidal invasion in postmenopausal patients.

Atrophy also can occur:

  • with hypothalamic amenorrhea caused by excessive exercise or marked weight loss
  • during the postpartum period and breast-feeding
  • with the use of some low-estrogen (20 μg) contraceptives and medroxyprogesterone acetate
  • after radiation or chemotherapy
Resolve the problem with local estrogen.

Fortunately, atrophy is easily reversed with local estrogen in the form of cream, tablets, or the vaginal ring. Because the latter does not elevate circulating estradiol levels after the first 24 hours of use, many oncologists are willing to allow this therapy for breast cancer patients.4

When dyspareunia persists despite local estrogen use, we must seek out other causes.

CAUSE 2A skin disease

Dermatitis. There are 2 types of dermatitis: eczematous, in which the irritant is essentially unknown, and contactant, which arises from known irritants or allergens. In some cases, the exposure to an irritant may be fairly recent. In others, the continuing combination of irritants and tight clothing or abrasive activity eventually leads to symptoms.

Physical findings of dermatitis include erythema (with or without scaling) and fissuring—especially of the perineum. A biopsy is diagnostic.

Recommended treatment includes meticulous vulvar hygiene and the use of 2.5% hydrocortisone cream twice daily for 14 to 30 days, followed by twice-weekly “maintenance” applications. For moderate or severe cases, a medium-potency steroid (betamethasone valerate 0.1%) or an ultrapotent steroid (clobetasol 0.05%) may be used in the same manner. In addition, physicians should educate patients with dermatitis about the chronicity of the condition and the importance of eliminating the cause, if possible.

Poorly treated eczema leads to lichen simplex chronicus. One clue to this condition is a history of atopy or eczema elsewhere on the body.

Lichen sclerosus and lichen planus. These dermatoses cause changes in the color and texture of the epithelium.

Because lichen planus can produce erosion of the vestibule, it often is mistaken for vestibulitis. With this condition, erosions are intensely erythematous and vary from small areas to involvement of the entire vestibule. You will also note a serpiginous white border or subtle white reticules adjacent to erosions.

Both lichen sclerosus and lichen planus can produce intense itching or progress without clinical symptoms.

Lichen sclerosus, meanwhile, causes whitened epithelium with the thinned and wrinkled appearance of cigarette paper; areas of hyperkeratosis also may be present. Changes may occur from the periclitoral area to the anus in a keyhole configuration.

Both lichen sclerosus and lichen planus:

  • can produce intense itching or progress without clinical symptoms
  • can scar extensively and cause bridging synechiae at the fourchette, elimination of the labia minora, and fusion of the prepuce over the glans clitoris
  • can produce anal fissuring and painful defecation


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