As indicated above, dyspareunia is best treated via a cooperative team of professionals. A thorough physical examination by a skilled physician is necessary, along with laboratory tests, to make the initial diagnosis. Not only does the physical examination allows the identification of organic factors that may contribute to the dyspareunia, but it permits the possibility of having a positive educational experience with respect to the genitalia (Steege 1984). For example, if the woman is provided with a hand mirror, she can learn about her vulvar and vaginal anatomy in a straightforward way, thus challenging prior myths and misperceptions. Moreover, to the extent that the physical examination is comfortable, it may instill optimism that vaginal penetration and distension can be pain-free. Clearly, if obvious physical factors can be identified, appropriate medication and/or physical intervention should be undertaken.
However, even when organic factors are identified and treated, sex therapy is often necessary. Even in the absence of acute pain, the long-standing negative association of sex with physical or psychological discomfort often remains and must be dealt with if the woman is to enjoy an active sexual life.
Therapy usually involves the woman and her partner, seen both together and individually. During the couple evaluation, note is taken of the way in which the couple interacts - for example, the ease and directness of couple communication, the presence or absence of mutual respect and affection, the distribution of power in the relationship, and their conflict management skills. A history of their courtship is important, with particular attention directed to their early history of sexual exchange. When did sexual difficulties first arise? How were these difficulties handled? What accommodations were made? What treatments were sought? Why is the couple seeking treatment at this time? It is important to determine the partner’s degree of sympathy for the woman’s complaints of dyspareunia and whether the couple have developed alternatives to intercourse as a way of maintaining physical intimacy.
With the patient alone, an attempt is made to develop a complete understanding of the precipitating and long-term causes of the dyspareunia (e.g., sexual abuse history, gynecological trauma history, psychosexual history). The woman should be encouraged to provide her personal theory or explanation of why she experiences sexual pain and what she has done to minimize or eliminate it. Have there been times when there was no discomfort? When? What are the characteristics of occasions when the pain is mild and when it is severe? What would be different if sex were pain-free? What are the potential costs of resolving the problem? Who cares more about resolving the problem, she or her partner? Does she want children? Why or why not? These and other questions are explored and discussed throughout therapy.
Training in progressive muscle relaxation may be helpful as an adjunct to treatment, as may instruction in Kegel exercises. Providing the woman “tools” that will help her control the situation is essential, since these women often feel quite fearful and helpless sexually. Relaxation exercises should be undertaken prior to vulvar and vaginal exploration. Masturbation can be suggested as well, since self-stimulation (as opposed to partner stimulation) enables the woman to desensitize to touching her genitalia, provides sexual arousal prior to vaginal exploration, and permits her to control the pace and type of sexual stimulation. If she is loath to undertake vaginal exploration with her fingers, vaginal dilators can be prescribed. Progress is easily charted, as the woman moves to successively larger dilators.
It should be noted that some women are reluctant to use dilators because of fear of pain or infection. At times, dilator insertion may trigger repressed memories of genital trauma or childhood sexual abuse. Flashbacks can occur in which a woman “relives” a traumatic event. It is important that such memories be processed during sessions; often, after recall of repressed events, treatment proceeds more smoothly.
At the same time that sexual exercises are suggested, with variations in the amount of genital pressure and penetration, psychotherapeutic work continues with identification and discussion of the cognitive beliefs and assumptions the patient holds about sex, intrapsychic issues and conflicts, and interpersonal difficulties. It is not uncommon to find that patients embrace a variety of erroneous beliefs. One woman believed, for example, that by maintaining her “hymen,” she was ensuring her purity. She was surprised to learn that her hymen had already been broken during cycling as a child and was no longer “protecting” the entrance to her vagina. Many women have no realistic idea about either the length of their vagina or its potential elasticity.
At times, the partner is invited to join sessions in an effort to work on couple issues and to ensure his or her continued support, encouragement, and involvement. The partner may be invited, as well, to observe the woman as she inserts the dilator and, eventually, to insert either a dilator or his fingers, with the woman’s instruction and guidance. Always, though, it is stated and reiterated that the woman is in charge of these exploratory and instructional sessions, and she is free to interrupt or terminate them at any time if she feels anxious or uncomfortable.
In general, treatment involves a combination of behavioral, cognitive, and interpersonal interventions. Through learning to relax and control vaginal dilation and penetration, the woman develops greater confidence in her ability to experience pain-free vaginal penetration and coitus. Involving the partner initially as an observer and later as an active participant in treatment helps pave the way for comfortable couple interactions. Challenging unrealistic or unexplored cognitive beliefs and assumptions enables the woman to reassess and “update” her sexual values and assumptions. If memories of traumatic sexual events or childhood sexual abuse arise either spontaneously or following flashbacks triggered by specific activities, they can be explored and processed. One woman, for example, reacted with fear, anxiety, and tears when her husband encouraged her verbally to “just relax.” In exploring her intense reaction to these words, she recalled that her father would utter these same words when he sexually molested her as a child.
Although treatment for dyspareunia is rarely either straightforward or brief, significant progress can be achieved, and therapeutic outcome can be quite positive. Nevertheless, there are some women who persist in their report of pain and go from one doctor to another seeking, but rarely finding, “medical magic.” Obviously, in some cases, unresolved reports of pain, along with numerous other symptoms, may be indicative of somatization disorder. More often, though, persisting pain is the result of inadequate diagnosis and treatment.
Revision date: July 8, 2011
Last revised: by Andrew G. Epstein, M.D.