Treatment of Dyspareunia

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.