Brenda (age 55) and Alexander (age 57) had been married for 30 years when they were referred to a sex and couple therapy clinic for dyspareunia by her gynecologist. A comprehensive pain assessment revealed that Brenda experienced a "rubbing, cutting, and sometimes burning" pain upon penetration and a deeper "dull, pulling pain" during intercourse. She reported that the pain started 4 years ago, at a time when she began to experience hot flashes and irregular periods, with an increase in intensity of the superficial pain over the last year. Attempts to lessen the pain through the use of water-based lubricants and topical estradiol cream had not been successful, and she did not wish to try systemic hormone replacement therapy for fear of developing breast cancer. A detailed sexual history revealed that Brenda had suffered from intermittent pain during intercourse for at least 15 years but had never complained about it, and that Alexander had always had difficulties with ejaculatory control. Over the past 4 years, Brenda reported difficulty getting sexually aroused, diminished lubrication, postcoital bleeding, and less interest in sex. Their current sexual frequency was less than once every 3 months, a frustrating situation for Alexander, who had hoped that their youngest child leaving home in the previous year would result in more frequent sexual activity. In the previous 5 years, the couple had also experienced significant life stressors including the sudden death of Brenda's mother and major financial problems. The couple was seen in therapy to help overcome their sexual difficulties, to manage the pain, and to receive support and advice concerning their stressful life situation.
As women approach middle-age and menopause, physiological aging, psychosocial factors, and declining levels of endogenously produced sex hormones caused by ovarian senescence can exert significant effects on their sexual response cycle. As such, comprehensive enquiry of dyspareunic pain characteristics and history, climacteric symptoms, as well as changes in sexual functioning, urogenital anatomy, marital/partner relations that have occurred are essential in the assessment of post-menopausal dyspareunia. The many anatomical changes, within but not limited to the urogenital region, experienced by aging women (e.g., reduced vaginal and/or clitoral size, loss of fat and subcutaneous tissue from the mons pubis, arteriosclerosis) can result in decreased sexual arousal, vaginal dryness, and dyspareunia (23). Dyspareunia may also result from iatrogenic efforts, including pelvic or cervical surgery and radiotherapy, and pharmacotherapy (24). Moreover, it is considered a secondary symptom of atrophic vaginitis, often accompanied with postcoital bleeding (25). Physical examination following reliable criteria such as the Vaginal Atrophy Index (26), hormonal assays, and cytological evaluation (i.e., pap smear) are essential in the diagnosis of vulvovaginal atrophy.
Psychosocial difficulties that commonly affect postmenopausal women may impinge on sexual functioning and affect pain perception. Intrapersonal issues, such as negative perceptions of menopause, body image, and postreproductive sexuality, often function as self-fulfilling prophecies and foster sexual dysfunction in the menopause (27). Interpersonal factors such as marital/ relationship difficulties, partner's sexual dysfunction (e.g., erectile dysfunction, decreased desire), and loss of social support may also be implicated (28). Clinicians should carefully assess for possible non-biomedical factors that may play a role in maintaining postmenopausal dyspareunia before making a diagnosis or prescribing treatment.
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