• DOI:10.4172/2573-0347-C1-018
• Corpus ID: 51745982

improving care for one in five women evaluating and managing dyspareunia

@inproceedings{Scemons2018improvingCF,
  title={improving care for one in five women evaluating and managing dyspareunia},
  author={D. Scemons and T. Egan},
  year={2018}
}

• D. Scemons, T. Egan
• Published 28 April 2018
• Medicine

Although one in five women will suffer from dyspareunia during her lifetime, only 15% of providers inquire about it. Unless the healthcare provider asks direct questions about this symptom most women will not discuss it. The following article examines several differential diagnoses and suggests interventions for dyspareunia, which can often be provided in the primary care setting. Etiologies of dyspareunia are both pathophysiological and psychosocial with both medications and nonpharmacological interventions potential treatment options. Cognitive Behavioral Therapy (CBT) and sexual education are psychological management choices with positive outcomes. Nurse Practitioners (NPs) have the necessary skills and knowledge to focus on improving the health of female patients by facilitating a discussion of dyspareunia at each well woman encounter. During their lifetime at least 1 in 5 women or 20% are affected by dyspareunia. Yet only 15% of healthcare providers investigate whether female patients experience painful intercourse. Etiologies are heterogeneous, from psychosocial issues such as anxiety which may reduce vaginal lubrication and triggering muscle spasms, to pathophysiological such as atopic skin changes, dysfunction of abdominal organs, and physiological changes related to pregnancy and menopause. Encouraging each woman to discuss dyspareunia during the well woman encounter provides patients reassurance that dyspareunia is a commonplace and reasonable subject of medical concern. Treatments are available, but should only be offered once communication is established between the patient and the provider. Definition, Under diagnosis and Epidemiology Various definitions of dyspareunia include “recurrent or persistent pain with sexual activity that causes marked distress or interpersonal conflict,” an “Insidious biopsychosocial pain cycle,” and “The pain-dominated perception of a mosaic of factors [which are] multifactorial, multisystemic, and complex [1-3]. Women are unlikely to discuss the issues of vaginal symptoms or sexual difficulties with their providers. However, these women are often open to exploring the diagnosis and treatment of dyspareunia if the provider introduces the discussion. When asked, only 10 15% of women disclosed that the provider inquired about vaginal symptoms. [4]. This provider avoidance may be due to a perceived difficulty in the management of dyspareunia, despite the plethora of potential diagnoses that can be treated in the primary care or women’s health setting [5]. Numerous women seeking treatment express that 1) their concerns are invalidated, 2) they receive an unsatisfying response from the provider, or 3) the condition is dismissed as unimportant, all of which adds to the patient’s distress [5,6]. Diverse researchers cite varying statistics, but the overall trend is well-defined. During their lifetime dyspareunia affects somewhere between 1:5 and 1:3 women. During a 2-year study, 7.5% of British women suffered from dyspareunia and 10-28% experience dyspareunia in a lifetime [5]. American women have a lifetime prevalence of 33%, while 17-36% of new mother’s Citation: Scemons D, Egan T (2018) Improving Care for One in Five Women: Evaluating and Managing Dyspareunia. Int J Nurs Res Health Care: IJNHR-124. DOI: 10.29011/ IJNHR-124. 100024 2 Volume 2018; Issue 03 experience dyspareunia six months postpartum [6,7] Approximately 15% of women are distressed by vulvodynia and an additional 15% of women experience provoked vulvodynia [3,8] Irrespective of the exact number, women complain more regularly of pain during intercourse than of any other sexual difficulty [9]. Over 96% of women suffering from dyspareunia are heterosexual, but women who sleep with women and men also experience sexual pain [10]. The women affected represent all national origins and socioeconomic classes and range in age from pre-menarche to older adult. With the exception of young children, all primary care settings are appropriate places to screen patients for dyspareunia. Causes of Dyspareunia Dyspareunia may be divided into deep pain in the vagina, cervix, and abdomen, and entry pain occurring at the introitus [1,3]. Differential diagnoses for entry pain include skin conditions, vulvodynia, and vaginismus. Pain that may extend from entry to deep includes vaginal atrophy, vaginal dryness, and perivaginal infections such as urethritis, Sexually Transmitted Infections (STIs), and cystitis. Deep pain may be the result of endometriosis, pelvic inflammatory disease, uterine myomas, adnexal pathology, irritable bowel syndrome, Chron’s disease, or sequalae of birth or surgery such as episiotomy or hysterectomy [1,11]. There is concern that classifying pain as deep or entry will reduce the likelihood of viewing the problem wholistically [5]. The authors of this paper are concerned that, along with the risk of treating a body part rather than a person, dyspareunia may be diagnosed in a psychiatric rather than a somatic fashion despite the medical nature of most causes of the disorder. History and Physical Examination The foundation for determining a differential diagnosis of dyspareunia is the history and physical [1]. NPs should routinely inquire about discomfort during intercourse as an element of each well woman visit. The patient may not have shared or may feel anxious sharing a vaginal symptom with a healthcare professional [6]. By repeating this inquiry over several visits the topic may become easier for the woman to discuss because it legitimizes dyspareunia as a medical problem that can be addressed with the assistance of a healthcare provider [11]. When obtaining a history, the NPs should, Explain the connection between body and mind in the area of 1. sexuality and pain. Demonstrate a nonjudgmental attitude, 2. Progress from a detailed medical history to a focused history 3. of the patient’s sexual pain [8]. Consider age, post-menopausal women are more likely to 4. have vulvovaginal atrophy; women of childbearing age may have postpartum or post-surgical pain [1]. Complete pain assessment including the quality and location 5. of the pain. Burning pain at the urethral meatus and bladder points to cystitis, while pelvic or adnexal pain often indicates endometriosis or cancer [8]. Complete a sexual assessment including desire, arousal, and 6. orgasm. This discussion and the information obtained may improve understanding of the interaction between psychosocial and physiological functioning for the individual [8]. The physical exam begins with inspection, which may reveal rashes and lesions. A mirror allows the woman to visualize and better understand her anatomy while participating in the exam [1]. In order to minimize pain, invite the woman to open her own labia and retract the clitoral hood. A thorough musculoskeletal, integumentary, and nervous assessment of the lumbar and pelvic region is fundamental [6]. Use a cotton swab to pinpoint localized pain. Discharge may be noted, suggesting various infections including bacterial vaginosis and STIs [1]. Begin palpation with a single finger, exploring the structures of the introitus and then the vagina. Pelvic floor muscles should be evaluated for tenderness and strength [1,6]. Use the smallest available speculum to inspect the cervix and to assess the vagina for atrophy and dryness. The cervix may be painful even when normal in appearance if previous cervicitis or obstetric trauma is part of the history [1]. Swabs should be collected for STI testing as indicated [11]. Defer the bimanual exam to the end of the physical assessment as it may cause pain or muscle spasm [6]. Include a rectovaginal exam to assess for constipation and levator ani spasm [8]. Assessment and Management of Psychosocial and Psychosexual Effects of Dyspareunia (Table 1) Many forms of dyspareunia include a psychological component. Depression, low self-esteem, and poor body image correlate 1. with dyspareunia, as do certain cognitive styles: pain hypervigilance and catastrophizing [5]. Relationship distress contributes to and may adversely affect 2. the patient’s relationships [8]. A comorbid condition of sexual difficulties including 3. inadequate sexual desire and arousal. Twice as many women with dyspareunia report disinterest in sexual intercourse compared to those without pain [5]. Difficulty communicating sexual preferences even with a 4. supportive partner, leading to inadequate lubrication and pain [8]. Thus, sexual education forms an important part of the treatment plan for most forms of dyspareunia [3,8]. NPs should, Citation: Scemons D, Egan T (2018) Improving Care for One in Five Women: Evaluating and Managing Dyspareunia. Int J Nurs Res Health Care: IJNHR-124. DOI: 10.29011/ IJNHR-124. 100024 3 Volume 2018; Issue 03 Inquire how the pain has affected the couple’s intimacy, what the couple has tried to resolve the problem, and what they believe will 1. happen to their relationship if it is not resolved [11]. Focus the woman’s attention on the positive aspects of her sexual relationships. 2. Discuss and discourage self-blame and hopelessness with the patient. 3. Encourage masturbation and foreplay as a way to increase the woman’s psychological and physical comfort with intimate contact. 4. Consider suggesting the woman take a break from intercourse until her pain is better managed [8]. 5. Educate women and their partners on the etiology, anatomy and pathophysiology of their vaginal pain condition. This may encourage sexual openness and may alleviate relationship distress during the diagnosis and treatment process, encouraging a return to health [3]. Diagnosis Etiology Symptoms Treatment Notes Postpartum Dyspareunia Vaginal tearing, stretching, episiotomy [1,12] 59-73% of women experience vaginal tear or cut during birth [12]. Predictors: In primiparas, twice as prevalent in breast feeders as bottle feeders [11] fatigue, stress, vacuum assisted delivery [12] During reproductive ages Physical