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 findings: dry mucosa, birth trauma evidence both at entry and deeply [1]

First line: Lubricants are the first-line treatment [4].

Transcutaneous Electronic Nerve Stimulation (TENS) effective while supine or seated, not while standing [13]. Dubious utility in the real world [14].

Time

Surgical revision is a second line treatment option for poorly healed tears and episiotomies causing lasting pain [4].

Approximately 40 % of women experience dyspareunia during the first 3 months postpartum, dropping to 22 % after 6 months [1].

More than 30 % of women experiencing perineal pain after giving birth continue to complain of dyspareunia at six months [1].

Skin Changes: Contact dermatitis

Exposure to latex, the spermicide nonoxynol-9, or personal hygiene products.

Fungal and bacterial dermatitides may also lead to dyspareunia [8].

Pruritus, rash, erythema [15]

Physical findings: skin thickening, dampness in vulvar area, vulvar pain with speculum insertion [15]

Eliminate the irritant or treat the infection [10].

Common irritants: abnormal vaginal discharge, excessive hygiene, feminine hygiene products, feces, hair dryer, medications (alcohol based products, propylene glycol, spermicides), soaps/detergents, or sweat [16].

Skin Changes: Vulvar lichenification,

Painful and/or pruritic Inflammatory conditions of the vulva implicated in dyspareunia.

All painful and/or pruritic [13]

There are 3 forms

• Lichen Planus
• Lichen Sclerosis
• Lichen Simplex Chronicus

All painful and/or pruritic [13]

Physical findings: squamous hyperplasia, intertrigo [16,15]

Refer to each etiology

Lichen Planus,

Vulvar Lichen Planus (LP)

An autoimmune problem which affects the vagina, the vulva, and may include the oral mucosa.

It is sometimes comorbid with other autoimmune issues.

Three subtypes:

• erosive LP
• hypertrophic LP
• papulosquamous LP

The most frequent variant erosive LP, appears as raw, lacy white erosions in the medial vulva and often the vagina [13,18]. It may lead to vaginal adhesions or even complete obstruction of the vaginal introitus [13,18].

LP most commonly affects women in their 50-70 [18].

Symptoms of erosive LP are dysuria, dyspareunia, and pain, which may impact the patient’s ability to perform personal hygiene or limit sitting and ambulation [13,17].

Hypertrophic and papulosquamous LP more frequently causes pruritus [13,18].

Physical findings: All ages found at entry visible lesions, visible mucosal abnormality [1].

First line: Topical steroid creams

rectal steroid suppositories inserted vaginally

Oral steroids may be indicated.

Refractory cases may require immunosuppressants including azathioprine, methotrexate, or mycophenolate mofetil [13,18].

Photodynamic therapy [13,18]

Surgery to remove adhesions [13].

Biopsy to exclude squamous cell carcinoma, which occurs in 1-3% of LP lesions [13,18].

Lichen Sclerosis (LS)

Familial or associated with other autoimmune disorders including thyroiditis [13,19]

It is underdiagnosed [19].

Occurs mainly in the vulva and perineum, without affecting the vagina [13,19].

Affects other body areas in 6-20% of patients [13,19].

LS most frequently affects either pre-pubertal girls or post-menopausal women.

Squamous cell carcinoma and changes to the vulvar architecture may occur. Differentiate from LS [17].

Approximately 40% of adults with LS are asymptomatic leading to under-diagnosis [13].

.

Asymptomatic cases, compounded by a failure to carefully assess the perineum and vulva, may cause a delay in diagnosis [13,20].

Symptomatic patients experience pain, dyspareunia, burning, and vaginal and anal pruritus with frequent or dull, painful vulvar discomfort with remissions and relapses [19,20,16].

Physical findings: red patches, plaques [16] The skin texture is fragile, like thin paper [19,20].

The condition causes ivory or white, pale, shiny plaques and papules, which may be accompanied by fissures, hyperkeratosis, purpura, ulcerations, or erosisons [13,20].

First line: Ultrapotent steroid ointment, the first-line treatment for vulvar LS, is effective in greater than 95% of cases,

Topical testosterone is no more useful than Vaseline.

Once controlled, patients should continue a low or moderate potency steroid for maintenance therapy [13].

Biopsy is recommended to definitively diagnose LS in adults [13,20].

Adolescents should be biopsied only if they are unresponsive to treatment. LS may lead to an elevated risk of genital cancer [19,20].

Biopsy nevi may to rule out melanoma. Despite the rarity of melanoma as a comorbidity with LS.

Lichen simplex chronicus (LSC) is a form of chronic atopic dermatitis affecting the vulva.

Frequent abrasion or chemical irritants [13].

LSC is the most common dermatosis of the vulva in older women [21].

Skin thickened by constant excoriation, increasing the risk of secondary infection [13].

Pruritus is severe and causes sleep disturbances [13].

Physical findings: Lichenoid plaques do not involve the vagina but appear on the perineum and the labia minora and majora [13,16,17,15].

Psychosocial support and patient education are critical to successful treatment [13].

Medical treatments include

Topical"

• high potency topical steroids,
• lidocaine
• antihistamine ointments,

Oral medications

• calcineurin inhibitors,
• oral first-generation antihistamines to reduce nighttime scratching [13].

Differential diagnoses may include LP, contact dermatitis, or candidiasis.

Due to the chronic nature of the condition, treatment must be ongoing.

Vaginal Atrophy

Estrogen depletion causing vaginal atrophy affects 40-50% of post-menopausal women.

Another is the use of oral contraceptive pills by premenopausal women [1,10].

Change in vaginal flora, a decline in the proportion of Lactobacillus and an increase in the proportion of Streptococcus and Prevotella species [22,23] may be noted.

Complaints of

• pain,
• itching (puritis)
• pain urinating (dysuria)
• vaginal dryness [8,22].

Physical findings include

• thinning and fragility of the vaginal mucosa and loss of vaginal rugae [10,22].

Topical estrogen creams

Ospemifine 60 mg/d PO daily [23]

• SERM (selective estrogen receptor modulator) estrogen agonist/antagonist.

• lowers the vaginal pH [24].
• increases sexual comfort approximately 10% over [25]

• Safety studies of ospemifine conducted over the course of a year showed no clinically significant changes in serum chemistries and no pathological changes in the breasts or endometrium as demonstrated by breast exam and endometrial biopsy [13,23].

• Endometrial thickness, measured with vaginal ultrasound, did increase. adverse effect reported [25,24].

• The medication was well tolerated, with hot flashes being the most common adverse effect reported [24].

While in the same class of medications as tamoxifen, ospemifene is useful in treating dyspareunia as it acts mainly as an estrogen agonist in the vaginal epithelium, increasing superficial cells and decreasing parabasal cells [25,24].

Investigational

• REJOICE study of TX-004HR, a vaginal 17β-estradiol softgel found that doses between 4 and 25 mcg vaginally were effective in reducing dyspareunia within 2 weeks [26].

• Oral probiotics or a probiotic pessary [22].

Further study is necessitated to determine if reversing alteration in the vaginal fauna will provide relief from vaginal atrophy

Vaginal Dryness

May stem from

• psychological causes such as
  • disinterest in   sexual intercourse,
  • personal

discomfort with

sexual pleasure,

• • history of sexual

abuse [1,27].

• physiological causes
  • hypothalamic-

pituitary

dysfunction,

• • estrogen

deficiency,

• • menopause,
  • atherosclerosis,
  • diabetic

neuropathy

• Sequelae of cancer treatment may cause vaginal dryness, as may medications including oral contraceptives [1,2].
• Peri- and post-menopausal hormonal change is the most common cause.

As with most forms of dyspareunia, vaginal dryness may interfere with the women’s intimate relationships, thereby reducing her quality of life [27].

Physical findings: dry, thin, less elastic, possibly inflamed, fragile vaginal tissues, decreased lubrication and secretion [16,17].

First line: Vaginal lubricants once underlying disorders have been ruled out [1].

Vaginal moisturizers, applied every 1-3 days rehydrate dry mucosa.

In addition to the use of lubricants and moisturizers, oral ospemifene has been shown to decrease dyspareunia in women suffering from vaginal dryness [25].

More about lubricants:

• Lubricants provide short-term relief, but act quickly.
• Additives may irritate some patients.
• Most women fare better if the lubricant or moisturizer chosen has similar pH and osmolality to normal vaginal secretions [27].

Vaginismus

Vaginismus is the painful, involuntary pelvic floor contractions causing difficulty penetrating the vagina [1].

Only applies if woman desires intercourse [3].

Affects 1-7% of women [28].

Psychological:

• anxiety
• stress
• previous sexual experience [28,30].

Physiological:

• adhesions from prior surgery
• vaginal trauma including postpartum sequelae [30].

Assessment: This is where the applicator and gentle exam is essential.

Physical findings: involuntary, painful contractions of pelvic floor during pelvic exam [1]

Muscle relaxants, lubricants containing lidocaine, anxiolytics and antidepressants may be effective [28]

Cognitive behavioral therapy 40% effective alone [29].

A 5-week regimen using a combination of CBT, vaginal dilators, Kegel exercises, and intravaginal Botox injections, supplemented by office, telephone, and email follow up is 70% effective [31].

In cases involving adhesions, lysis may be required before dilators can be used [8,10].

Vulvodynia

Vulvodynia is an idiopathic chronic vulvar pain lasting more than 3 months. It is a diagnosis of exclusion [32,33].

Vulvodynia is classified as unprovoked, provoked by touch, or mixed.

It is categorized as

• generalized vulvodynia,

• vestibulodynia,
• clitorodynia.

Affects 7-8% of women [28].

There is some debate as to whether vulvodynia is somatoform or neuropathic in nature. Vulvodynia and vestibulodynia may be viewed as neuropathic inflammatory issues.

Biopsies show increased numbers of nerve endings near the Bartholin’s gland [3].

Neuropathic changes may be sequela of

• long term vaginal dryness
• repeated infections [10].

• Cutting, stabbing or burning pain,
• Irritation,
• Pruritus,
• Rawness, or a stinging sensation [10].
• Older women complain of unprovoked, constant pain, while younger women complain of dyspareunia with intercourse [32].

Physical findings: pain may be provoked during the pelvic exam. Evidence of vaginal dryness of chronic nature [10].

Validate the woman's pain and reinforce that this is a real medical condition.

Discontinue:

• ineffective medications and use of harsh soaps;
• Replace with daily application of a moisturizing barrier cream [32].

Develop, with the client, a treatment plan, to manage flare-ups [6].

Medications:

• Lidocaine gel may reduce the pain of intercourse.
• Topical estrogens during perimenopause and menopause may provide some relief [32].
• Botox,
• Pudendal nerve blocks,
• Anticonvulsants,
• Tricyclic antidepressants [33].

Physiological:

• Physiotherapy of the pelvic floor muscles, including
  • trigger point
  • myofascial release therapy
  • soft tissue mobilization,
  • muscle exercise [28]
• Biofeedback
• Transcutaneous Electrical Nerve Stimulation (TENS) [33].

Psychological:

A team approach including sexual and cognitive behavioral therapy is recommended to ameliorate physical and psychosocial effects.

Sexual education, couples counseling, yoga, meditation, and cognitive behavioral therapy are helpful in managing pain-related psychosocial distress [6,20,21].

CBT appears to give lasting results - improvement continuing after formal therapy has been completed [29].

Vestibulectomy is a treatment of last resort for women with unmanageable pain gravely compromising quality of life [33].

The effects on quality of life: Pain may impediment to wearing underwear or clothing, forcing some women to become homebound [32].

Women may be distressed by the inability to identify a specific cause of the pain [3].