BMJ  2004;328:1357 (5 June), doi:10.1136/bmj.328.7452.1357

Primary care

10-minute consultation

Female dyspareunia

¹ Alec Turnbull Clinic, East Oxford Health Centre, Oxford OX4 1XD, ² Warneford Hospital, Oxford OX3 7JX

Introduction

A 30 year old woman tells you she has experienced pain during sexual intercourse since the birth of her first baby a year ago. She has now lost interest in sex. Her husband is becoming impatient, and she asks you for help.

What issues you should cover

Ask about the nature of the pain—When and where does she feel the pain? Is it near the vaginal entrance on initial penetration or is it felt more deeply on thrusting? Does she have any other abdominal pains? Does she feel that she is "too tight" to allow penetration? The dyspareunia may be accompanied by vaginismus. Does she experience pain every time she attempts intercourse? If not, what is different about the times when she doesn't have pain? Is she more relaxed, and if so why?

Other symptoms—Does she have a vaginal discharge? This may indicate infection or other pathology. Is she depressed?

Sex before she had the baby—Was intercourse previously free of pain, and did she enjoy sex? How did the pregnancy affect sex?

The delivery—Was there trauma? Did she have a tear or episiotomy? If so, does she feel confident that it healed well? Did she examine herself after the birth to ascertain when penetration might be painless? Are there other issues about the birth?

Foreplay and non-penetrative sexual behaviour—Is she becoming aroused and lubricating? Lubrication and expansion of the upper vagina occur only with arousal. Does she reach orgasm?

Her relationship—Has her relationship with her partner changed since the birth? If so, how? Do they find time to enjoy themselves as a couple? Are they affectionate? Do they find it difficult to switch roles from parents to lovers? Is she concerned about her pain and her loss of interest in sex, or is it just her husband who views it as a problem?

Feelings about becoming a parent—Ask her what becoming parents has meant to them both. Was the pregnancy planned? Does the baby sleep in their bedroom? If so, how do they feel about this? Is she using contraception, and does she trust it? Is she still breast feeding?

What you should do

• Do an abdominal and vaginal examination to exclude a physical cause.
  
• If psychological issues connected with the birth are important, she may wish to discuss these with a counsellor. The British Association for Counselling and Psychotherapy will provide a list of local counsellors.
  
• If you think relationship difficulties are an important factor, talking through them with her may encourage her to talk to her husband and try to resolve them. You could recommend that they see a couples counsellor in the practice or at Relate.
  
• A penetration desensitisation programme, in which she is encouraged to insert one finger, then two, then three into her vagina, while relaxing the lower vaginal muscles, can be very effective for dyspareunia and vaginismus. Clear instructions and regular follow up are vital for success.
  
• If psychosexual problems persist refer her to a psychosexual therapist at your local family planning clinic, Relate, or a sexual problems clinic. Her partner should usually be involved at this stage, if you have not already seen them together. The British Association for Sexual and Relationship Therapy can recommend private therapists.
  

Useful reading Binik YM, Bergeron S, Khalifé S. Dyspareunia. In Leiblum SR, Rosen RC, eds. Principles and Practice of Sex Therapy. 3rd ed. New York: Guilford Press, 2000: 154-80 Dean J. ABC of sexual health: examination of patients with sexual problems. BMJ 1998;317: 1641-3[Free Full Text] Graziottin A. Clinical approach to dyspareunia. J Sex Marital Ther 2001;27: 489-501[Medline] Hawton K. Sex therapy: a practical guide. Oxford: Oxford University Press, 1985 Ramage M. ABC of sexual problems: management of sexual problems. BMJ 1998;317: 1509-12[Free Full Text]

Resources for patients Self help books Litvinoff, S. The Relate guide to sex in loving relationships. London: Vermilion, 1992 Litvinoff, S. The Relate guide to better relationships. London: Vermilion, 1992 Sources of help British Association for Sexual and Relationship Therapy, PO Box 13686, London SW20 9ZH (tel 020 8543 2707; www.basrt.org.uk) Relate (national office), Herbert Gray College, Little Church Street Rugby CV21 3AP (tel 01788 573241; www.relate.org.uk) British Association for Counselling and Psychotherapy, 1 Regents Place, Rugby CV21 2PG (tel 01788 550899; www.counselling.co.uk)

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This is part of a series of occasional articles on common problems in primary care

This series is edited by general practitioners Ann McPherson and Deborah Waller (ann.mcpherson{at}dphpc.ox.ac.uk)

The BMJ welcomes contributions from general practitioners to the series

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