Menopause is defined as the permanent cessation of menses as documented for 12 consecutive months.1 The mean age of onset of menopause in the United States is 51, with 95% of women becoming menopausal between 44 and 55 years of age.1 This process occurs due to a significant decrease in the production of estrogen (hypoestrogenism) by the ovaries.1 Vaginal epithelium, cervix, endocervix, myometrium, and endometrium are estrogen-dependent tissues.1 Estrogen works in the vagina by maintaining the collagen content of the epithelium, optimal genital blood flow, acid mucopolysaccharides, and hyaluronic acid.2 Hypoestrogenism leads to atrophic changes in vaginal tissues. Cervical secretions decrease in amount, and the vaginal epithelium becomes thin. As a result, women experience vaginal dryness while attempting or during sexual intercourse, leading to dyspareunia.1  

Dyspareunia is defined as recurrent or persistent pain with sexual activity.3 It may cause discernable distress or interpersonal conflict for women. It can have a significant impact on a woman’s life by disrupting daily living, including but not limited to the ability to wear certain types of clothing.4 Additionally, it may serve as a barrier to physical intimacy between women and their partners.4 Some women may feel a lack of femininity due to their inability to have sexual intercourse,4 which may lead to depression and anxiety.5 If not diagnosed and treated appropriately, dyspareunia can increase the risk of women experiencing these negative outcomes.

Initiating the Conversation

Approximately 20% of menopausal women are affected by dyspareunia.4 However, only 15% of healthcare providers investigate whether female patients experience this condition.4 Healthcare providers should routinely ask about discomfort during intercourse, especially in menopausal patients, as a component of each well-woman visit.6 Studies have shown that approximately 50% of women do not initiate discussions about their symptoms of vaginal pain during intercourse with their medical practitioners.3 Clinicians should be aware that women may feel anxious about sharing this information during an office visit.4 Establishing a good rapport with female patients at risk for this condition is recommended before broaching this sensitive subject. Additionally, clinicians should personally be comfortable discussing the subject matter before initiating the conversation with their patients.

Assessment

Women who experience dyspareunia during menopause may report a history of vaginal dryness; decreased vaginal lubrication during sexual activity; decreased arousal, orgasm, or sexual desire; and/or itching or burning with dysuria.3,7 Physical examination findings may include loss of vaginal rugae along with thin, pale, and inelastic mucosa.3  

Dyspareunia in menopause can be diagnosed with a comprehensive medical history and pelvic examination. The medical history should include detailed sexual, gynecologic, and obstetric histories. Laboratory testing is not usually required or indicated.8 Diagnosis can be made based on the clinical manifestation described previously.

Management Options

Dyspareunia in menopause can be managed medically with prescription and nonprescription therapies. Topical estrogen, selective estrogen receptor modulators, vaginal dehydroepiandrosterone (DHEA), and vaginal lubricants and moisturizers are viable treatment options.3,8 Treatment selection should be based on a woman’s comprehensive medical history, preference, and ability to take medication as directed.