Management of sexual pain in females

Explain to anyone experiencing painful sex that continuing to have painful intercourse can exacerbate and prolong the problem. Advise them to stop intercourse or any activities that exacerbate pain, but continue other ways of being intimate or sexual if comfortable to do so, until the pain is adequately treated or resolved. Patient education is available from the Australian and New Zealand Vulvovaginal Society, the Pelvic Pain Foundation and the Jean Hailes website.

Note: Advise people that continuing to have painful sex can exacerbate and prolong the problem.

If postmenopausal vulvovaginal atrophy is the cause of sexual pain, treatment with intravaginal estrogen formulations and nonhormonal therapies may be beneficial. Systemic menopausal hormone therapy is often not sufficient.

Note: Intravaginal estrogen is often required to manage urogenital symptoms in menopause, as systemic estrogen therapy may be inadequate.

Vaginal laser therapy is not recommended currently for postmenopausal vulvovaginal atrophy or sexual pain, as evidence for benefit is insufficient.

Vulvodynia is best managed by a multidisciplinary team. Treatment includes:

  • avoidance of potential skin irritants and improved skin moisture
  • treatment of any concurrent vaginal candidiasis
  • topical lidocaine (2% gel or 5% ointment applied to the vestibule daily) to reduce peripheral-central sensitisation in vulvodynia; it is not recommended for use before sex as people are advised not to continue with painful sex
  • topical amitriptyline (2 to 5% in a neutral base and applied to the vestibule twice daily)
  • low-dose tricyclic antidepressants for chronic pain
  • gabapentin and pregabalin
  • referral to a vulval specialist (who may be a general practitioner, dermatologist, gynaecologist or sexual health physician with a specialist interest). See the Australian and New Zealand Vulvovaginal Society.

Management of vaginismus is also best achieved by a multidisciplinary approach including:

  • education about the condition
  • exploring, understanding and managing any psychosexual causes such as fear of vaginal penetration, anticipation of pain, understanding cultural or religious taboos around sex
  • referral to pelvic floor physiotherapists with specialist experience in treating sexual pain through a range of techniques, including pelvic floor relaxation, posture, breathing techniques, and bladder and bowel retraining. See the Jean Hailes website for information on pelvic floor dysfunction and pelvic muscle training
  • referral to an experienced practitioner for training in the use of dilators and vibrators
  • psychological and behavioural interventions; counselling, including cognitive behavioural and supportive therapies, is effective; relaxation techniques, mindfulness and meditation are also recommended.

Referral is also indicated for other conditions causing painful sex. Consider: