Dyspareunia - Differential Diagnosis

Differential Diagnosis

Many sufferers will see several doctors before a correct diagnosis is made. Many gynecologists are not familiar with this family of conditions, but awareness has spread with time. Sufferers are also often hesitant to seek treatment for chronic vulvar pain, especially since many women begin experiencing symptoms around the same time they become sexually active. Moreover, the absence of any visible symptoms means that before being successfully diagnosed many patients are told that the pain is "in their head".

Complaints of sexual pain that is – dyspareunia or vulvodynia – typically fall into one of three categories: vulvar pain (pain at the opening or at the external genitalia), vaginal pain, or deep pain, or some combination of all three. There is some evidence for the existence of several subtypes of dyspareunia (Binik et al., 2000): vulvar vestibulitis syndrome (VVS) – the most common type of premenopausal dyspareunia – vulvar or vaginal atrophy (which typically occurs postmenopausally), and deep dyspareunia or pelvic pain (associated with such gynecological conditions as endometriosis, ovarian cysts and pelvic adhesions, inflammatory disease, or congestion).

Vulvar vestibulitis is the most common subtype of vulvodynia affecting premenopausal women which causes dyspareunia, and it tends to be associated with a highly localized "burning" or "cutting" type of pain.

Vaginal atrophy as a source of dyspareunia is most frequently seen in postmenopausal women and is generally associated with estrogen deficiency. Estrogen deficiency is associated with lubrication inadequacy, which can lead to painful friction during intercourse.

In women with VVS and vulvar/vaginal atrophy, the pain is associated with penetration or with discomfort in the anterior portion of the vagina. There are some women, however, who report deeper vaginal or pelvic pain. Little is known about these deeper types of pain syndromes, except that they are thought to be associated with gynecological conditions such as endometriosis, ovarian cysts, pelvic adhesions, or inflammatory disease.

Dyspareunia is a complex problem and frequently has a multifactorial aetiology. A new way has been recently suggested to define dyspareunia by dissecting it into primary, secondary, and tertiary sources of pain.