Taking the Pain out of Talking to Your Patients with Dyspareunia

Narrator: This is ReachMD. The following activity, titled “Taking the Pain out of Talking to Your Patients with Dyspareunia” is provided by Omnia Education and supported by an independent educational grant from AMAG Pharmaceuticals.

This short video case study is presented by Dr. David J. Portman, Director Emeritus at the Columbus Center for Women’s Health Research and Adjunct Instructor of Obstetrics and Gynecology at the Ohio State University in Columbus, Ohio.

The following is an example of a doctor-patient interaction regarding available treatment options for managing dyspareunia.

Dr. Portman: Vulvar vaginal atrophy, or VVA, affects about half of the 64 million postmenopausal women in the U.S. VVA stems from the loss of estrogen stimulation on vaginal and vulvar tissue, which can lead to symptoms of dyspareunia - or painful sexual intercourse. This, in turn, can negatively impact sexual function and sexual relationships, reducing overall quality of life.

On this program, I’ll be sharing a sample conversation with a postmenopausal patient centering on dyspareunia diagnosis and management, and I’ll give examples of how to discuss this issue in terms your patients will understand.

Karen: Hi, Doctor.

Dr. Portman: Hi Karen, what brings you in to the office today?

Karen: Well it’s a little embarrassing.

Dr. Portman: Now you’ve been my patient for a long time and you can tell me anything. There’s nothing you need to feel embarrassed about here.

Karen: Well, I’ve noticed lately that when Tim and I have sex, it doesn’t feel the same. There’s pain now. It’s like I’m tearing and burning after. I’ve tried some over-the-counter lubricants and moisturizers, but that really hasn’t helped, so I made this appointment. I just don’t feel like we can have sex anymore because of the pain, but I also don’t want to make my husband feel like it’s his fault. It’s really affecting our intimacy and how I feel about myself as a woman

Dr. Portman: How long has this been going on?

Karen: I started to notice little changes over the last year or two, but now its really become noticeable and it bothers me a lot.

Dr. Portman:  Karen, let me start by assuring you that what you’re describing are some very common symptoms we address here for women after menopause. And I know  from your medical history that you haven’t had a period in about 4 years. Any bleeding at all since then, any vaginal discharge?

Karen: No, none.

Dr. Portman: Any other symptoms, like hot flashes or night sweats?

Karen: Those stopped several years ago. I know you mentioned when they were really bad that I could try hormone treatment, but I was a little concerned about that with my mother’s history of breast cancer.  And then they eventually did go away on their own.

Dr. Portman:  Any other vaginal symptoms, or symptoms around the opening, or bladder

Karen: It does feel dry on the outside, like my exercise clothes, they irritate me more lately. I thought the vaginal moisturizer I tried would help, but it didn’t.

Dr. Portman:  We’ll do an exam next, but this sounds very consistent with genitourinary syndrome of menopause, and namely painful sex associated with vulvo-vaginal atrophy, or VVA for short.

Karen: I thought I was past menopause since my hot flashes went away years ago.

Dr. Portman: Well the decline in the amount of hormones your body makes can not only cause hot flashes, which often do go away on their own with time, but menopause can lead to dryness and pain due to a lack of lubrication, and that can get worse over time. The vagina and the surrounding tissues can become dry, stretch less easily, and can be very painful with intercourse, which you described as a tearing sensation.

Karen: Is there anything else it could be?

Dr. Portman: We’ll make sure it isn’t an infection or another skin condition of the vulva or vagina, but painful sex associated with menopause is very common and many women experience this.

Karen: Is there any treatment?

Dr. Portman: Well you’ve tried over-the-counter lubricants and vaginal moisturizers, which help some women, but you didn’t improve with that.  Since your own estrogen and other hormone levels have been declining, the approach to address this is to give you back what’s missing. There’s several vaginal estrogen products approved—cream, vaginal tablets and a ring— to treat and relieve your symptoms.

Karen: I’m still concerned about estrogen. All the warnings I read last time for that hot flash treatment frankly scared me and my husband. I didn’t feel it was worth the risks.

Dr. Portman: I understand where you’re coming from. These vaginal estrogen treatments though are lower doses than for hot flashes and are only applied locally, but they do carry similar warnings.

Karen: Are there more options?

Dr. Portman: Well theres a pill that you take by mouth, called ospemifene, which you would take daily with food. It acts like an estrogen on some tissues, and blocks estrogen on others. It comes with some warnings similar to estrogen like blood clots and stroke and also uterine cancer, but those are rare, and the medication works a little differently than estrogen.

Karen: Is there anything that doesn’t carry these warnings?

Dr. Portman: There has been a new treatment recently approved by the FDA for painful sex in menopause. It’s an intravaginal DHEA insert called prasterone. It’s used nightly with an applicator. DHEA is an inactive steroid made by your adrenal gland, it falls significantly in menopause and it can be converted by your own body to estrogen and testosterone, which are important for maintaining normal genital health.  There is very little absorption of hormones into your bloodstream and no reported side effect warnings for cancer, blood clots, or cardiovascular disease, and the most common side effect reported is vaginal discharge. If we start you on this treatment, you should notice some relief in several weeks and then significant improvement of your pain in about 12 weeks. But first let’s do your exam and confirm if this is menopause-related painful intercourse, and then we can talk about what the different options are for you and what’s right for you.

Karen:  Alright thanks Dr. Portman.

Dr. Portman Closing:  As you can see from my conversation with Karen, it’s important to validate the patient’s symptoms and normalize them. Let her know that this is a very common condition women experience in menopause, that it can be ongoing and worsen over time. The good news is that there are multiple treatment options, but you need to individualize. Tell the patient about what those options are, find out which one’s right for her, which one fits in with her lifestyle and hopefully you can come to an informed decision with her and help her face this very common condition in menopause.

Narrator: This activity was provided by Omnia Education. For more information, visit ReachMD.com/Omnia.This has been ReachMD: Be part of the knowledge.