Genitopelvic Pain/Penetration Disorder

General measures include wearing cotton underwear during the day, washing with a mild soap (only using soap on the hairy areas of the genitals), and avoiding douching and over-the-counter vaginal deodorants. Using an unscented, unflavored lubricant during sex can reduce vaginal dryness, which causes pain during intercourse.

Vaginal lubricants and moisturizers include food-based oils (such as coconut oil), silicone-based lubricants, and water-based products. Water-based lubricants dry out quickly and may have to be reapplied, but they are preferred over petroleum jelly or other oil-based lubricants. Oil-based lubricants tend to dry the vagina and can damage latex contraceptive devices such as condoms and diaphragms. They should not be used with condoms. Silicone-based lubricants can be used with condoms and diaphragms, as can water-based lubricants. Women can ask their doctor which type of lubricant would be best for them.

When treating genitopelvic pain/penetration disorder, doctors or other team members often do the following:

Sexual activities that do not involve penetration can help couples attain mutual pleasure (including having orgasms and ejaculation). An example is stimulation involving the mouth, hands, or a vibrator.

Spending more time in foreplay may increase vaginal lubrication and thus make intercourse less painful.

For deep pain, using a different position for intercourse may help. For example, being on top can give women more control of penetration, or another position may limit how deeply the penis can be thrust.

Psychologic therapies, such as cognitive-behavioral therapy and mindfulness-based cognitive therapy (MBCT), may benefit some women. Mindfulness involves focusing on what is happening in the moment, without making judgments about or monitoring what is happening. Such therapies help women manage their fear and anxiety about pain during sexual intercourse.

Doctors may refer women to a qualified sex therapist for psychologic therapies.

Pelvic floor physical therapy can often benefit women with genitopelvic pain/penetration disorder. It includes pelvic floor muscle training, sometimes with biofeedback, to teach women how to consciously relax their pelvic muscles. These exercises teach women to tighten these muscles and then relax them.

Physical therapists may use other techniques to stretch and relax tight pelvic muscles. Techniques include

Levator ani syndrome (vaginismus) can be treated with progressive desensitization (done by hand or with dilators). This technique enables women to gradually get used to the genital area being touched. The next step is taken only when the woman is comfortable with the previous step.

For superficial pain, pelvic floor physical therapy is key because involuntary contraction of the muscles around the vagina's opening is often part of the problem. Applying an anesthetic ointment and taking sitz baths may help, as may liberally applying a lubricant before intercourse.

More specific treatment depends on the cause, as in the following:

Estrogen can be inserted into the vagina as a cream (with a plastic applicator), as a tablet, or in a ring (similar to a diaphragm). These topical forms of estrogen can relieve symptoms that affect the vagina and urinary tract. If women are also having hot flashes, doctors may instead prescribe estrogen taken by mouth or estrogen patches applied to the skin. If women have a uterus (that is, they have not had a hysterectomy), they are given estrogen plus progestogen (a version of the hormone progesterone) because taking estrogen alone increases risk of cancer of the lining of the uterus Cancer of the Uterus The most common type of cancer of the uterus develops in the lining of the uterus (endometrium) and is called endometrial cancer. Endometrial cancer usually affects women after menopause. It... read more (endometrial cancer). Low doses of estrogen are used. Estrogen patches are usually preferred over tablets for postmenopausal women.

In postmenopausal women, a synthetic form of dehydroepiandrosterone (DHEA) called prasterone, inserted into the vagina, can also relieve vaginal dryness and make sex less painful.

Ospemifene (a selective estrogen receptor modulator, or SERM) and estrogen affect vaginal tissues in a similar way. Like estrogen, ospemifene can be used to relieve vaginal dryness and other symptoms that involve the vagina and/or urinary tract.

Drugs used to treat neuropathic pain Adjuvant Analgesics Pain relievers (analgesics) are the main drugs used to treat pain. Doctors choose a pain reliever based on the type and duration of pain and on the drug's likely benefits and risks. Most pain... read more (pain due to damage of the nervous system) can help lessen the pain in provoked vestibulodynia. They include the antiseizure drugs gabapentin and pregabalin and the antidepressants amitriptyline and nortriptyline.

Various creams that contains gabapentin and amitriptyline can be applied directly to the vagina's opening. These treatments may help relieve the pain and have fewer side effects.

Botulinum toxin type A, injected into the pelvic floor muscles, is usually used only to treat provoked vestibulodynia when no other treatments have been effective. It is used only for a short period of time.

Vestibulectomy (removal of the area around the vagina's opening) is rarely done. It is usually done in women who have never had pain-free sexual intercourse.