Treatment of Female Dyspareunia

Initial Non-Hormonal Approach

The American College of Obstetricians and Gynecologists recommends applying vaginal moisturizers 3-5 times per week to the vagina, vaginal opening, and external vulva for symptom relief in patients with dyspareunia 1
Water-based or silicone-based lubricants can provide immediate relief during sexual activity for patients with dyspareunia 2, 1
Hyaluronic acid gel with vitamins E and A may help prevent vaginal mucosal inflammation, dryness, and bleeding in patients with dyspareunia 1
Topical vitamin D or E may provide symptom relief for patients with dyspareunia, although evidence is limited 3, 1

Pelvic floor physical therapy can improve sexual pain, arousal, lubrication, orgasm, and satisfaction in patients with dyspareunia 4, 3, 1
Vaginal dilators can help with vaginismus, vaginal stenosis, and allow identification of painful areas in a non-sexual setting for patients with dyspareunia 3, 1
Cognitive behavioral therapy has been shown to be effective at improving sexual function in patients with dyspareunia 3
Topical lidocaine applied to the vulvar vestibule before penetration can help with persistent introital pain in patients with dyspareunia 4, 1

Low-dose vaginal estrogen therapy is the most effective treatment for vaginal dryness, itching, discomfort, and painful intercourse in patients with dyspareunia 4, 3, 1
Vaginal DHEA (prasterone) can improve sexual desire, arousal, pain, and overall sexual function without clinically important systemic estrogenic activity in patients with dyspareunia 4, 3, 1
Ospemifene (oral SERM) can effectively treat vaginal dryness and dyspareunia in large trials 4, 3, 1
Intravaginal testosterone cream can improve vaginal atrophy and sexual function in postmenopausal women with dyspareunia 4, 1

For premenopausal women with low desire, flibanserin can result in approximately 1 additional satisfying sexual event every 2 months 4, 1
For breast cancer patients, non-hormonal options (moisturizers, lubricants, pelvic floor therapy) are recommended as first-line treatment for dyspareunia 2, 1
Low-dose vaginal estrogen can be considered as second-line treatment for breast cancer patients with dyspareunia after thorough discussion of risks and benefits 2, 1

Absolute contraindications to hormonal treatment include history of hormone-dependent cancers, undiagnosed abnormal vaginal bleeding, active or recent pregnancy, and active liver disease 1