Female dyspareunia in all its states

Female dyspareunia in all its states

France – Dyspareunia, a pivotal symptom between gynecology and sexology, is the perception of pain during vaginal penetration and/or due to coital movements. Moreover, it would be more accurate to speak of dyspareunia in the plural, as it brings together a variety of pathologies that are both organic and psychological. These two aspects of dyspareunia were explored in Francophone Days of Sexology and Sexual Health (JE3S; 8-10/09/22, Montpellier) [1]. The lighting of Drs. Carine Martin and Patrick Leuilletmedical gynecologists and sexologists.

Dyspareunia, entities at the limit of the psyche and the soma

Dyspareunia is a disorder related to genito-pelvic pain or penetration that has existed for 6 months, according to the Diagnostic and Statistical Manual of Mental and Psychiatric Disorders (DSM5).

“Vaginaism, vulvodynia and dyspareunia are thus mentioned in the same entity, hence a probable source of confusion”, points out the Dr Carine MARTINmedical gynecologist and sexologist, teaching manager DIU of Sexology – Study of Human Sexuality (Faculty of Lille).

The prefix “dys” for “difficulty” refers to “algo” pain and “pareunia” to coupling. Dyspareunias are split into two main entities describing either intromission or superficial pain, or deep pain. Moreover, they can be primary or secondary. They are frequent, and concern 10 to 40% of women according to studies. [2].

“A more realistic frequency is probably around 20%, that is to say one in five women,” she says. The periods at risk of intromission dyspareunia are the beginning of sexuality, postpartum and menopause, with sometimes premature ovarian failure [3].

A more realistic frequency is probably around 20%, ie one in five women.

Because of their multiple consequences, these pains require specialized care. Indeed, dyspareunia can “contaminate” the other phases of the sexual response, also generate anticipatory anxiety, desire and arousal disorders, difficulties in letting go at the risk of anorgasmia, vaginal dryness, disorders of sexual receptivity, an unconscious work of integration of pain during sexual intercourse… “and, as a result, even more dyspareunia! completes Dr. Martin. A vicious circle sets in. We must remind patients in the preamble that it is normal not to desire a moment which we know will be painful”.

In addition to these consequences, dyspareunia is often responsible for the estrangement of the protagonists. The woman avoids painful intercourse. With less seduction and femininity, she seeks not to please, deploys avoidance behaviors.

Dyspareunia, a frequent reason for consultation

“It is up to us, caregivers, to move away from the complaint to enter into the patient’s story in order to understand the symptom, through an exchange rather than an interrogation, continues the expert. This will have to scan the medical history (medical and surgical history, past or current treatments, type of contraception, ongoing follow-ups, painful events knowing how to “measure” the intrusive side). »

The emotional life must be approached, on the situation of the woman (as a couple or not, and if so for how long), the agreement and the communication between the partners.

The symptoms must be specified, relating to the reality of dyspareunia (vaginismus, vulvodynia, etc.) and the type (intromission, pain outside vaginal penetration, etc.). Finally, associated symptoms must be sought, at the level of the vulva, the vagina, possible losses, urinary disorders (cystitis, etc.), digestive disorders (a tendency to constipation, etc.), dysmenorrhea, etc.

Then comes the moment to approach sexuality, starting by specifying whether dyspareunia is a primary or secondary disorder, its seniority, its location “at the entrance or at the bottom”, its possible manifestation with other partners, the screenings STIs, etc. the doctor must have the patient specify the course of the cycle of sexual response (desire, pleasure, orgasm, pain, etc.), the exact moment of onset of the pain, in relation (or not) to a certain duration of penetration, the frequency of intercourse, etc.

A major question to ask is the woman’s adaptation to the situation: “I clench my teeth…”, “I stop all physical contact”, “external stimulation and caresses without penetration with great pleasure”…

How to explore female genital pain?

The clinical examination, proposed and not imposed, is carried out with kindness, respect, and all possible precautions. The caregiver applies these three principles: communicate, explain, reassure. The woman must be able to undress out of sight and wear a linen [4].

Then, the cartography of the painful zones will make it possible to identify a dyspareunia of intromission or deep. To this end, observation of the vulva is essential, such as vaginal examination with one finger (if an authorized profession), then, if possible, the fitting of a speculum, as small as possible. The healthcare professional must assess the possibility of a pelvic ultrasound, assess the vaginal flora and offer screening (chlamydia, gonococcus, ECBL).

In summary, the clinical examination of dyspareunia includes the vulva, the vestibule, the vaginal flora, the perivaginal muscles and their tone, the bony pelvis, the hinges, the pelvic pain and, more broadly, the examination of genital pain, the vesico-urinary sphere, the anorectal and digestive sphere, the veins, the nerves, and finally the general state (BMI, general dermatological aspect: psoriasis, eczema, oral lesions…).

Paraclinical examinations (ultrasound and pelvic MRI) are essential in deep dyspareunia and sometimes useful in intromission dyspareunia.

“Deep dyspareunia generates intromission dyspareunia, but not the other way around,” recalls Dr. Martin. Indeed, by dint of undergoing painful penetrations, muscular hypertonia sets in, hence the appearance of intromission dyspareunia secondary to deep dyspareunia. In addition, deep dyspareunia can progress to vulvodynia. »

Deep dyspareunia generates intromission dyspareunia but not the reverse.

Intromission dyspareunia: which examinations?

Deep dyspareunia: which examinations?

ON: Estroprogestin

“Coital sexuality should be strongly discouraged in the event of pain on penetration, while waiting to find a solution, warns Dr. Martin. The health professional must invite the patient to develop sensoriality, sensuality, to restore the other moments of sexuality, to consider the skin as the first organ of communication, and can propose Sensate Focus [5], a method of therapeutic relaxation to create shared pleasure. »

Coital sex should be strongly discouraged in the event of pain on penetration, pending a solution.

The psychogenic component of dyspareunia

“The diagnosis of organicity remains the pivot of the cure, it initially refers the consultation to the field of the usual gynecological clinic, leaving aside the complaint of an erotic nature – without however underestimating it. You should know, however, that when a woman consults for dyspareunia, this symptom can take on a completely different meaning (conscious or unconscious), suggests the Dr Patrick Leuilletgynecologist, sexologist, sex therapist and director of education for the IUD in Sexology and the Study of Human Sexuality in Amiens. Especially if dyspareunia has persisted for several months or even years. »

When a woman consults for dyspareunia, she very often hides her complaint behind other terms and other complaints and the pain seems to be, for some, the only “presentable” symptom.

Any lesional genital pathology or sine materia is necessarily taken, as soon as it lasts, in a complex system of individual and conjugal resonance, which sometimes takes precedence over the starting point which is then no more than an irritative thorn ( or even the memory of the thorn), according to her singular history, her beliefs, her ideas on femininity, the couple, fertility, the place of sexuality.

It is worth remembering that the human being lives first in an imaginary body before being physical, invested with meanings and values ​​with which he integrates the world in him and integrates himself into the world. . This is why each organ and each disease challenges both the collective imagination and the individual imagination, and refers to a singular symbolism and to fantasies linked to the body. In fact, the sick part of the body puts everyone’s imagination to work and tells something about itself.

Consequently, “any sexual symptom is a ‘password’, a ‘visiting card’ in sexology to enter into a relationship with the therapist, says Dr. Patrick Leuillet: pain ‘proposed’, ‘exposed’ to the therapist. Female sexuality and its fulfillment in pleasure is a long path requiring psychocorporal learning in a more general context of authorization of the woman herself to pleasure, a context in which appears the need for intelligence to take power over the body. instinct, and probably the need to transgress the “law” of pain, lot of women and heritage of the cultural past. Menstruation, defloration, childbirth; everything that Freud called the biological rock of announced pain. »

Psychogenic dyspareunia… The quest for meaning

The psychogenic reading draws on the living continuum of the construction of female sexuality, seen as evolving from birth to death and responsive to life events and experience. In psychogenic dyspareunia, “we can distinguish psychosexual problems, marital and/or relational conflicts, depressive syndromes and neurotic states, summarizes Patrick Leuillet. Most often, psychosomatic dyspareunia is neurotic by reactivation of trauma memories in childhood or during first sexual intercourse. »

Most often, psychosomatic dyspareunia is neurotic by reactivation of trauma memories in childhood or during first sexual intercourse.

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