SAN DIEGO (EGMN) –The prevalence of dyspareunia in menopausal women ranges from 11% to 45%, according to the best estimates in the medical literature.
However, “the literature [on this topic] is terribly flawed,” Dr. Andrew T. Goldstein said at the annual meeting of the North American Menopause Society.
“Age alone is often used instead of menstrual status, there’s a failure to indicate surgical versus natural menopause, and there’s a failure to indicate if women are on hormone replacement therapy, and if so, what types. Also, the use of validated questionnaires is sorely lacking,” said Dr. Goldstein, an ob.gyn. practicing in Annapolis, Maryland, who specializes in the treatment of vulvovaginal disorders.
If anything, he continued, the prevalence of dyspareunia in menopausal women seems to be increasing because of a variety of factors, including the fact that fewer women are taking hormone therapy; 22%-45% of women not on hormone therapy have dyspareunia. In addition, “changing attitudes of postmenopausal women and their sexuality [are factors]. They expect to have sex later in life.”
Another contributing factor is the proliferation of phosphodiesterase type 5 inhibitors in recent years, which allow the partners of these women to remain sexually active, resume sexual activity, or increase sexual activity.
“Changes in the types of [hormone therapy] are also contributing, going from systemic [HT] to such things as vaginal estradiol tablets or rings which do not treat the vulva,” he said.
Dr. Goldstein cautioned clinicians not to assume that the cause of dyspareunia in menopausal women is always atrophic vaginitis. “There are many different causes of postmenopausal dyspareunia,” he said.
Many premenopausal women have dyspareunia that is never adequately treated, Dr. Goldstein added. A study by other researchers showed that 40% of women with vulvar pain never sought primary treatment (J. Am. Med. Womens Assoc. 2003;58:82-8). “In addition, at best, only 75% of women given adequate estradiol treatment are cured of their pain,” Dr. Goldstein said.
However, with a thorough history, physical, and differential diagnosis, “the specific disease process can be determined, and this will determine the correct diagnosis and treatment,” he noted.
Evaluations should include an assessment of when the dyspareunia started, the location of the pain, and the nature of the symptoms. “Different symptoms point us in different directions,” Dr. Goldstein said. “A throbbing, dull, or stabbing pain can often suggest a pelvic floor dysfunction, whereas dryness or tearing can suggest an estrogen deficiency or vulvar dermatoses. Symptoms such as hesitancy, urgency, frequency, or incomplete emptying, constipation, and rectal fissures can also suggest hypertonus pelvic floor muscles.”
He recommended that the physical exam include a careful inspection of the vulva, as at least 75% of dyspareunia cases are vulvar in origin. Special attention should be paid to the vulvar vestibule, “but we have to look at all of the structures,” he said.
The exam also should include vulvoscopy to look for areas of erythema, lichenification, fissures, erosions, ulcerations, scarring and architectural changes, evidence of atrophy, hypopigmentation and hyperpigmentation, and evidence of vulvar intraepithelial neoplasm, he said.
Another component of his exam is the “Q-tip test.” Begin by touching a moistened Q-tips swab lateral to Hart’s line, Dr. Goldstein said, and then just medial to Hart’s line. Touch the vestibule at 1 o’clock and 11 o’clock adjacent to the urethra at the ostia of the Skene’s glands. Then touch the vestibule at 4 o’clock and 8 o’clock at the ostia of the Bartholin’s gland.
“Frequently there will just be pain posteriorly and not anteriorly,” Dr. Goldstein said. “I believe that if you just have posterior pain and not anterior pain, that’s almost always a sign of hypertonus of the pelvic floor musculature, and that’s often the cause of the dyspareunia. If you have diffuse pain at the entire vestibule, that [points to] an intrinsic problem within the vestibular tissue.”
Evaluation of the pelvic floor muscles is also warranted for all women who present with dyspareunia. For this, he said, insert one finger through the hymenal ring. Press posteriorly toward the rectum, and tell the patient “this is pressure.” Then palpate the pubococcygeal, transverse perineal, and internal obturator muscles.
“For each muscle,” he said, “ask, ‘Is this pressure or pain?’ Are there trigger points? Is there hypertonicity? Can she relax the muscles?”
Next, palpate the urethra and bladder. This “should cause urgency but not burning or pain,” Dr. Goldstein said. “If there is intrinsic pain of the bladder, this may suggest interstitial cystitis/painful bladder syndrome.”
Last, palpate the pudendal nerves at the ischial spines. Are the nerves more painful than the muscles, or is one side more tender? Tender nerves can indicate pudendal neuralgia or entrapment.
Lab tests should include a wet mount, “which is absolutely essential”; cultures for speciation and sensitivity; tests for gonorrhea, chlamydia, and herpes simplex virus types 1 and 2; and serum tests of estradiol, total and free testosterone, and sex hormone–binding globulin.
“I’m a big proponent of vulvar punch biopsies,” Dr. Goldstein added. “I always send my punch biopsies with a differential diagnosis to a dermatopathologist, and I always close the biopsy with one or two interrupted Vicryl sutures.”
Atrophic vulvovaginitis is the most common cause of dyspareunia in menopausal women, he said, followed by pelvic floor dysfunction and vulvar dermatoses. Less common causes include vulvar granuloma fissuratum, desquamative inflammatory vaginitis, and interstitial cystitis.
He said he believes the addition of low-dose testosterone to estradiol helps to treat atrophy at the vulvar vestibule, but he acknowledged that this belief is based on his clinical experience and that there aren’t evidence-based studies to support this treatment.
Dr. Goldstein disclosed that he serves on the advisory boards of Boehringer Ingelheim and Wyeth. He has also received research funding from Novartis.
Copyright (c) 2009 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.
圣地亚哥（EGMN）—— 根据医学文献中的最佳估计值，绝经期妇女性交困难的患病率介于11%~45%。
但在北美绝经学会年会上，Andrew T. Goldstein博士称，“针对这一主题的相关文献存在很大局限性。”
来自美国马里兰州安纳波利斯的妇产科医生Goldstein博士擅长治疗外阴阴道疾病，他指出，“很多研究都只统计了年龄，而忽视了月经状态；也没有统计是手术绝经还是自然绝经；没有指出是否接受了激素替代治疗，即便有所提及也没有明确是哪种类型的激素替代治疗。此外，极少采用经过确证的调查问卷。”
Goldstein博士继续指出，绝经期妇女性交困难的患病率呈上升趋势的原因是多方面的，其中包括接受激素治疗的女性越来越少，而22%~45%没有接受激素治疗的女性都存在性交困难。此外，原因还包括“绝经后妇女的生活态度和性欲都发生了变化。他们希望在中老年时期继续享受性生活。”
另一大原因是，近年来越来越多的男性开始使用磷酸二酯酶5型抑制剂，这使得绝经后妇女的伴侣能够维持性欲、继续享受性生活甚至增加性生活。
“激素治疗类型的改变也是导致性交困难患病率上升的原因之一，从以前常用的全身性激素治疗逐渐变为局部治疗，如雌二醇阴道片或无法作用于外阴的阴道环。”
Goldstein博士提醒临床医生不要轻易认为导致绝经期妇女出现性交困难的原因大多都是萎缩性阴道炎。他说：“导致绝经后性交困难的原因很多。”
Goldstein博士补充道，许多妇女在绝经前就存在性交困难，但从未接受过充分治疗。其他研究者开展的一项研究显示，40%的患有外阴痛的女性从未接受过基本的治疗(J. Am. Med. Womens Assoc. 2003;58:82-8)。“而且，在接受了雌二醇充分治疗的女性中，最多仅有75%的女性外阴痛得以治愈。”
但Goldstein博士也指出，只要进行了全面的病史采集、体格检查和鉴别诊断，“就可以确定每位患者的具体病程，从而制定出正确的诊疗方案。”
病情评估应包括性交困难开始出现的时间、疼痛部位以及症状特点。Goldstein博士指出，“不同的症状所提示的意义也不同。跳痛、钝痛或刺痛通常提示盆底功能障碍性疾病，而干痛或撕裂痛常提示雌激素缺乏或外阴皮肤病。起尿缓慢、尿急、尿频或排空不全、便秘、肛裂等症状也可提示盆底肌张力过高。”
Goldstein博士建议体格检查时应仔细检查外阴，因为至少有75%的性交困难病例起源于外阴。应特别注意观察外阴前庭，他说：“当然所有结构都必须检查。”
此外，还应行外阴镜检查，以便寻找出现红斑、苔藓样变、裂口、糜烂、溃疡、瘢痕及空间形态变化的区域，并寻找提示萎缩、色素减退和色素沉着的证据以及提示外阴上皮内瘤变的证据。
Goldstein博士指出，他在检查中还会采用“棉签试验(Q-tip test)”。用湿棉签触及Hart线的外侧，然后再移至Hart线的内侧。在尿道旁Skene腺开口的1点和11点处触及外阴前庭，然后再在Bartholin腺开口的4点和8点处触及外阴前庭。
Goldstein博士称，“通常只有后侧出现疼痛，前侧疼痛较为少见。我认为如果患者只有后侧疼痛而无前侧疼痛，那么一般都提示盆底肌张力过高，通常这就是导致性交困难的原因所在。如果患者整个前庭都有弥漫性疼痛，则提示前庭组织本身的问题。”
此外，所有出现了性交困难的女性都应接受盆底肌肉检查。用一根手指通过处女膜环插入阴道，并向后按压直肠，同时告知患者“开始施压了。”然后触摸耻骨尾骨肌、会阴横肌和闭孔内肌。
Goldstein博士指出，“应仔细检查每块肌肉，明确患者是只感觉到压力还是有疼痛？有无疼痛触发点？有无肌张力过高？患者能够放松这些肌肉吗？”
下一步再触及尿道和膀胱。这一动作“会引起尿急，但不会导致灼热或疼痛。如果出现了膀胱本身的疼痛，则可能提示间质性膀胱炎或膀胱疼痛综合征。”
最后触及位于坐骨棘的阴部神经。触及神经时产生的疼痛是否比触及肌肉时更剧烈？是否某一侧的触痛更明显？神经触痛可能提示阴部神经痛或阴部神经压迫。
实验室检查应包括湿涂片检查，“这是一项绝对有必要进行的检查”；标本培养以确定菌种分类及药敏性；淋病、衣原体、1型和2型单纯疱疹病毒检测；雌二醇、总睾酮和游离睾酮以及性激素结合球蛋白的血清水平检测。
Goldstein博士补充道，“我强烈支持进行外阴钻取活检。我常将钻取到的活组织连同鉴别诊断意见一起送至皮肤病理科。采集到活检组织后，我通常用1~2针可吸收缝线(Vicryl)行间断缝合。”
萎缩性外阴阴道炎是导致绝经期妇女性交困难的最常见原因，其次是盆底功能障碍性疾病和外阴皮肤病。其他相对不常见的原因包括外阴裂隙性肉芽肿、脱屑性阴道炎和间质性膀胱炎。
Goldstein博士认为，在雌二醇的基础上加用小剂量睾酮将有助于治疗外阴前庭萎缩，但他同时也指出这种做法仅仅基于他自己的临床经验，尚未开展相关的循证研究。
Goldstein博士称其受聘于勃林格殷格翰公司和惠氏公司的咨询委员会，还接受了诺华公司提供的研究经费。
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