Published On: Wed, Jul 10th, 2013

Vaginal Atrophy, Dyspareunia, Estrogen, Breast Cancer & the Psychosocial Environment

womanonthebeachDr. Bob Berger, MS, MVSc, PhD

Dyspareunia refers to painful sexual intercourse. Dyspareunia is also defined as a persistent or recurrent pain of the genitalia that may occur before, during, or after intercourse.

This type of pain, which is directly connected with coitus, is a symptom and not a “disease” itself. This symptom is significantly more prevalent in woman than in men, (at a ratio of approximately 5:1), and may develop due to either a true medical (i.e., physiological), condition, or may stem/originate from psychological issues.

What should be emphasized is that although specific causes of dyspareunia may be initiated and/or perpetuated by psychological issues, the physical symptoms that the individual presents should be acknowledged by the physician/clinician as being truly physiological (at least in the majority of cases), and not psychosomatic in nature, although in some individual cases, psychosomatic tendencies could extend specific symptoms indefinitely.

Although dyspareunia in women, when experienced post-menopause, is attributed mostly to the decline in, and even to the near absence of, total body estrogen, as well as to vulvovaginal atrophy and dryness, very little has been studied or evaluated concerning the psychosocial factors which may be attributed to and implicated in postmenopausal dyspareunic pain1.

Two important variables to recognize are the dyadic (“pairing” of couples), and cognitive factors which come into play before, during, and post-sexual intercourse, in which the former factor is obviously absent during self-gratification and/or autoeroticism. This should support the fact that there is a definite association between actual coitus and dyspareunia, and also that psychosocial factors do come into play here. The fear and stress of not being able to attain orgasm, or to otherwise please the partner, could in itself, prolong or even worsen an already existing dyspareunic condition.

Statistics show that vaginal atrophy, which is an integral symptom and/or part of dyspareunia, has adverse physical as well as emotional effects on postmenopausal woman as well as on their partners. These findings should encourage a much better and more open communication about these issues between the couples themselves and their health care providers2.

When woman are both physically, as well as mentally, coping with vaginal atrophy, dryness and dyspareunia, all issues still meet at the “intersection” of hormone involvement and regulation; and most of this centers around the hormone estrogen. This is not meant to omit the important androgen, testosterone, but estrogen dominance and/or deficiency does both directly as well as indirectly affect testosterone balance and regulatory function.

Although many physicians and OBGYN clinicians will prescribe vaginal estrogen (usually at a low, effective dose), for treating vulvar and vaginal atrophy (VVA), many woman are not good candidates for this, nor do many respond well to this type of therapy3.

As a safer and more effective protocol, selective estrogen receptor modulators (SERMs),are now being seriously considered (and generally used), as a replacement therapy for estrogen in order to elicit the specific responses and positive effects on targeted tissues which have minimal to no negative (or even potentially harmful), effects on other tissues3.

From the Departments of Obstetrics and Gynecology, University of Virginia, and the Keck School of Medicine, University of Southern California, activity profiles of SERMs in various tissues were preformed. SERMs with positive vaginal effects on postmenopausal symptomatic woman, (such as the improvement in the vaginal maturation index, reduced vaginal pH, and general improvement in the signs and symptoms of VVA), included lasofoxifene (clinical development on hold), and ospemifine (approved for the treatment of VVA-related dyspareunia, with a class effect warning of potential venous thrombosis risk). SERMs that showed “less than positive” overall health effects were tamoxifen and arzoxifene, which have no specific positive vaginal effects, but have reported variable or adverse gynecologic effects3. Raloxifene, although it does not improve VVA, can be used safely in combination with vaginal estrogen, while bazedoxifene has not demonstrated efficacy for VVA, but when used in combination with oral conjugated equine estrogens, improves the signs and symptoms of VVA3.

The bottom line here is that SERMs that specifically target underlining VVA pathophysiology may provide alternative therapies that are more beneficial and possess fewer side and negative effects. These may prove to be quite beneficial for postmenopausal symptomatic woman suffering from VVA and dyspareunia who have nowhere to turn without putting themselves in possible and/or considerable health risk.

There is a strong correlation between the use of both SERMs as well as aromatase inhibitors (AIs), and issues concerning breast cancer, as there is a high prevalence of this type of cancer, especially in the postmenopausal population where many of these woman suffer from VVA and dyspareunia.

Aromatase inhibitors work by inhibiting the action of aromatase, (an enzyme that is very active in both sexes as we age), which converts androgens (i.e., testosterone), to estrogens (i.e., estrone, estriol, and estradiol), via a process called “aromatization”. The AIs, which block the production of estrogen by stopping this conversion and lowering body-estrogen levels, are still considered a form of alternative therapy (i.e., adjuvant endocrine therapy), which clinicians utilize in order to decrease the concentration of estrogen in the body, and in turn, lower the risk of excessive estrogen stimulation on ER+ (estrogen-driven), breast cancer cells and their receptor sites. (A few examples of popular “selective” AIs are anastrozole (Arimidex), and letrozole (Femara).

Scientists and clinicians from the Department of Obstetrics and Gynecology at Orebro University Hospital, Sweden, investigated the sexual function of postmenopausal breast cancer patients who were being treated with AIs using a population-based, cross-sectional study of postmenopausal breast cancer patients on adjuvant endocrine treatment and age-matched controls both with and without estrogen treatment. In this study, sexual function was assessed via a standardized questionnaire 4. The results showed that 42.4% of the AI-treated breast cancer patients were dissatisfied with their sex-life in general, with 50% reporting no sexual interest at all; this dissatisfaction/lack of sexual interest was significantly greater than that of the control group patients and the patients who were being treated with tamoxifen (a SERM)4. In this study, 73.9 % and 56.5% of the AI-treated patients also reported insufficient lubrication and dyspareunia, respectively, (but both significantly greater than in the control woman), irrespective of hormone use. It is also important to note that the tamoxifen-treated patients reported significantly more dyspareunia, but resembled the controls in all the other factors4.

The bottom line is that the use of SERMs, (for the treatment of VVA, vaginal dryness, and dyspareunia), as well as AIs, (for preventing the aromatization of androgen compounds into estrogens), have the capacity to create and/or propagate sexual dysfunction on a wide scale, and regardless of the situation, on physical as well as on mental and psychosocial levels. Although this is a major world-wide problem that affects many millions of woman at any given time, it still exists as a highly underestimated one.



1. Kao, A. and Binik, Y.M., et al. (2012) Biopsychosocial predictors of postmenopausal dyspareunia: the role of steroid hormones, vulvovaginal atrophy, cognitive-emotional factors, and dyadic adjustments. J. Sex. Med., 9, 2066.

2. Nappi, R.E. and Kingsberg, S., et al. (2013) The CLOSER (CLarifying Vaginal Atrophy’s Impact On SEx and Relationships) Survey: Implications of Vaginal Discomfort in Postmenopausal Woman and in Male Partners. J. Sex. Med., [Epub ahead of print]

3. Pinkerton, J.V. and Stanczyk, F.Z., (2013) Clinical effects of selective astrogen receptor modulators on vulvar and vaginal atrophy. Menopause, [Epub ahead of print]

4. Baumgart, J. and Nilsson, K., et al. (2013) Sexual dysfunction in woman on adjuvant endocrine therapy after breast cancer. Menopause, 20, 162.




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