The management of PVD includes psychological methods to address the chronic internal stress and possibly adjunctive medications, simultaneously or subsequently. The psychological methods include CBT and mindfulness. Particular attention is paid to the catastrophic thinking. Giving the woman as much information as appropriate on the mechanisms of chronic pain allows her to see the role of the emotions experienced alongside the physical sensation of pain. Realizing that her thoughts can alter her emotions moves her onto understanding how cognitive therapy will change her pain intensity. Mindfulness has been used for 3,500 years for ameliorating chronic pain but only recently in Western medicine. Given its use in other pain conditions, it was added to the holistic treatment of PVD (106). Chronic pain medications include tricyclic antidepressants and antiseizure drugs. Applications of local anesthetics and or local anti-inﬂammatories such as sodium cromoglycate can be used. Topical steroids need to be avoided because initial benefit moves onto worsening of the presumed neurogenic inﬂammation. Evidence-based guidelines suggesting which medical treatment to choose are lacking. A typical outcome of the psychological therapy is that pain intensity and distress lessen sufficiently to allow the woman who regains her sexual confidence with nonpenetrative sex sometimes to begin to include intercourse. Prior to doing so she might use topical local anesthetic on residual areas of allodynia. Her expectation of less pain combines with her expectation of reward to reduce the intensity of the dyspareunia. The local anesthetic may contribute to a positive experience.
Introital pain may be caused by conditions other than PVD. The differential diagnosis includes recurrent tears of the posterior fourchette, which may be treated with the topical application of estrogen or testosterone and, if necessary, a perineorrhaphy. Other diagnoses are congenital abnormalities, including a hymenal ring that is rigid, scar tissue (e.g., from episiotomy repairs), a vaginal septum, and, much more commonly, vaginitis or vulvitis, sometimes resulting from the use of over-the-counter vaginal sprays and douches. One important common cause of dyspareunia is friction from inadequate genital sexual arousal. Estrogen deficiency with inadequate lubrication, progressing to loss of elasticity and thinning of the epithelium from vaginal atrophy, is another common cause. This condition is easily treated with local estrogen therapy. Deep dyspareunia resulting from pelvic disease, including endometriosis, is managed by treatment of the underlying conditions.
Because sexual dysfunction in older women can be related to a variety of factors, broad-spectrum treatment approaches are needed in which individual, interpersonal, and sexual aspects can be addressed simultaneously. The following steps in therapy are recommended:
To encourage the woman to take responsibility for discovering what provides sexual pleasure and arousal and to learn to guide her partner toward stimuli and contexts (surroundings and time of day) that are pleasurable to her now, as they may be different and more complicated than when she was a younger woman and possibly her relationship was relatively new.
To assist her to understand that a more rewarding outcome will increase her sexual motivation. Factors relating to the couple’s sexual style and even sexual dysfunction in the partner may need to be addressed.
To counsel her that women can begin rewarding sexual experiences in the absence of desire, which can be reassuring and therapeutic.
To acknowledge that resentment, frustration, and disappointment toward her partner will very likely preclude arousal and pleasure: the couple may benefit from referral for relationship counseling.
To advise that deep-seated psychological distress from factors in her development or current refractory mood disorders may require referral to a psychologist or a psychiatrist.