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Dyspareunia, or pain during sexual intercourse, is among the problems most frequently reported by postmenopausal women. Past literature has almost unanimously attributed dyspareunic pain occurring during or after the menopausal transition to declining estrogen levels and vaginal atrophy.

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To critically review the literature on the prevalence, risk factors, etiology, clinical presentation and treatment of post-menopausal dyspareunia. The present review also examines the traditional and widely held conceptualization of postmenopausal dyspareunia as a direct symptom of Painfully sex ends with sex cream flow decline. Searches of medical and psychological databases were performed for relevant articles and empirical studies.

The methodological quality and outcomes of the studies were systematically reviewed. Available empirical evidence suggests that dyspareunia is common in postmenopausal women, and that it is not highly correlated with menopausal status, estrogen levels or vaginal atrophy. Decreasing levels of endogenous estrogen contribute to the development of dyspareunia in postmenopausal women suffering from vaginal atrophy. Hormonal supplementation is beneficial in alleviating their pain.

However, a substantial proportion of treated women do not report relief. Postmenopausal dyspareunia occurring concurrently with vaginal atrophy is strongly associated with a lack of estrogen in the genital tract.

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However, a significant percentage of postmenopausal women experience dyspareunic pain that is not caused by hypoestrogenism. It is likely that other types of dyspareunia that occur premenopausally are also occurring in postmenopausal women.

Research is needed to adequately address this issue. A change in perspective toward a multiaxial pain-focused approach is proposed for future research concerning dyspareunia in postmenopausal women. Dyspareunia, or pain during sexual intercourse, is among the problems most frequently reported by postmenopausal women 12. For women of all ages, dyspareunic pain often results in distress, decreased sexual functioning and enjoyment, relationship difficulties and reduced quality of life 3 — 5.

For postmenopausal women, dyspareunia may also accentuate personal issues related to aging, body image and health. As with most female sexual difficulties occurring during midlife and beyond, dyspareunia is typically considered to be a consequence of declining ovarian hormone levels 67. As a result of aging tissue and decreasing Painfully sex ends with sex cream flow of endogenously produced estrogens during menopause, in particular estradiol E 2atrophic changes may be observed in the external genital region, introitus and vagina ie, vaginal atrophy.

The resulting symptoms may Painfully sex ends with sex cream flow itching, vulvar pruritus, vaginal dryness and dyspareunia 8. Not surprisingly, medical and pharmaceutical attention has focused on postmenopausal dyspareunia and its relationship to estrogens.

Consequently, hormone replacement therapy HRT has long been considered the frontline and almost exclusive treatment for painful intercourse in post-menopausal women 79. Moreover, vulvar and pelvic pain conditions commonly affecting premenopausal women eg, provoked vestibulodynia, vulvodynia, vaginismus may also exist in postmenopausal women and have been more or less ignored. This seems odd because the main presenting complaint is pain.

The lack of interest in the actual pain is reflected by the almost total absence of clinical or research reports about postmenopausal dyspareunia in the pain literature.

The present review examines the traditional and widely held conceptualization of postmenopausal dyspareunia as a relatively direct symptom of hormonal decline. To identify research relevant to the present review, searches of the electronic databases PsycInfo, MEDLINE, Biosis and Excerpta Medica were performed for articles and empirical studies published in English-language journals between January and August concerning the prevalence, etiology or treatment of dyspareunia in perimenopausal or post-menopausal women.

Hence, the keywords dyspareunia, coital pain, sexual function, sexuality, sexual dysfunction, vaginitis, urogenital, genital or vaginal were combined with the keywords menopause, climacteric, perimenopause, postmenopause, aging, hormone, estrogen or hormone therapy. In addition, a manual search of pertinent books, journals and a review of the reference sections of included papers was performed.

The first author performed database searches, Painfully sex ends with sex cream flow germane articles to extract research findings and evaluated study quality by the type of research protocol used. The coauthors were involved in the research evaluation and verification process. Before discussing the available evidence, it is important to consider general methodological issues that were commonly encountered in the reviewed articles.

In critically assessing the past literature, differences in study design and subject variables made it difficult to compare or aggregate findings Painfully sex ends with sex cream flow different investigations. For example, a widespread shortcoming of the reviewed literature was the failure to report or distinguish between reproductive stages eg, 10— Age alone, and not menstrual status, was often used to gauge the reproductive phases of participants.

This is problematic, because there is a large variance in the age at which individual women experience menopause.

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As such, the effects of age and menopause were confounding variables in these investigations. Moreover, discrepancies existed in how reproductive phases were defined. The World Health Organization 16 suggested the standardized definitions for the stages of the female reproductive life cycle listed in Table 1. These World Health Organization definitions will be used in the present review unless otherwise specified.

Data from reference Another common methodological limitation of the literature was the failure to indicate whether women were on HRT eg, 417— If HRT was specified, studies often failed to distinguish between the varying replacement regimens which can have potentially different effects on the urogenital system and sexual functioning eg, 22— Studies often also failed to differentiate between surgically and naturally menopausal women eg, 2025— This is an important factor to consider because hysterectomy and oophorectomy may cause altered sexual response and functioning 28 — The failure to use standardized measures of pain and sexuality was another frequent limitation of the literature eg, 172231 Standardized and validated pain measures, such as the McGill-Melzack Pain Questionnaire 33were never used.

Also, although there are few Painfully sex ends with sex cream flow and validated assessment instruments of female sexual dysfunction for use in postmenopausal women, such as the McCoy Female Sexuality Questionnaire 34 and the Female Sexual Function Index 35their use would have been valuable in disentangling the occurrence of different problems. For example, the symptoms of lack of lubrication during intercourse and pain during intercourse were often grouped together eg, 2036— These problems can occur separately and may have different causes.

Population-based prevalence studies of dyspareunia were heterogeneous in research methodologies and sample populations. Many studies included women who were likely to be post-menopausal because they were middle-aged or older. They could not be integrated into the present summary because they did not report or separately analyze findings by reproductive phase eg, 10—15 Studies were also excluded if Painfully sex ends with sex cream flow clustered other symptoms, such as lack of lubrication or vaginal dryness, together with dyspareunia eg, 36 As Table 2 illustrates, findings from population-based studies are disparate.

Recent studies eg, 2441 have obtained higher prevalence estimates than older investigations eg, 1718which may be, in part, a product of changing attitudes about sexual functioning in aging populations. For example, some studies only queried sexually active women about sexual difficulties or pain during intercourse eg, 18 As such, they may have under-represented their findings, because many women do not engage in sexual activity because it is too painful.

On the other hand, the differences may, at least in part, reflect sociocultural, lifestyle, biological and variations of reporting methods among differing populations.

For example, major international differences in rates of dyspareunia in to year-old women have been found in a global investigation of 29 countries Moreover, ethnic differences in reported rates of dyspareunia in premenopausal and perimenopausal women have also been found The most recent population-based prevalence investigations specifically examining postmenopausal women not taking HRT estimated that between All studies were cross-sectional.

HRT Hormone replacement therapy.

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Patient population prevalence studies are important because they help to elucidate the clinical load of a particular problem in the health care setting. As a result, they may feel less embarrassed about disclosing pain experienced during sexual intercourse. Alternatively, dyspareunia may be one of the reasons women seek treatment in special clinics.