Dyspareunia কী?
Dyspareunia হলো যৌন সম্পর্কের আগে, সময়, বা পরে recurrent/persistent genital বা pelvic pain, যা রোগীর distress বা sexual avoidance তৈরি করে। এটি superficial/entry pain বা deep pelvic pain—দুইভাবে দেখা যায়। Clinical evaluation-এ pain location, onset, discharge/bleeding, STI risk, postpartum/menopause status, trauma history, pelvic exam, cotton-swab test, single-digit pelvic-floor exam এবং bimanual exam গুরুত্বপূর্ণ।
Cause of Dyspareunia:-
A. Superficial / Entry dyspareunia
- Inadequate lubrication — low arousal, anxiety, SSRI/antihistamine, postpartum/lactation
- Vulvovaginal candidiasis — itching, curdy discharge, vulvar erythema
- Bacterial vaginosis — fishy odor, thin grey discharge
- Trichomoniasis / STI-related vaginitis — frothy discharge, strawberry cervix
- Cervicitis — Chlamydia, gonorrhea, Mycoplasma; postcoital bleeding/discharge
- Genital herpes — painful vesicle/ulcer
- Genitourinary syndrome of menopause / vaginal atrophy — dryness, burning, spotting
- Vulvodynia / vestibulodynia — cotton-swab tenderness, burning pain >3 months
- Vaginismus / pelvic floor hypertonicity — involuntary tightening, penetration fear
- Dermatoses — lichen sclerosus, lichen planus, contact dermatitis
- Postpartum scar / episiotomy scar / obstetric trauma
- Bartholin cyst/abscess, urethral pain syndrome, interstitial cystitis
B. Deep dyspareunia
- Endometriosis — dysmenorrhea, chronic pelvic pain, deep dyspareunia
- Pelvic inflammatory disease — PID
- Adenomyosis / fibroid / uterine retroversion / prolapse
- Ovarian cyst, adnexal mass, pelvic adhesions
- Chronic pelvic pain syndrome
- IBS/IBD, bladder pain syndrome
- Pelvic surgery/radiation-related fibrosis
প্রধান কারণগুলো (Must Causes)
A. Superficial / Entry Dyspareunia
- অপর্যাপ্ত lubrication – low arousal, anxiety, SSRI/antihistamine, postpartum/lactation
- Vulvovaginal candidiasis – itching, curdy discharge, vulvar erythema
- Bacterial vaginosis – fishy smell, thin grey discharge
- Trichomoniasis / STI-related vaginitis – frothy discharge, strawberry cervix
- Cervicitis – Chlamydia, Gonorrhea, Mycoplasma; postcoital bleeding
- Genital herpes – painful vesicles/ulcers
- Genitourinary syndrome of menopause / Vaginal atrophy – dryness, burning, spotting
- Vulvodynia / Vestibulodynia – cotton-swab test positive, burning pain >3 months
- Vaginismus / Pelvic floor hypertonicity – involuntary tightening, penetration fear
- Dermatoses – lichen sclerosus, lichen planus, contact dermatitis
- Postpartum scar / episiotomy scar / obstetric trauma
- Bartholin cyst/abscess, urethral pain syndrome, interstitial cystitis
B. Deep Pelvic Dyspareunia
- Endometriosis – dysmenorrhea, chronic pelvic pain
- Pelvic inflammatory disease (PID)
- Adenomyosis / Fibroid / Uterine retroversion / Prolapse
- Ovarian cyst, adnexal mass, pelvic adhesions
- Chronic pelvic pain syndrome
- IBS / IBD, bladder pain syndrome
- Pelvic surgery / radiation-induced fibrosis
Symptoms:-
লক্ষণগুলো (Symptoms)
Pain pattern
- প্রবেশের সময় – vulvodynia, vaginismus, dryness, candidiasis, atrophy
- Deep thrust – endometriosis, PID, adnexal pathology, fibroid/adenomyosis
- Burning / stinging – vestibulodynia, Candida, atrophy
- Cramping / deep ache – endometriosis / PID / adhesion
- Certain position only – deep pelvic pathology / pelvic floor issue
সংযুক্ত লক্ষণ
- Itching + curdy discharge → Candida
- Fishy smell + thin discharge → BV
- Frothy discharge + cervicitis → Trichomonas
- Postcoital bleeding/discharge → Cervicitis, cervical lesion
- Fever + lower abdominal pain + cervical motion tenderness → PID
- Severe dysmenorrhea + infertility + deep pain → Endometriosis
- Dryness + burning + postmenopausal/lactational → GSM / vaginal atrophy
- Fear/avoidance + pelvic floor tightening → Vaginismus / GPPPD
৪. Clinical Diagnosis / পরীক্ষা
- Pain location: entry না deep
- Discharge, odor, itching, ulcer, bleeding, fever
- STI risk, pregnancy test
- External genital inspection
- Cotton-swab test → vestibulodynia
- Vaginal pH, wet mount, KOH / whiff test
- Single-digit pelvic floor exam
- Bimanual exam → uterine / adnexal tenderness
- Imaging: transvaginal US / MRI / laparoscopy (if endometriosis suspected)
৫. Investigations
- Pregnancy test
- Urine R/E ± culture
- CBC, ESR/CRP
- Blood sugar – recurrent Candida
- HIV, VDRL/RPR, HBsAg, anti-HCV
- Vaginal pH, wet mount, KOH microscopy
- NAAT – Chlamydia, Gonorrhea, Trichomonas
- Fungal culture – recurrent Candida
- Transvaginal ultrasound – fibroid, cyst, endometrioma
- MRI pelvis – deep infiltrating endometriosis
- Diagnostic laparoscopy – adhesion / endometriosis
Clinical Diagnosis — কীভাবে clinically ধরবেন
History checklist
- Pain: superficial না deep, onset, duration, severity, relation with cycle
- Discharge, odor, itching, dysuria, ulcer, fever
- STI risk: new/multiple partner, condom use, partner symptoms
- Obstetric history: postpartum, lactation, episiotomy scar
- Menopause/amenorrhea/low estrogen state
- Past PID, endometriosis, pelvic surgery
- Medication: SSRI, antihistamine, OCP, isotretinoin
- Psychosexual: anxiety, trauma, relationship distress
Examination
- External vulva inspection: erythema, fissure, ulcer, dermatosis, scar
- Cotton-swab/Q-tip test: vestibulodynia/vulvodynia localization
- Speculum exam: discharge, cervicitis, atrophy, bleeding, cervical lesion
- Vaginal pH + wet mount + KOH/whiff test
- Single-digit exam: pelvic floor spasm/tenderness
- Bimanual exam: cervical motion tenderness, uterine/adnexal tenderness/mass
AAFP review specifically recommends external genital inspection, cotton-swab pressure testing, single-digit pelvic floor assessment, and bimanual exam for dyspareunia evaluation.
4. Specific Investigations
Basic
- Urine pregnancy test — reproductive-age patient
- Urine R/E ± culture — dysuria/UTI symptoms
- CBC, CRP/ESR — suspected PID/systemic infection
- Blood glucose/HbA1c — recurrent Candida
- HIV, VDRL/RPR, HBsAg, anti-HCV — STI risk
Vaginal/cervical tests
- Vaginal pH
- Saline wet mount: clue cell, trichomonad, WBC
- KOH microscopy: Candida hyphae/pseudohyphae
- Whiff test
- NAAT for Chlamydia, Gonorrhea, Trichomonas
- Fungal culture/sensitivity — recurrent/complicated Candida
- Cervical cytology/HPV test — if screening due or postcoital bleeding
Imaging
- Transvaginal ultrasound — fibroid, adenomyosis, ovarian cyst, endometrioma
- MRI pelvis — deep infiltrating endometriosis/complex pelvic pathology
- Diagnostic laparoscopy — suspected endometriosis/adhesion when symptoms persist despite initial workup; NICE notes endometriosis diagnosis may involve ultrasound, MRI, or laparoscopy depending on context.
5. Differential Diagnosis — shortcut
| Pain type | Most likely DDx |
| Entry burning pain | vulvodynia, Candida, atrophy, dermatitis |
| Entry tightness/fear | vaginismus, pelvic floor hypertonicity |
| Deep pelvic pain | endometriosis, PID, ovarian cyst, fibroid |
| Pain + fishy discharge | BV |
| Pain + ulcer/vesicle | genital herpes |
| Pain + fever + CMT | PID |
| Pain + postmenopausal dryness | GSM/vaginal atrophy |
| Pain + dysmenorrhea/infertility | endometriosis |
6. Management / Treatment — cause-specific
General management for all dyspareunia
- Treat the specific cause, not pain alone.
- Avoid painful penetration until acute infection/inflammation improves.
- Use water-based lubricant; avoid perfumed soap, vaginal douching, irritant gel.
- Pelvic floor physiotherapy for pelvic floor tenderness/spasm.
- CBT/sex therapy for fear-avoidance, trauma-related pain, vaginismus.
- Treat sexual partner when STI/trichomoniasis/gonorrhea/chlamydia/PID suspected.
A. Vulvovaginal candidiasis
CDC recommends topical azole or fluconazole for VVC; severe VVC may need fluconazole 150 mg repeated after 72 hours, and recurrent VVC may need induction followed by weekly fluconazole for 6 months. Oral fluconazole should not be used in pregnancy; topical azole for 7 days is recommended.
1. Generic name: Fluconazole
Therapeutic category: Antifungal
Pharmacological class: Triazole antifungal
Dose:
- Uncomplicated: 150 mg PO single dose
- Severe: 150 mg PO now + repeat after 72 hours
- Recurrent: 150 mg on day 1, 4, 7; then 150 mg weekly × 6 months
Purpose: Candida eradication; itching, discharge, vulvar inflammation কমানো
Side effects: nausea, abdominal pain, headache, rash, rare hepatotoxicity, QT prolongation
Interactions: warfarin ↑INR, sulfonylurea hypoglycemia, phenytoin, carbamazepine, statins, QT-prolonging drugs
Bangladesh available brand examples: Fluconal 150 mg, Fluconazole 150 mg, Olif 150 mg, Omastin 50 mg/150 mg.
2. Generic name: Clotrimazole vaginal tablet
Therapeutic category: Topical vaginal antifungal
Pharmacological class: Imidazole antifungal
Dose: 500 mg intravaginal single dose at bedtime or 200 mg at bedtime × 3 days
Purpose: Candida vaginitis; pregnancyে topical azole preferred
Side effects: local burning/irritation
Interactions: minimal; vaginal products may reduce condom integrity depending on base
Bangladesh available brand examples: Afun VT 200 mg, Dermasim VT 200 mg/500 mg.
B. Bacterial vaginosis — BV
CDC recommended BV regimens include metronidazole 500 mg PO twice daily for 7 days, metronidazole gel 0.75% intravaginally for 5 days, or clindamycin cream 2% intravaginally for 7 days. Condom use during treatment and avoiding douching are advised; clindamycin cream can weaken latex condoms/diaphragms for several days.
1. Generic name: Metronidazole
Therapeutic category: Antiprotozoal/antibacterial
Pharmacological class: Nitroimidazole
Dose: 500 mg PO twice daily × 7 days
Purpose: BV anaerobic organisms; odor/discharge কমানো
Side effects: metallic taste, nausea, abdominal discomfort, dark urine, peripheral neuropathy with prolonged use
Interactions: warfarin ↑INR, lithium ↑toxicity, disulfiram reaction risk; alcohol warning still used in many labels
Bangladesh available brand examples: Flagyl 400 mg, Metro 400 mg, G-Metronidazole 400 mg; IV form 500 mg/100 ml.
2. Generic name: Clindamycin vaginal cream
Therapeutic category: Vaginal antibacterial
Pharmacological class: Lincosamide antibiotic
Dose: 2% cream, 5 g intravaginally at bedtime × 7 days
Purpose: BV alternative, especially metronidazole intolerance
Side effects: vaginal candidiasis, irritation, diarrhea, rare C. difficile colitis
Interactions: oil-based cream weakens latex condoms/diaphragms
Bangladesh available brand examples: Cleocin vaginal cream 2%, Clindacin vaginal cream 2%, Clindax vaginal cream 2%.
C. Trichomoniasis
For women, CDC recommends metronidazole 500 mg twice daily for 7 days; tinidazole 2 g single dose is an alternative. Partners must be treated, and intercourse should be avoided until both partners complete treatment and symptoms resolve.
1. Generic name: Metronidazole
Dose: 500 mg PO twice daily × 7 days
Purpose: Trichomonas eradication; reinfection কমাতে partner treatment mandatory
Side effects/interactions: same as above
Brand examples: Flagyl 400 mg, Metro 400 mg, G-Metronidazole 400 mg.
2. Generic name: Tinidazole
Therapeutic category: Antiprotozoal
Pharmacological class: Nitroimidazole
Dose: 2 g PO single dose
Purpose: Trichomoniasis alternative; GI side effect comparatively কম হতে পারে
Side effects: nausea, metallic taste, dizziness
Interactions: warfarin, lithium, disulfiram; avoid in pregnancy unless specialist decision
Bangladesh available brand examples: T-zol 500 mg / 1 g.
D. Cervicitis / Chlamydia / Gonorrhea-risk
CDC cervicitis regimen is doxycycline 100 mg twice daily for 7 days, with concurrent gonorrhea treatment if risk is high or gonorrhea cannot be excluded. Gonorrhea regimen is ceftriaxone 500 mg IM single dose; chlamydia should be treated if not excluded.
1. Generic name: Doxycycline
Therapeutic category: Antibiotic
Pharmacological class: Tetracycline
Dose: 100 mg PO twice daily × 7 days
Purpose: Chlamydia/cervicitis coverage
Side effects: nausea, photosensitivity, esophagitis
Interactions: iron, calcium, antacid, milk reduce absorption; warfarin ↑INR; avoid pregnancy
Bangladesh available brand examples: Doxy-A 100 mg, Doxicline 100 mg, Doxin 100 mg, Doximet 100 mg.
2. Generic name: Ceftriaxone
Therapeutic category: Antibiotic
Pharmacological class: 3rd-generation cephalosporin
Dose: 500 mg IM single dose; if body weight >150 kg with gonorrhea, 1 g IM
Purpose: Gonorrhea coverage
Side effects: injection-site pain, diarrhea, rash, biliary sludge, rare anaphylaxis
Interactions: avoid IV calcium-containing solution in neonates; caution severe beta-lactam allergy
Bangladesh available brand examples: Ceftron 500 mg vial, Oricef 500 mg vial, Traxef 500 mg vial, Ceftriaid 500 mg vial.
3. Generic name: Azithromycin
Therapeutic category: Antibiotic
Pharmacological class: Macrolide/azalide
Dose: 1 g PO single dose — alternative for chlamydia, especially pregnancy/compliance issue
Side effects: GI upset, QT prolongation
Interactions: QT-prolonging drugs, warfarin monitoring
Bangladesh available brand examples: Zimax 500 mg tablet/capsule, Zibac 200 mg/5 ml, Virzith 500 mg.
E. Pelvic inflammatory disease — PID
For mild-to-moderate outpatient PID, CDC recommends ceftriaxone 500 mg IM single dose + doxycycline + metronidazole for 14 days; no improvement within 72 hours requires reassessment/hospital-level care.
Regimen:
- Ceftriaxone 500 mg IM stat
- Plus Doxycycline 100 mg PO twice daily × 14 days
- Plus Metronidazole 500 mg PO twice daily × 14 days
Purpose: Gonorrhea, chlamydia, anaerobes, BV-associated organisms coverage
Partner management: recent partners need evaluation/treatment; abstain until treatment complete and symptoms resolve.
F. Genitourinary syndrome of menopause / vaginal atrophy
Local vaginal estrogen improves dryness and dyspareunia in GSM; NAMS notes estrogen creams/tablets/inserts are often used daily for 2 weeks initially, then maintenance dosing.
1. Generic name: Estriol vaginal cream
Therapeutic category: Local estrogen therapy
Pharmacological class: Estrogen
Dose: Common regimen: 0.5 g intravaginal nightly × 2–3 weeks, then 2–3 times/week maintenance
Purpose: vaginal epithelium thickening, pH/lubrication improvement, dyspareunia কমানো
Side effects: local irritation, breast tenderness, spotting
Contraindication/caution: unexplained vaginal bleeding, estrogen-dependent cancer, active VTE/liver disease—specialist advice
Interactions: systemic absorption low, but caution with aromatase inhibitors
Bangladesh available brand examples: Ovestin vaginal cream 0.1%, Gynest 0.1%, Femastin 0.1%, SRT 0.1%.
2. Generic name: Conjugated estrogen vaginal cream
Therapeutic category: Local estrogen therapy
Pharmacological class: Estrogen mixture
Dose: 0.5 g intravaginal daily × 2 weeks, then twice weekly maintenance
Bangladesh available brand examples: Estracon 0.0625%, Premarin 0.0625%.
G. Endometriosis / cyclic deep dyspareunia
NICE describes endometriosis as chronic hormone-mediated disease with chronic pain, painful periods, subfertility and sexual impact; first-line options include analgesics such as NSAIDs and hormonal treatments, while second-line may include GnRH agonists/surgery depending on fertility goals and severity.
1. Generic name: Ibuprofen
Therapeutic category: Analgesic/anti-inflammatory
Pharmacological class: NSAID
Dose: 400 mg PO every 8 hours PRN after food, usually 3–5 days around menses/pain flare
Purpose: prostaglandin-mediated pelvic pain/dysmenorrhea কমানো
Side effects: gastritis, GI bleeding, renal injury, BP increase
Interactions: anticoagulants, antiplatelets, ACEi/ARB + diuretic, steroids, other NSAIDs
Bangladesh available brand examples: Flamex 400 mg, Profen 400 mg, Inflam 400 mg.
2. Generic name: Naproxen sodium
Therapeutic category: Analgesic/anti-inflammatory
Pharmacological class: NSAID
Dose: 500 mg initially, then 250 mg twice daily PRN; or 500 mg twice daily short course after food
Purpose: longer-acting NSAID for dysmenorrhea/deep pain
Side effects/interactions: same NSAID class
Bangladesh available brand examples: Naproxen 500 mg, Naprox 500 mg, Napryn 500 mg, Naproxin 500 mg.
3. Generic name: Dienogest
Therapeutic category: Hormonal therapy for endometriosis
Pharmacological class: Progestin
Dose: 2 mg PO once daily, usually 3–6 months then reassess; longer under specialist follow-up
Purpose: estrogen effect suppression on endometriotic tissue; pelvic pain/deep dyspareunia কমানো
Side effects: irregular bleeding, breast tenderness, mood change, acne, headache
Interactions: CYP3A4 inducers/inhibitors: rifampicin, carbamazepine, phenytoin, some antiretrovirals, azole antifungals
Bangladesh available brand examples: Dinogest 2 mg, Dinosen 2 mg, Daizy 2 mg, Neogest 2 mg, Venesa 2 mg.
4. Generic name: Leuprorelin acetate
Therapeutic category: Advanced endometriosis hormonal suppression
Pharmacological class: GnRH agonist
Dose: 3.75 mg IM/SC every 4 weeks, usually up to 6 months; add-back therapy often needed
Purpose: ovarian estrogen suppression for severe endometriosis pain
Side effects: hot flush, vaginal dryness, mood change, bone mineral density loss
Interactions/caution: osteoporosis risk, pregnancy contraindicated, specialist-only
Bangladesh available brand example: Lucrin Depot 3.75 mg vial.
H. Vulvodynia / vestibulodynia / neuropathic vulvar pain
ACOG emphasizes that persistent vulvar pain is complex, often not rapidly resolved, and is best managed with individualized multidisciplinary care.
1. Generic name: Lidocaine hydrochloride gel/jelly
Therapeutic category: Topical local anesthetic
Pharmacological class: Amide local anesthetic
Dose: 2% gel, thin layer to vestibule 10–15 minutes before intercourse/exam; wipe excess before intercourse
Purpose: temporary pain reduction in provoked vestibular pain
Side effects: local burning, numbness, partner numbness, rare systemic toxicity if overused
Interactions: other local anesthetics, class I antiarrhythmics
Bangladesh available brand examples: Xylogel 2%, Z-Lidocaine 2%, Jasocaine 2%, GP Caine 2%.
2. Generic name: Amitriptyline
Therapeutic category: Neuropathic pain modulator
Pharmacological class: Tricyclic antidepressant
Dose: 10 mg at night; titrate by 10–25 mg every 1–2 weeks; usual 25–75 mg nightly; trial 8–12 weeks
Purpose: neuropathic burning pain, sleep improvement
Side effects: sedation, dry mouth, constipation, urinary retention, weight gain, QT prolongation
Interactions: MAOI, SSRI/SNRI, alcohol/CNS depressants, QT-prolonging drugs
Bangladesh available brand examples: Tryptin 10 mg/25 mg, Amit 10 mg/25 mg, Amitip 10 mg.
3. Generic name: Gabapentin
Therapeutic category: Neuropathic pain modulator
Pharmacological class: Gabapentinoid
Dose: 300 mg at night day 1; 300 mg twice daily day 2; 300 mg three times daily from day 3; titrate based on response/tolerance
Purpose: neuropathic vulvar/pelvic pain; use with pelvic floor therapy
Side effects: dizziness, somnolence, edema, weight gain
Interactions: antacids reduce absorption; opioids/alcohol/CNS depressants ↑sedation/respiratory risk
Bangladesh available brand examples: Gabapen 100/300 mg, Gabastar 100/300 mg, Gabantin 100/300 mg, Gaba 300 mg.
I. Genital herpes-related painful sex
CDC recommends for first clinical episode genital herpes: acyclovir 400 mg orally three times daily for 7–10 days, with extension if healing incomplete.
Generic name: Acyclovir
Therapeutic category: Antiviral
Pharmacological class: Guanosine nucleoside analogue
Dose: 400 mg PO three times daily × 7–10 days
Purpose: HSV lesion healing, pain and viral shedding reduction
Side effects: nausea, headache, renal crystalluria rare
Interactions: nephrotoxic drugs, probenecid
Bangladesh available brand examples: Simplovir 400 mg, Virux 400 mg, Acerux 400 mg, Clovir 400 mg, Novirax 400 mg.
7. Prevention — কীভাবে কমানো যায়
- Adequate foreplay + water-based lubricant ব্যবহার
- Vaginal douching, perfumed wash, antiseptic vaginal wash avoid
- Condom use; STI screening for patient and partner when risk present
- Trichomonas/chlamydia/gonorrhea/PID হলে partner treatment ছাড়া cure অসম্পূর্ণ
- Recurrent Candida হলে diabetes control, unnecessary antibiotic avoid
- Menopause/lactation/postpartum dryness হলে moisturiser ± local estrogen after evaluation
- Pelvic floor spasm হলে early pelvic-floor physiotherapy + dilator training
- Endometriosis symptoms থাকলে delay না করে gynecology referral
- Painful sex “normal” ধরে সহ্য করা উচিত নয়—persistent pain হলে pelvic exam দরকার
Overview / Summary
Dyspareunia হলো painful sexual intercourse, যার cause superficial/entry বা deep pelvic origin হতে পারে। সবচেয়ে গুরুত্বপূর্ণ causes: Candida, BV, Trichomonas, cervicitis/STI, PID, GSM/vaginal atrophy, vulvodynia, vaginismus, pelvic floor dysfunction, endometriosis। Treatment সবসময় cause-specific: infection হলে microbiology-guided antimicrobial, atrophy হলে local estrogen, pelvic floor pain হলে physiotherapy, endometriosis হলে NSAID/hormonal therapy ± specialist surgery.
Actionable Plan / Steps
- Pain location নির্ধারণ করুন: entry বনাম deep.
- Discharge/odor/itching/ulcer/bleeding/fever/STI risk জিজ্ঞেস করুন।
- Pregnancy test + pelvic exam + pH/wet mount/KOH/NAAT করুন।
- Red flags থাকলে urgent referral: fever, severe pelvic pain, adnexal mass, postmenopausal bleeding, suspicious cervical lesion, pregnancy with pain/bleeding.
- Empiric treatment শুধু clear syndrome বা high STI/PID risk হলে; otherwise test-guided treatment.
- Follow-up: infection/PID হলে 48–72 hours clinical response; STI হলে partner treatment and retesting per guideline.
Reference List
Textbooks
- Williams Gynecology, 5th ed. Chapters: Female Sexual Function/Dysfunction, Pelvic Pain, Vulvovaginitis, Endometriosis.
- Berek & Novak’s Gynecology, 17th ed. Chapters: Vulvar disorders, Sexual dysfunction, Endometriosis, PID.
- Harrison’s Principles of Internal Medicine, 21st ed. Chapters: Sexually Transmitted Infections, Antimicrobial therapy.
- Davidson’s Principles and Practice of Medicine, 24th ed. Infectious disease/STI sections.
- Robbins & Cotran Pathologic Basis of Disease, 10th/11th ed. Chapters: Female genital tract pathology—endometriosis, PID, vulvar disorders.
Guidelines
- CDC. Sexually Transmitted Infections Treatment Guidelines, 2021—BV, candidiasis, trichomoniasis, cervicitis, gonorrhea, PID, herpes.
- NICE NG73. Endometriosis: diagnosis and management; NICE technology appraisal discussions for hormonal options.
- ACOG Committee Opinion No. 673. Persistent Vulvar Pain.
- NAMS. 2020 Genitourinary Syndrome of Menopause Position Statement.
Peer-reviewed articles with DOI
- Steege JF, Zolnoun DA. Evaluation and treatment of dyspareunia. Obstet Gynecol. 2009;113(5):1124–1136. DOI: 10.1097/AOG.0b013e3181a1ba2a.
- Sorensen J, Bautista KE, Lamvu G, Feranec J. Evaluation and Treatment of Female Sexual Pain: A Clinical Review. Cureus. 2018;10(3):e2379. DOI: 10.7759/cureus.2379.
- ACOG Committee Opinion No. 673: Persistent Vulvar Pain. Obstet Gynecol. 2016;128:e78–e84. DOI: 10.1097/AOG.0000000000001645.
- The North American Menopause Society. The 2020 GSM position statement. Menopause. 2020;27(9):976–992. DOI: 10.1097/GME.0000000000001609.
Md.Rafiqul Islam Lipu,Date:-23-05-2026,Saturday Time:-08-27-35 Pm