Assessment and management of dyspareunia in peri- and postmenopausal women: A phenotype-based gynecologic approach

Dyspareunia in peri- and postmenopausal women is common, clinically consequential, and often undertreated in gynecologic practice. Although genitourinary syndrome of menopause (GSM) is a frequent contributor, intercourse-related pain may also reflect vestibular, pelvic floor, dermatologic, inflammatory, treatment-related, and psychosocial factors. This narrative review provides a practical phenotype-based framework for assessment and management when GSM, vestibular pain, and pelvic floor dysfunction coexist, and when deep-pain phenotypes require broader pelvic evaluation. PubMed/MEDLINE, the Cochrane Library, and selected guideline sources were searched for English-language literature published from January 2014 to March 2026, prioritizing guidelines, systematic reviews, randomized or sham-controlled trials, and examination-based studies relevant to office gynecology. History should distinguish superficial from deep pain, provoked from spontaneous symptoms, and urinary, dermatologic, inflammatory, and psychosocial features. Examination should proceed from vulva and vestibule to vagina and pelvic floor, with bimanual assessment and selective imaging when deeper pathology is suspected. Management includes education, irritant avoidance, moisturizers and lubricants, and prescription therapy for clinically significant GSM, usually low-dose vaginal estrogen, with prasterone or ospemifene as selected alternatives. Pelvic floor physiotherapy should be considered when tenderness, guarding, or penetration-limiting hypertonicity is present. Because menopause-specific pelvic floor evidence remains limited, related recommendations are framed as cautious extrapolations from broader dyspareunia, vulvodynia, and chronic pelvic pain literature.