Post-coital bleeding (PCB) is one of the most important symptoms to take seriously in general practice — it has a 3–6% positive predictive value for cervical cancer in the context of dyspareunia, which meets the NICE threshold for urgent referral. The GP should examine the cervix (or arrange urgent colposcopy) regardless of the patient's cervical smear history — smear tests screen for pre-cancer (CIN) but do not detect all invasive cancers. FGM is a mandatory reporting duty for all clinicians under the Female Genital Mutilation Act 2003 — any girl under 18 presenting with FGM-related pathology (including dyspareunia) must be referred to safeguarding services. Adult FGM should be sensitively explored in appropriate contexts (Sub-Saharan Africa, Middle East, South Asia, Southeast Asia) and specialist support offered.

The superficial/deep distinction is the primary clinical diagnostic step in dyspareunia assessment — it determines the likely anatomical level of pathology and directs investigation and referral. Deep dyspareunia is endometriosis until proven otherwise in premenopausal women — endometriosis affects 1 in 10 women of reproductive age, causes on average 7–10 years of diagnostic delay in the UK, and is the most common gynaecological cause of deep dyspareunia. The classic triad (dysmenorrhoea + deep dyspareunia + subfertility) is highly specific. Vaginismus (genitopelvic pain/penetration disorder) is an involuntary muscle spasm of the pelvic floor that prevents penetration — it is not a voluntary response and is extremely distressing. It responds well to specialist psychosexual therapy and pelvic floor physiotherapy.

Lichen sclerosus carries a 5% lifetime risk of vulval squamous cell carcinoma — this makes annual vulval review mandatory for all patients with lichen sclerosus, regardless of symptom control. Good compliance with topical clobetasol (which suppresses chronic inflammation) reduces but does not eliminate this risk. Patients should be taught vulval self-examination and instructed to report any new lump, ulcer, or persistent sore area promptly. GSM is dramatically undertreated — a 2019 British Menopause Society survey showed that only 7% of women with GSM symptoms had received treatment despite the condition being highly responsive to topical vaginal oestrogen. Systemic HRT does not reliably treat GSM — topical vaginal oestrogen (e.g., Vagifem 10 mcg pessary, Ovestin cream) is required and is safe even in breast cancer survivors as the systemic absorption is negligible.

The Q-tip test is a simple, reproducible office test for vestibulodynia — it identifies allodynia (pain from light non-painful touch) at the vestibule and maps its distribution. A positive Q-tip test at the vestibule, combined with a normal vulval appearance, is pathognomonic of provoked vulvodynia. Transvaginal ultrasound is the most important pelvic investigation — it identifies endometriomas (ground glass cystic ovarian masses), fibroids, and pelvic fluid. A normal TV-USS does not exclude endometriosis (peritoneal deposits and adhesions are not visible on USS) — if clinical suspicion is high (dyspareunia + dysmenorrhoea + subfertility), refer for laparoscopy despite normal USS. CA125 is not a diagnostic test for endometriosis — it is elevated in only 20–30% of endometriosis cases and has poor specificity.

NICE NG73 (Endometriosis, 2017) recommends that patients with suspected endometriosis should be referred to a specialist endometriosis service when GP management is insufficient — this is now defined as a designated endometriosis centre rather than a general gynaecology clinic. These specialist centres provide laparoscopic diagnosis and treatment including excision of deep infiltrating endometriosis, which has significantly better outcomes than ablation. The average diagnostic delay for endometriosis in the UK is 7–10 years — largely because GPs and gynaecologists historically normalised dysmenorrhoea and dyspareunia in young women. Recognition that these symptoms require investigation and treatment is a key educational message. NICE also emphasises that a negative ultrasound or laparoscopy does not exclude endometriosis — clinical diagnosis and empirical treatment with the COCP or progestogens are appropriate while awaiting specialist review.

Continuous COCP (without a pill-free interval) suppresses endometrial and ectopic endometrial tissue activity by maintaining consistent progestogenic and oestrogenic suppression — the cyclical bleeding during pill-free intervals stimulates endometriosis. Continuous use is supported by NICE NG73 and the British Society for Gynaecological Endoscopy. Amitriptyline for vulvodynia works via several mechanisms: sodium channel blockade (reduces afferent C-fibre activity), noradrenaline and serotonin reuptake inhibition (modulates pain processing), and NMDA receptor blockade (reduces central sensitisation). Starting dose is 10 mg nocte with gradual titration — this reduces sedation side effects. Response is assessed at 6–8 weeks. Alternative: duloxetine 30–60 mg OD (SNR inhibitor — particularly if depression co-exists).

Vaginal trainers (dilators) are a NICE-recommended treatment for vaginismus and are prescribable on the NHS (FP10 ACBS — Advisory Committee on Borderline Substances). Many GPs are unaware that they can prescribe dilators — this results in patients purchasing them privately when they are available free on the NHS. The sensate focus programme (Masters and Johnson, 1970) remains the gold standard psychosexual therapy approach — it systematically removes performance anxiety and penetration expectation from sexual activity and rebuilds sensory intimacy. It has strong evidence across 50+ years of use. The key message for patients with vaginismus is: this is a physical condition (involuntary muscle spasm) that is treatable — it is not a reflection of desire or attraction to their partner.

Regular vaginal stimulation (via sexual activity, masturbation, or dilator use) is evidence-based maintenance therapy for both GSM and post-vaginismus treatment — it maintains vaginal blood flow, elasticity, and lubrication. "Use it or lose it" is a genuine physiological principle for vaginal health in the postmenopausal state — vaginal atrophy accelerates without regular stimulation. Vulval hygiene avoidance of soap is critically important for vulvodynia and lichen sclerosus — many patients are inadvertently worsening their condition with daily soap washing. Studies show that 60% of vulvodynia patients use soap or antiseptic on the vulva — switching to water-only washing alone improves symptoms in 30% of cases without any pharmacological treatment.

Endometriosis significantly reduces ovarian reserve — anti-Müllerian hormone (AMH) levels are lower in women with endometriosis compared to age-matched controls, and the reduction accelerates with each surgical intervention. Women with endometriosis who wish to conceive should be advised not to delay — referral to fertility services earlier than the conventional "after 12 months trying" guideline is appropriate. NICE NG73 specifically advises earlier referral for women with known endometriosis. The annual lichen sclerosus review is a medicolegal obligation — patients with lichen sclerosus who develop vulval SCC in the absence of documented annual reviews represent a potential negligence claim. Every patient should have a written recall system in the clinical record.