Medical interventions for dyspareunia target the disease entity believed to be causing the pain, and include such dissimilar interventions as intravaginal application of oestrogen cream or anaesthetic ointment, surgical repair of the vulvar region, and the extraction of abnormal growths in the adjacent viscera. (85) When dyspareunia has been a long-standing problem medical correction is seldom sufficient treatment, regardless of physical pathology; the psychological fear of the pain recurring persists.(86,87) Fordney(86) reported that 16 out of 18 women who underwent medical procedures for dyspareunia did not improve until completing a course of sex therapy. Similarly, Schover et al.(87) noted that the factors that predicted the best post-surgical outcome for a group of women with vulvar vestibulitus were their willingness to engage in psychological treatment, higher socio-economic status, and specific localized areas of vulvar pain.

Vaginismus is typically treated through a combination of the following:

1. banning intercourse;

2. in vivo graduated self-insertion of dilators of increasing size;

3. systematic desensitization;

4. Kegel exercises (see above);

5. interpretation of resistance and psychodynamic fears.

Masters and Johnson(!9 reported a 100 per cent success rate in their treatment of 29 women. Similarly, Scholl reported that 83 per cent of his sample successfully completed therapy and were having intercourse at the 1-year follow-up.(88) Spence(26> suggests that more treatment sessions are required when women have experienced the dysfunction over extended periods of time, have undergone surgery, have thoughts that they are anatomically abnormal, or have negative attitudes toward their genitals. Fewer treatment sessions were related to a strong desire for pregnancy, the presence of an assertive husband, and the woman's knowledge about sexuality.

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