A patient’s narrative of his/her illness provides essential information to determine the correct diagnosis of the presenting complaint. However, a woman’s experience of dyspareunia is usually more complicated than other medical conditions. In addition to her pain, an affected woman may experience embarrassment, shame, guilt, loss of self-esteem, frustration, depression, and anxiety. Therefore, it is important for a clinician to use communication skills that enhance openness, comfort, trust, and confidence.

In general, a woman with sexual pain will see several clinicians in an effort to evaluate and treat her condition [1]. As a result, women may feel patronized, marginalized, and ostracized from these previous encounters, which can add to the burden of their illness. It is essential for the clinician to address these feelings in order to establish a constructive and trusting relationship with patients who experience sexual pain.

Furthermore, a clinician should refrain from being either too formal or too casual when obtaining the medical history. Providers should avoid being careless with words as patients may search for meaning in everything they say. A clinician should not display extreme reactions such as surprise, grimaces, or laughter while the patient gives her narrative. Privacy and assurances of confidentiality are essential when conducting the interview. Some patients may want a spouse, sexual partner, relative, or friend present during the interview or examination. While this may allow the patient to feel more comfortable, it also may inhibit the patient from disclosing pertinent aspects of her medical, social, relationship, or sexual history.

While it is important to ask direct questions to obtain specific information such as medication usage, it is equally essential to ask open-ended questions that allow a patient to describe her experience of the condition [2]. This process can be facilitated by encouraging the patient to give as much detailed information as possible and avoiding the temptation to frequently interrupt the patient’s narrative. Throughout the whole process, displaying empathy, understanding, and acceptance is essential. Repeating the information back to the patient to confirm the accuracy of her history is also an important component.

While each clinician must establish his/her own routine, the author has found it especially helpful to provide a new patient the first 10 minutes of the interview to give her narrative of the experience of her condition. Before she starts, she is asked to try to be as specific as possible and to try to follow a sequential timeline of her disease process. She is allowed to talk virtually uninterrupted for this time. Frequently, a patient will cry, and there may be moments of silence, but this can be cathartic for her and conveys the message that she will not be rushed, ignored, or devalued in the doctor–patient relationship. If there is not enough time to focus on a specific complaint during a single visit, the patient should be reassured of the importance of her problem and scheduled for a follow-up appointment to address that issue alone.

After taking the patient’s history, it may be necessary to clarify her expectations. She may have several different complaints, so it will be important to determine which of these she feels is her chief complaint. For example, she may complain of generalized vulvar pain and burning, pain during intercourse, decreased libido, and difficulty achieving orgasm. While it is possible that one intervention can solve all of these problems, it is likely that a sequence of treatments will be needed.

Many medications can cause dyspareunia. Therefore, it is essential to develop a timeline of medication use and compare it to the timeline of the patient’s sexual pain history. Because more than 90% of women take prescription medication [7], a discussion of the most commonly prescribed medications and their association with dyspareunia is warranted. In addition, it is important to note that patients frequently do not disclose use of herbal supplements to clinicians; thus, it is important to ask about herbs, vitamins, and alternative therapies during the medication history.

Antibiotics are the most common prescription medication that women use. While antibiotics do not directly cause sexual pain, long-term exposure does predispose women to chronic yeast infections, which may be a causative agent of the pain. Hormonal contraceptives (e.g., oral contraceptives, transdermal patch, vaginal ring) are the second most common prescription medication used by reproductive-aged women. The use of oral contraceptives is highly associated with vestibulodynia (formerly termed vestibulitis), the most common cause of dyspareunia in premenopausal women. In one case-control study, women who used oral contraceptives were 9.3 times more likely to develop vestibulodynia than controls [8]. In addition, women who used low-dose ethinyl estradiol oral contraceptives were more likely to develop vestibulodynia [9]. It has also been suggested that oral contraceptives may cause vestibulodynia by decreasing free circulating testosterone which may be harmful to the epithelium of the vulvar vestibule (see Chapter 28).

Lastly, approximately 20% of reproductive-aged women use prescription medications for anxiety and depression. Psychotropic medications are more frequently implicated as a cause of hypoactive sexual desire disorder (HSDD) and female sexual arousal disorder (FSAD), than sexual pain [10]. However, both HSDD and FSAD can contribute to dyspareunia due to their effects on vaginal lubrication.

It is also important to recognize that some aspects of a patient’s medical history may be inaccurate. For instance, a woman’s self-diagnosis of a vulvovaginal yeast infection is wrong about half the time [11]. In addition, studies surprisingly show that physician-aided diagnosis of candidiasis is frequently incorrect unless microscopy and culture are used [12]. While specific data are lacking, the author frequently finds that some women have a very difficult time localizing their sexual pain. They may incorrectly identify the location of their dyspareunia; localizing it to the vagina while an examination reveals that the pain is originating from the vulva or bladder.