Female infertility is a multifaceted issue that can arise from various underlying causes. The primary categories of female infertility include ovulatory disorders, tubal factors, endometriosis, and other medical conditions. Each of these categories encompasses specific conditions that can significantly impact a woman's ability to conceive.

Ovulatory disorders account for approximately 25% of infertility cases, with conditions such as Polycystic Ovary Syndrome (PCOS) being prevalent . Tubal factors, often resulting from pelvic inflammatory disease or previous surgeries, can also significantly impact fertility . Understanding these causes allows clinicians to tailor their approach to each patient effectively.

• Thorough Evaluation is Key: A comprehensive assessment, including medical history, physical examination, and diagnostic tests, is essential for identifying the underlying causes of infertility. Hormonal assessments and imaging studies are critical components of this process.

• 
  

• Targeted Management Based on Cause: Management should be tailored to the specific diagnosis. Ovulatory disorders may benefit from lifestyle changes and medications, while tubal factor infertility may require surgical intervention or assisted reproductive technologies (ART).

• 
  

• Importance of Specialist Referral: Timely referral to a fertility specialist or reproductive endocrinologist is essential, especially for cases requiring advanced interventions. Collaboration with specialists ensures patients receive the most appropriate care for complex infertility issues.

• 
  

• Evidence-Based Approach: Staying updated on the latest evidence-based guidelines enables primary care clinicians to provide optimal initial care and recognize when specialist input is necessary.

1. **Abebe, M., Afework, M., & Abaynew, Y.** (2020). Primary and secondary infertility in Africa: systematic review with meta-analysis. *Fertility Research and Practice, 6*(1). [https://doi.org/10.1186/s40738-020-00090-3](https://doi.org/10.1186/s40738-020-00090-3)
2. **Abrão, M., Muzii, L., & Marana, R.** (2013). Anatomical causes of female infertility and their management. *International Journal of Gynecology & Obstetrics, 123*(S2). [https://doi.org/10.1016/j.ijgo.2013.09.008](https://doi.org/10.1016/j.ijgo.2013.09.008)
3. **Boltz, M., Sanders, J., Simonsen, S., & Stanford, J.** (2017). Fertility treatment, use of in vitro fertilization, and time to live birth based on initial provider type. *The Journal of the American Board of Family Medicine, 30*(2), 230-238. [https://doi.org/10.3122/jabfm.2017.02.160184](https://doi.org/10.3122/jabfm.2017.02.160184)
4. **Dhananjaya, S., Madhu, K., & Amiti, A.** (2014). Role of diagnostic hysterolaparoscopy in evaluation of primary and secondary infertility. *Journal of Evolution of Medical and Dental Sciences, 3*(9), 2194-2207. [https://doi.org/10.14260/jemds/2014/2126](https://doi.org/10.14260/jemds/2014/2126)
5. **Hinton, L., Kurinczuk, J., & Ziebland, S.** (2012). Reassured or fobbed off? Perspectives on infertility consultations in primary care: a qualitative study. *British Journal of General Practice, 62*(599), e438-e445. [https://doi.org/10.3399/bjgp12x649133](https://doi.org/10.3399/bjgp12x649133)
6. **Kabadi, Y., & Harsha, B.** (2016). Hysterolaparoscopy in the evaluation and management of female infertility. *The Journal of Obstetrics and Gynecology of India, 66*(S1), 478-481. [https://doi.org/10.1007/s13224-016-0863-5](https://doi.org/10.1007/s13224-016-0863-5)
7. **Khanuja, P., Sunny, J., & Pawar, S.** (2017). Study on infertility—etiology, medication therapy management, and outcomes at a tertiary care hospital. *International Journal of Infertility & Fetal Medicine, 8*(3), 106-112. [https://doi.org/10.5005/jp-journals-10016-1158](https://doi.org/10.5005/jp-journals-10016-1158)
8. **Madhuri, N., Rashmi, H., Sujatha, M., & Dhanyata, G.** (2019). Role of diagnostic hysterolaparoscopy in the evaluation of female infertility. *International Journal of Research in Medical Sciences, 7*(5), 1531. [https://doi.org/10.18203/2320-6012.ijrms20191630](https://doi.org/10.18203/2320-6012.ijrms20191630)
9. **Nida, .., Qureshi, M., Usman, H., Akram, A., Khan, S., Jawad, N., … & Bhutta, M.** (2022). A cross-sectional study on serum follicle stimulating hormone and luteinizing hormone in patients with anovulatory disorders with primary infertility. *PJMHS, 16*(12), 490-492. [https://doi.org/10.53350/pjmhs20221612490](https://doi.org/10.53350/pjmhs20221612490)
10. **Nour-Eldein, H.** (2013). Family physicians’ attitude and practice of infertility management at primary care - Suez Canal University, Egypt. *Pan African Medical Journal, 15*. [https://doi.org/10.11604/pamj.2013.15.106.1762](https://doi.org/10.11604/pamj.2013.15.106.1762)
11. **Palmer-Wackerly, A., Voorhees, H., D'Souza, S., & Weeks, E.** (2019). Infertility patient-provider communication and (dis)continuity of care: an exploration of illness identity transitions. *Patient Education and Counseling, 102*(4), 804-809. [https://doi.org/10.1016/j.pec.2018.12.003](https://doi.org/10.1016/j.pec.2018.12.003)
12. **Stanford, J., Carpentier, P., Meier, B., Rollo, M., & Tingey, B.** (2021). Restorative reproductive medicine for infertility in two family medicine clinics in New England, an observational study. *BMC Pregnancy and Childbirth, 21*(1). [https://doi.org/10.1186/s12884-021-03946-8](https://doi.org/10.1186/s12884-021-03946-8)
13. **Verma, K., & Baniya, G.** (2016). A comparative study of depression among infertile and fertile women. *International Journal of Research in Medical Sciences*, 3459-3465. [https://doi.org/10.18203/2320-6012.ijrms20162312](https://doi.org/10.18203/2320-6012.ijrms20162312)

Starting in September 2024, significant reforms to death certification laws in the UK will enhance the accuracy, quality, and scrutiny of mortality data. These updates aim to streamline the certification process while ensuring that key details about the cause of death are carefully reviewed and documented.

One of the central changes includes the addition of medical examiners who will independently review each Medical Certificate of Cause of Death (MCCD), adding a level of verification to support attending practitioners and improve public health insights. The new MCCD format now has more detailed sections to record the chain of events leading to death and includes specific fields for information on ethnicity, maternal status, and any medical devices or implants.

These updates will impact clinical practice by improving the precision of death reporting, providing crucial data for national and local health analysis, and ensuring a supportive process for families during bereavement. The following outlines the main changes and their implications for healthcare providers in the UK.

Key Impact on GPs in the UK

The 2024 reforms to the UK death certification process, particularly the removal of Cremation Form 4, are expected to impact GP incomes due to the elimination of payments previously associated with the form. 

1. Removal of Cremation Form 4:

   • Change: Cremation Form 4, which required a doctor’s certification for cremation cases, has been permanently removed for all deaths in England and Wales as of September 9, 2024.
   • Financial Impact: The removal of this form eliminates a long-standing source of additional income for GPs, especially for resident doctors who frequently completed these forms. GPs were typically compensated for each Cremation Form 4 completed, which represented a modest but steady income.

Sharing Patient Records with Medical Examiners:

• Change: GPs are now required to share relevant parts of the deceased patient’s medical records or a summary with the Medical Examiner.
• Impact: This requires GPs to prepare and provide patient information in a timely manner, usually within 72 hours of the death, adding an administrative task. However, as most cases do not require a verbal discussion with the Medical Examiner, the administrative burden is partially managed, though still unpaid.

New Obligations without Payment:

• Change: Under the new system, doctors must declare any hazardous implants directly on the Medical Certificate of Cause of Death (MCCD), replacing what was previously documented on the cremation form.
• Impact: This additional responsibility is considered a statutory obligation with no associated fee, adding unpaid administrative work for doctors.

Transition to Mandatory Medical Examiner Review:

• The requirement for all MCCDs to be reviewed by a Medical Examiner for cases not referred to a coroner adds another layer of review without direct compensation for GPs.
• Impact: This change not only removes payments from cremation form fees but may also increase administrative workload, as GPs must prepare information for Medical Examiners without additional pay.
• 
  

No Requirement for Verbal Discussion:

• Change: In most cases, GPs are not required to have a direct conversation with the Medical Examiner, as records or summaries typically suffice.
• Impact: This limits time spent on discussions and may streamline the referral process, though the GP still needs to compile and provide relevant documentation for review.

Timeframe for Referral:

• Change: GPs or duty clinicians are expected to send the referral to the Medical Examiner typically within 72 hours of the death occurring.
• Impact: This new timeframe creates an additional administrative deadline for GPs to meet. While it ensures prompt certification, it may increase pressure on GPs to complete records-sharing quickly, adding to their workload, particularly in busy practices or in cases where record compilation is time-consuming.

Support from Medical Examiners for Complex Cases:

• Change: Medical Examiners can assist GPs with complex cases, especially where coroner notification is necessary.
• Impact: Although there’s no financial compensation involved, this support can reduce the administrative and procedural burden for GPs in challenging cases, ensuring that complex certifications are handled more accurately and efficiently.

Nationwide and Permanent Change:

• This change affects all GPs across England and Wales, marking a shift in an additional income source that many GPs previously had benefited from.
• 
  
• Impact: The nationwide reform means all practitioners will experience the same financial adjustments, with no flexibility or alternative income from the removed cremation form fees.

References

1. https://www.parkmedical.org.uk/2024/10/02/sept-2024-new-medical-examiner-changes-for-death-certificates/
2. https://www.gov.uk/government/publications/changes-to-the-death-certification-process
3. https://www.kctrust.co.uk/blog/revolutionising-death-certificates
4. https://portcullis-surgery.co.uk/changes-to-the-death-certification-and-registration-process-effective-from-september-2024/
5. https://www.nafd.org.uk/2024/09/09/death-certification-reforms-in-england-and-wales-go-live-just-after-midnight/
6. https://www.gov.uk/government/publications/changes-to-the-death-certification-process/an-overview-of-the-death-certification-reforms
7. https://www.england.nhs.uk/long-read/national-medical-examiners-guidance-for-england-and-wales/
8. https://www.reddit.com/r/doctorsUK/comments/1fnlzwd/cremation_form_and_fee_removed_for_doctors/
9. https://www.gov.scot/publications/funeral-expense-assistance-scotland-amendment-regulations-2024-business-regulatory-impact-assessment/
10. https://www.gov.uk/government/collections/cremation-forms-and-guidance
11. https://www.gov.uk/government/publications/medical-practitioners-guidance-on-completing-cremation-forms

Vulvodynia is a complex and often misunderstood condition characterized by chronic vulvar pain without an identifiable cause. It can manifest as either provoked pain, which occurs upon touch or pressure, or unprovoked pain, which arises spontaneously. This condition significantly impacts the quality of life of affected individuals, leading to physical, psychological, and social challenges. The prevalence of vulvodynia is notable, with estimates suggesting that it affects approximately 8-12% of women, indicating a substantial public health concern that primary care clinicians must address (Cox & Neville, 2012; Kim et al., 2019).

**Risk Factors for Vulvodynia:**

1. **Biological Factors**
- **Neurogenic Inflammation**: Increased nervous system sensitivity and hyperinnervation in the vulvar region, often due to chronic inflammation or injury, can lead to persistent pain【Barry et al., 2019; Tonc, 2023】.
- **Hormonal Influences**: Fluctuations in estrogen levels can affect vulvar tissue sensitivity and increase pain perception【Sacinti, 2023】.
- **Comorbid Conditions**: Disorders like interstitial cystitis, commonly seen alongside vulvodynia, can intensify symptoms and complicate diagnosis【Kahn et al., 2010; Reed et al., 2014】.

2. **Psychological Factors**
- **Mental Health History**: Anxiety, depression, or trauma, especially from sexual abuse, increases the risk for vulvodynia【Silva et al., 2023; Tribó et al., 2019】.
- **Pain-Psychology Connection**: Psychological distress can amplify pain, contributing to vulvodynia's persistence【Tribó et al., 2019; Bergeron et al., 2014】.
- **Comorbid Psychological Disorders**: High prevalence of anxiety and depression among vulvodynia patients complicates treatment【Thornton & Drummond, 2015; Sadownik, 2014】.

3. **Social Factors**
- **Adverse Experiences**: Childhood trauma and negative relationships increase susceptibility to chronic pain, potentially due to maladaptive coping【Sacinti, 2023; Bergeron et al., 2014】.
- **Societal Stigma**: Stigma around sexual health and pain can cause isolation and delay treatment-seeking, worsening outcomes【Bergeron et al., 2014; Sadownik, 2014】.

Understanding these multifactorial risk factors is crucial for effective management and patient support in cases of vulvodynia.

**References:**

1. Chisari, C., & Chilcot, J. (2017). The experience of pain severity and pain interference in vulvodynia patients: the role of cognitive-behavioural factors, psychological distress, and fatigue. *Journal of Psychosomatic Research, 93*, 83-89. https://doi.org/10.1016/j.jpsychores.2016.12.010
2. Cohen-Sacher, B., Haefner, H., Dalton, V., & Berger, M. (2015). History of abuse in women with vulvar pruritus, vulvodynia, and asymptomatic controls. *Journal of Lower Genital Tract Disease, 19*(3), 248-252. https://doi.org/10.1097/lgt.0000000000000075
3. Cox, K., & Neville, C. (2012). Assessment and management options for women with vulvodynia. *Journal of Midwifery & Women's Health, 57*(3), 231-240. https://doi.org/10.1111/j.1542-2011.2012.00162.x
4. Khandker, M., Brady, S., Vitonis, A., MacLehose, R., Stewart, E., & Harlow, B. (2011). The influence of depression and anxiety on the risk of adult-onset vulvodynia. *Journal of Women’s Health, 20*(10), 1445-1451. https://doi.org/10.1089/jwh.2010.2661
5. Kim, S., Kim, J., & Yoon, H. (2019). Sexual pain and IC/BPS in women. *BMC Urology, 19*(1). https://doi.org/10.1186/s12894-019-0478-0
6. Paszkowski, T., & Baszak-Radomańska, E. (2021). Vulvodynia in prepubertal girls: diagnosis. *Ginekologia Polska.* https://doi.org/10.5603/gp.a2021.0190
7. Patla, G., Mazur-Biały, A., Humaj-Grysztar, M., & Bonior, J. (2023). Chronic vulvar pain and health-related quality of life in women with vulvodynia. *Life, 13*(2), 328. https://doi.org/10.3390/life13020328
8. Reed, B., Harlow, S., Sen, A., Edwards, R., Chen, D., & Haefner, H. (2012). Relationship between vulvodynia and chronic comorbid pain conditions. *Obstetrics and Gynecology, 120*(1), 145-151. https://doi.org/10.1097/aog.0b013e31825957cf
9. Tersiguel, A., Bodéré, C., Schöllhammer, M., Postec, E., Quinio, B., Brenaut, E., & Miséry, L. (2015). Screening for neuropathic pain, anxiety, and other associated chronic pain conditions in vulvodynia: a pilot study. *Acta Dermato-Venereologica, 95*(6), 749-751. https://doi.org/10.2340/00015555-2053
10. Torres-Cueco, R., & Nohales-Alfonso, F. (2021). Vulvodynia—it is time to accept a new understanding from a neurobiological perspective. *International Journal of Environmental Research and Public Health, 18*(12), 6639. https://doi.org/10.3390/ijerph18126639
11. Barry, C., Matusica, D., & Haberberger, R. (2019). Emerging evidence of macrophage contribution to hyperinnervation and nociceptor sensitization in vulvodynia. *Frontiers in Molecular Neuroscience, 12.* https://doi.org/10.3389/fnmol.2019.00186
12. Bergeron, S., Likes, W., & Steben, M. (2014). Psychosexual aspects of vulvovaginal pain. *Best Practice & Research Clinical Obstetrics & Gynaecology, 28*(7), 991-999. https://doi.org/10.1016/j.bpobgyn.2014.07.007
13. Kahn, B., Tatro, C., Parsons, C., & Willems, J. (2010). Prevalence of interstitial cystitis in vulvodynia patients detected by bladder potassium sensitivity. *Journal of Sexual Medicine, 7*(2_Part_2), 996-1002. https://doi.org/10.1111/j.1743-6109.2009.01550.x
14. Reed, B., Legocki, L., Plegue, M., Sen, A., Haefner, H., & Harlow, S. (2014). Factors associated with vulvodynia incidence. *Obstetrics and Gynecology, 123*(2), 225-231. https://doi.org/10.1097/aog.0000000000000066
15. Sacinti, K. (2023). Is vulvodynia associated with an altered vaginal microbiota?: a systematic review. *Journal of Lower Genital Tract Disease, 28*(1), 64-72. https://doi.org/10.1097/lgt.0000000000000780
16. Sadownik, L. (2014). Etiology, diagnosis, and clinical management of vulvodynia. *International Journal of Women's Health, 437.* https://doi.org/10.2147/ijwh.s37660
17. Silva, V., Silva, G., Sousa, M., Pereira, R., Barbosa, A., & Lima, J. (2023). Physical and social repercussions generated in women with vulvodynia: a bibliographical review. *International Journal of Health Science, 3*(8), 2-5. https://doi.org/10.22533/at.ed.159382331016
18. Thornton, A., & Drummond, C. (2015). Current concepts in vulvodynia with a focus on pathogenesis and pain mechanisms. *Australasian Journal of Dermatology, 57*(4), 253-263. https://doi.org/10.1111/ajd.12365
19. Tonc, E. (2023). Immune mechanisms in vulvodynia: key roles for mast cells and fibroblasts. *Frontiers in Cellular and Infection Microbiology, 13.* https://doi.org/10.3389/fcimb.2023.1215380
20. Tribó, M., Canal, C., Baños, J., & Robleda, G. (2019). Pain, anxiety, depression, and quality of life in patients with vulvodynia. *Dermatology, 236*(3), 255-261. https://doi.org/10.1159/000503321

Vaginismus is a complex and often misunderstood condition characterized by involuntary contractions of the pelvic floor muscles, which can hinder vaginal penetration and cause significant distress for affected women.

The DSM-5 defines vaginismus as part of the broader category of Genito-Pelvic Pain/Penetration Disorder (GPPPD). This disorder encompasses difficulties with vaginal penetration, often accompanied by pain, fear, or marked tightening of the pelvic floor muscles.

DSM-5 Definition of Vaginismus (as part of Genito-Pelvic Pain/Penetration Disorder)

Genito-Pelvic Pain/Penetration Disorder includes persistent or recurrent difficulties in one (or more) of the following areas:

1. Vaginal penetration during intercourse.
2. Marked vulvovaginal or pelvic pain during vaginal intercourse or attempted penetration.
3. Marked fear or anxiety about pain in anticipation of, during, or as a result of vaginal penetration.
4. Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.
5. 
   

Diagnostic Criteria:

• The symptoms must cause significant distress or interpersonal difficulty.
• The symptoms must be present for at least 6 months.
• The symptoms cannot be better explained by a nonsexual mental disorder, a medical condition, or the effects of a substance or medication.

Epidemiology

• Prevalence is estimated at 1-7% of women worldwide, though exact figures are challenging to determine due to underreporting.
• Most commonly affects women in their late teens to early 30s.
• Women seeking Tx for sexual dysfunction: 21-48% (Eserdağ et al., 2021; Ferreira & Souza, 2012)

Risk Factors

Presentation

Management requires a holistic, multidisciplinary approach targeting both psychological and physical factors. Clinicians must adopt a compassionate, sensitive method, recognizing the emotional and physiological aspects influencing patient comfort and cooperation in treatment.

Broad Principles of Management

1. Comprehensive Evaluation

   • Obtain detailed Hx: gynecological, obstetric, sexual, and urological.
   • Conduct genital exam (external/internal), assessing for anomalies, scarring, or inflammation.
   • Approach pelvic exams gradually, prioritize patient comfort and consent, and be prepared to pause or reschedule as needed.
   • 
     

2. Tailored, Multidisciplinary Approach

   • Behavioral Therapies: CBT for addressing anxiety, fear, and negative associations with intimacy.
   • Pelvic Floor Physical Therapy: Gradual muscle relaxation and control techniques.
   • Systematic Desensitization: Progressive vaginal dilator use, focusing on patient’s tolerance and goals.
   • 
     

3. Patient Education & Communication

   • Provide open, stigma-free information on sexual health, normalizing discussion around vaginismus to reduce shame and embarrassment.
   • Support patient’s own goals (e.g., pain-free intercourse, tampon use, or comfortable exams).
   • 
     

4. Partner Involvement & Sensate Focus

   • Involve partner (if applicable) in structured intimacy exercises to build trust, focusing on non-penetrative touch and reducing performance anxiety.
   • 
     

5. Pharmacological Interventions (if indicated)

   • Topical Anesthetics (e.g., lidocaine) or Botulinum Toxin Injections in select cases to alleviate pain and muscle spasm.
   • Topical Estrogen: Beneficial in cases with vulvovaginal atrophy or dryness (especially peri-/postmenopausal).
   • 
     

6. Consideration for Pregnant Patients

   • Recognize unique challenges in pregnant patients with vaginismus, ensuring supportive obstetric care to prevent avoidance due to past negative experiences or lack of provider understanding.
   • 
     

7. Assisted Reproduction Options

   • For patients aiming for conception, provide information on assisted reproductive options where vaginismus hinders natural conception efforts.

Women with vaginismus generally have a favorable prognosis, especially with appropriate treatment, which often leads to significant symptom improvement and greater sexual satisfaction. Success can depend on factors such as the condition’s duration, any coexisting psychological issues, and support from partners and healthcare providers. GPs play a key role in creating a supportive environment for open discussions on sexual health, helping to ensure timely diagnosis and effective treatment.

**References:**

1. Eserdağ et al. "Insights into the Vaginismus Treatment by Cognitive Behavioral Therapies: Correlation with Sexual Dysfunction Identified in Male Spouses of the Patients." *Journal of Family & Reproductive Health* (2021). doi:10.18502/jfrh.v15i1.6079
2. Ferreira and Souza. "Botulinum Toxin for Vaginismus Treatment." *Pharmacology* (2012). doi:10.1159/000337383
3. Marthasari et al. "Vaginismus and Infertility." *Indonesian Andrology and Biomedical Journal* (2020). doi:10.20473/iabj.v1i2.33
4. Banaei et al. "Bio-Psychosocial Factor of Vaginismus in Iranian Women." *Reproductive Health* (2021). doi:10.1186/s12978-021-01260-2
5. Muammar et al. "Management of Vaginal Penetration Phobia in Arab Women: A Retrospective Study." *Annals of Saudi Medicine* (2015). doi:10.5144/0256-4947.2015.120
6. Ramanathan et al. "Common Pitfalls in the Management of Vaginismus in Couples With Subfertility in India." *Journal of Psychosexual Health* (2022). doi:10.1177/26318318221089600
7. Demirci and Kabukçuoğlu. "‘Being a Woman’ in the Shadow of Vaginismus: The Implications of Vaginismus for Women." *Current Psychiatry Research and Reviews* (2020). doi:10.2174/2666082215666190917153811
8. Çankaya and Aslantaş. "Determination of Sexual Attitude, Sexual Self-Consciousness, and Sociocultural Status in Women With and Without Lifelong Vaginismus: A Case-Control Study." *Clinical Nursing Research* (2022). doi:10.1177/10547738221103334
9. Pereira et al. "Physiotherapy Protocol with Interferential Current in the Treatment of Vaginismus."
10. Pacik et al. "Case Series: Redefining Severe Grade 5 Vaginismus." *Sexual Medicine* (2019). doi:10.1016/j.esxm.2019.07.006
11. Çankaya and Aslantaş. "Determination of Dyadic Adjustment, Marriage and Sexual Satisfaction as Risk Factors for Women with Lifelong Vaginismus: A Case Control Study." *Clinical Nursing Research* (2021). doi:10.1177/10547738211046136
12. Pacik and Geletta. "Vaginismus Treatment: Clinical Trials Follow-Up on 241 Patients." *Sexual Medicine* (2017). doi:10.1016/j.esxm.2017.02.002
13. Zarski et al. "Efficacy of Internet-Based Guided Treatment for Genito-Pelvic Pain/Penetration Disorder: Rationale, Treatment Protocol, and Design of a Randomized Controlled Trial." *Frontiers in Psychiatry* (2018). doi:10.3389/fpsyt.2017.00260
14. Pacik. "Vaginismus: Review of Current Concepts and Treatment Using Botox Injections, Bupivacaine Injections, and Progressive Dilation with the Patient Under Anesthesia." *Aesthetic Plastic Surgery* (2011). doi:10.1007/s00266-011-9737-5
15. Achour et al. "Vaginismus and Pregnancy: Epidemiological Profile and Management Difficulties." *Psychology Research and Behavior Management* (2019). doi:10.2147/prbm.s186950

Premature ejaculation (PE) is a prevalent male sexual dysfunction characterized by ejaculation that occurs before or shortly after vaginal penetration, leading to distress and dissatisfaction in sexual relationships. The condition affects approximately 20% to 30% of men at some point in their lives, making it a significant concern in primary care settings (Eid, 2023; Saitz & Şerefoğlu, 2016).

The causes of PE can be summarised as

Management - Quick summary

**References:**

1. **Asimakopoulos, A., Miano, R., Agrò, E., Vespasiani, G., & Spera, E.** (2012). Does current scientific and clinical evidence support the use of phosphodiesterase type 5 inhibitors for the treatment of premature ejaculation? A systematic review and meta-analysis. *Journal of Sexual Medicine*, **9**(9), 2404-2416. [https://doi.org/10.1111/j.1743-6109.2011.02628.x](https://doi.org/10.1111/j.1743-6109.2011.02628.x)

2. **Ayribas, B., & Toprak, T.** (2020). New approach to patients with premature ejaculation: Do social cognition and attachment profiles play a role in premature ejaculation? *Andrologia*, **53**(1), e13882. [https://doi.org/10.1111/and.13882](https://doi.org/10.1111/and.13882)

3. **Bagcioglu, E., Efe, E., Bahçeci, B., & Söylemez, H.** (2013). Prematür ejakülasyon hastalarında mizaç ve karakter farklılıkları. *Nöro Psikiyatri Arşivi*, **50**(4), 332-336. [https://doi.org/10.4274/npa.y6443](https://doi.org/10.4274/npa.y6443)

4. **Chen, Z., Yuan, M., Ma, Z., Wen, J., Wang, X., Zhao, M., ... & Guo, L.** (2020). Significance of piezo-type mechanosensitive ion channel component 2 in premature ejaculation: An animal study. *Andrology*, **8**(5), 1347-1359. [https://doi.org/10.1111/andr.12779](https://doi.org/10.1111/andr.12779)

5. **Cooper, K., James, M., Kaltenthaler, E., Dickinson, K., Cantrell, A., Wylie, K., ... & Hood, C.** (2015). Behavioral therapies for management of premature ejaculation: A systematic review. *Sexual Medicine*, **3**(3), 174-188. [https://doi.org/10.1002/sm2.65](https://doi.org/10.1002/sm2.65)

6. **Doğan, K.** (2023). The effects of behavioral therapy given to men with premature ejaculation on symptoms and their partners’ sexual functioning and sexual quality of life. *Journal of Health Sciences and Medicine*, **6**(5), 974-980. [https://doi.org/10.32322/jhsm.1341975](https://doi.org/10.32322/jhsm.1341975)

7. **Doğan, K., & Keçe, C.** (2023). Comparison of the results of stop-start technique with stop-start technique and sphincter control training applied in premature ejaculation treatment. *PLOS ONE*, **18**(8), e0283091. [https://doi.org/10.1371/journal.pone.0283091](https://doi.org/10.1371/journal.pone.0283091)

8. **Eid, A.** (2023). Evaluation of serum prolactin and testosterone in premature ejaculation patients. *Journal of Advances in Medicine and Medical Research*, **35**(20), 222-241. [https://doi.org/10.9734/jammr/2023/v35i205193](https://doi.org/10.9734/jammr/2023/v35i205193)

9. **Guo, J., Wang, F., Zhou, Q., Qian, G., Gao, Q., Zhang, R., ... & Jannini, E.** (2020). Safety and efficacy of traditional Chinese medicine, *Qiaoshao* formula, combined with dapoxetine in the treatment of premature ejaculation: An open-label, real-life, retrospective multicentre study in Chinese men. *Andrologia*, **53**(1), e13915. [https://doi.org/10.1111/and.13915](https://doi.org/10.1111/and.13915)

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13. **Saitz, T., & Şerefoğlu, E.** (2016). The epidemiology of premature ejaculation. *Translational Andrology and Urology*, **5**(4), 409-415. [https://doi.org/10.21037/tau.2016.05.11](https://doi.org/10.21037/tau.2016.05.11)

14. **Santtila, P., Jern, P., Westberg, L., Walum, H., Pedersen, C., Eriksson, E., ... & Sandnabba, N.** (2010). The dopamine transporter gene (DAT1) polymorphism is associated with premature ejaculation. *Journal of Sexual Medicine*, **7**(4 Pt 1), 1538-1546. [https://doi.org/10.1111/j.1743-6109.2009.01696.x](https://doi.org/10.1111/j.1743-6109.2009.01696.x)

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Dyspareunia, defined as persistent pain during or after sexual intercourse, is a multifactorial cpndition. The causes of dyspareunia can be broadly categorized into physical, psychological, and situational factors, each contributing to the patient's experience of pain.

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