Assessment of vulvodynia symptoms in a sample of US women: a prevalence survey with a nested case control study

The association between vulvodynia and interstitial cystitis/bladder pain syndrome: A systematic review

BACKGROUND

Vulvodynia (VVD) is a debilitating chronic vulvar pain significantly affecting patients' quality of life. Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic and complex illness characterized by an unpleasant sensation related to the filling of the bladder and it strongly impacts patients' lives. The exact mechanisms of the two syndromes remain unknown, but there is an overlap between suspected pathophysiologies.

OBJECTIVE

To present an overview of the current research on the association between VVD and IC/BPS.

SEARCH STRATEGY

A systematic search of three electronic databases was conducted. Studies examining the correlation between VVD and IC/BPS with male and female patients aged over 18 years were included.

SELECTION CRITERIA

Studies assessing the coexistence of VVD and IC/BPS were included. Reviews, letters to the editor, conference abstracts, book chapters, guidelines, Cochrane reviews, and expert opinions were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers screened the studies for eligibility. Eligible studies were screened for quality.

MAIN RESULTS

A total of 13 studies were included in the final review. Among them, 11 presented a positive association between the two syndromes. The studies highlighted that VVD and IC/BPS share common comorbidities and possibly etiopathogenic pathways.

CONCLUSION

VVD and IC/BPS are both complex and multifactorial syndromes. This review highlights an association between them, but additional studies on the topic should be conducted for a more precise conclusion.

Investigating the overlapping presentation of irritable bowel syndrome and vulvodynia: a scoping review of the evidence and mechanisms

INTRODUCTION

Vulvodynia is a complex and multifactorial medical condition characterized by pain in the vulvar area without any identifiable cause. Vulvodynia is underdiagnosed, leading to increased risk of sexual dysfunction and reduced quality of life. Irritable bowel syndrome (IBS) is a gastrointestinal disorder predominantly affecting women. Vulvodynia and IBS frequently co-occur in women, with a 2- to 4-fold increased likelihood of IBS diagnosis in those with vulvodynia. These conditions may share underlying causes, highlighting the need for research to better understand their shared pathophysiology and develop effective therapeutics.

OBJECTIVE

The aim of this scoping review was to assess the evidence of simultaneous presentation of IBS and vulvodynia.

METHODS

A comprehensive search was conducted in 6 databases between inception of database and August 2023: PubMed, Web of Science, Scopus, Science Direct, Google Scholar, and Cochrane Library. Studies included primary research about IBS and vulvodynia in terms of presentation overlap, diagnosis, or treatment. Data were extracted from eligible studies, summarized, and collated.

RESULTS

Of the 306 unique articles identified, 33 were included in the final analysis: 20 cross-sectional studies, 4 case-control studies, 2 case reports, 4 cohort studies, 2 quasi-experimental studies, and 1 randomized trial. Common themes included a high prevalence of overlapping vulvodynia and IBS with a significant diagnostic delay in vulvodynia, mast cell involvement and visceral hypersensitization as common pathophysiology, and the need for a multimodal treatment.

CONCLUSION

Our review adds to the evidence that there is an association between vulvodynia and IBS. Despite this, research on the underlying molecular mechanisms of this association is scarce, and diagnostic delays persist for vulvodynia. Increasing awareness of the overlap of these conditions will improve screening for vulvodynia in the patient population with IBS, thereby improving the diagnostic delay, and understanding the pathophysiology will enable treatment strategies that address both conditions.

Genital Pain and the Spectrum of Bladder-Related Symptoms: Findings from the Prevention of Lower Urinary Tract Symptoms Research Consortium RISE FOR HEALTH Study, USA

INTRODUCTION AND HYPOTHESIS

Women with vulvovaginal or genital pain more commonly experience interstitial cystitis/bladder pain syndrome (IC/BPS) and urinary tract infections. However, the relationship between genital pain and bladder health is lacking.

METHODS

Women in the Prevention of Lower Urinary Tract Symptoms Consortium's RISE FOR HEALTH population-based study answered questions about bladder health globally, and across nine bladder health domains of holding, efficacy, social-occupation, physical activity, intimacy, travel, emotion, perception, and freedom. Bladder function was assessed across six indices including urinary frequency, sensation, continence, comfort, emptying, and dysbiosis (e.g., urinary tract infections). Participants were grouped by no pain beyond transitory events (i.e., minor headaches, toothaches, or sprains), nongenital-related pain only, and any genital pain using a validated pain diagram. Mean adjusted scores and indices were compared using general linear modelling.

RESULTS

Of 1,973 eligible women, 250 (12.7%) reported genital pain, 609 (30.9%) reported nongenital pain only, and 1,114 (56.5%) reported no pain. Women with any genital pain had lower (worse) adjusted mean scores across all bladder health scales (BHS; BHS global adjusted mean 47.5; 95% CI 40.8-54.1), compared with those with nongenital pain only (53.7; 95% CI 47.6-59.8), and no pain (59.3; 95% CI 53.3-65.4). Similarly, adjusted mean total Bladder Functional Index scores were lower for those with genital pain (63.1; 95% CI 58.4-67.9) compared with nongenital pain (72.1; 95% CI 67.7-76.5) and no pain (77.4; 95% CI 73.0-81.8).

CONCLUSIONS

Heightened awareness of the relationship between genital pain and bladder health should prompt clinicians caring for women with genital pain to assess bladder health and function.

Combined estrogen-progestin oral contraceptives and female sexuality: an updated review

INTRODUCTION

Sexual side effects of combined oral contraceptives (COCs) have not been fully understood, but increasing evidence prompts broader risk/benefit evaluation and merits inclusion in counseling on contraceptive options.

OBJECTIVES

The study sought to explore the impact of combined estrogens-progestin oral contraceptives on components of female sexuality, including sexual desire, anatomic genitourinary changes, lubrication, orgasm, provoked vestibulodynia, well-being, body image, partner preference, and relationship stability.

METHODS

A literature review was performed between April 2023 and January 2024 exploring the association between combined oral contraceptive pills and sexual health.

RESULTS

Although COCs decrease free testosterone, it is unclear if COCs affect sexual function, including desire. Antiandrogenic COCs do seem to have a negative effect on sexual arousal, lubrication, and orgasm. Provoked vestibulodynia may be related to early onset of COC use, low-estrogen pills, and antiandrogenic progestins. Emotional and sexual side effects are strong predictors of COC discontinuation. Longitudinal data indicate that using COCs when meeting and selecting a partner has implications on sexual satisfaction and relationship length. Analysis of data is complicated by various doses and forms of estrogen and progestin in COCs, which have changed over time.

CONCLUSION

Lack of randomized placebo-controlled studies and heterogenicity in study design hampers generalized statements about the effects of COCs on sexual function. Despite these challenges, consideration of sexual dysfunction when presenting and prescribing hormonal contraception is essential for informed consent, shared decision making, and ensuring reliable contraceptive choices.

A Network Analysis of the Fear Avoidance Model of Genital Pain

Using a novel data-driven network approach, this study aimed to examine the interconnection between the key elements of the Fear-Avoidance Model of female genital pain - sexual arousal, fear-avoidant cognitions, and motivational coping - and its associated factors to predict the intensity and frequency of genital pain across women over time. Network modeling allowed for a comprehensive evaluation of the Fear-Avoidance model while capturing the dynamic features of genital pain. We estimated a cross-sectional and a temporal, contemporaneous, and between-persons network model on convenience-based data of 543 female students (mean age = 23.7 years, SD = 3.6) collected at three time points. Results showed that lubrication, pain catastrophizing, pain avoidance, fear-avoidance beliefs, sexual satisfaction, anxiety, and frequency of coital and non-coital sex predicted pain, with lubrication being the most consistent predictor across estimations. The network of women with recurrent genital pain showed a similar pattern as the network of the total sample, except that pain avoidance and fear-avoidance beliefs rather than pain catastrophizing predicted pain directly, and frequency of coital and non-coital sexual activities played a more prominent role. These results suggest that the main problem of genital pain centers around women not being sufficiently aroused during intercourse and inadequate ways of pain coping, which are critical targets of cognitive-behavioral therapy treatment and should be developed further.

Chronic Pelvic Pain, Vulvar Pain Disorders, and Proteomics Profiles: New Discoveries, New Hopes

Chronic pelvic pain (CPP) is generally defined as non-cyclic pain perceived in the pelvic area that has persisted from three to six months or longer and is unrelated to pregnancy. The etiology of CPP is complex, multifactorial, with heterogeneous presentation, and includes several diseases such as endometriosis, adenomyosis, and interstitial cystitis/bladder pain syndrome. It may also be associated with sexual dysfunction, musculoskeletal disorders, and comorbid psychiatric symptoms. Vulvar pain disorders (VPDs) are typically categorized separately from chronic pelvic pain; among all VPDs, vulvodynia is a chronic vulvar pain of unknown etiology, lasting at least 3 months and that might be associated with other potentially linked factors. Proteomics represents a useful approach to study the proteome profiles of clinical samples. In this review, we have considered a selection of articles that have analyzed the protein abundance and novel protein species from various biological samples, including eutopic/ectopic endometrium, urine, serum, follicular, peritoneal fluid, and cervical mucus, potentially involved in the pathogenesis and progression of CPP and VPDs. These findings could represent valuable targets for paving the way for the differential diagnosis and therapeutic management of CPP and VDPs, thereby optimizing both the prevention and treatment of these conditions.

Medical Mistrust and Healthcare Seeking Among Women of Color with Chronic Vulvovaginal Pain

BACKGROUND

Chronic vulvovaginal pain (CVVP), an umbrella term encompassing several gynecological pain conditions (e.g., vulvodynia, vaginismus), has a prevalence rate of 7-8% in the USA and is characterized by considerable diagnostic delay in patient experience research. Furthermore, current research in this area focuses largely on the experiences of white women, while the experiences of women of color are underrepresented.

METHOD

In the present cross-sectional study (N = 488), we surveyed women of color (i.e., Asian, Black, and/or Hispanic/Latinx women) with CVVP about their perceptions and experiences with medical mistrust, healthcare seeking, and healthcare avoidance.

RESULTS

Using the suspicion subscale of the Group-Based Medical Mistrust Scale, we found significant racial and ethnic differences in medical suspicion scores, with non-Black Hispanic/Latinx women reporting the highest suspicion scores and non-Hispanic/Latinx Black women reporting the lowest scores. Racial differences disappeared, however, after examining medical mistrust and perceived discrimination as predictors for various healthcare outcomes related to the journey to diagnosis and healthcare avoidance behaviors. We found that while suspicion was a reliable predictor of increased diagnostic delay and healthcare avoidance in many contexts, the results for perceived discrimination were more varied, suggesting considerable nuance in the relationship between medical mistrust, perceived discrimination, and healthcare seeking outcomes.

CONCLUSION

These findings point to shared experiences of medical mistrust via suspicion that broadly characterize women of color's experiences in seeking CVVP-related care-future research is needed to examine nuances within racial and ethnic groups regarding their healthcare seeking experiences in the CVVP context.

Obstetric outcomes in women with vulvodynia or vaginismus

PURPOSE

Vulvodynia and vaginismus are common chronic vulvar pain disorders for which there is a paucity of literature on pregnancy outcomes of affected women. The study objective was to evaluate the associations between vulvodynia and vaginismus and obstetric outcomes.

METHODS

We performed a retrospective cohort study including all birth-related admissions from 1999 to October 2015 extracted from the Healthcare Cost and Utilization Project-National Inpatient Sample from the United States. Women with vulvodynia or vaginismus were identified using the appropriate ICD-9 codes. Multivariate logistic regression models, adjusted for baseline maternal characteristics, were performed to evaluate the effect of vulvodynia and vaginismus on obstetrical and neonatal outcomes.

RESULTS

A total of 879 obstetrical patients with vulvodynia or vaginismus were identified in our cohort of 13,792,544 patients admitted for delivery in US hospitals between 1999 and 2015, leading to an overall prevalence of 6 cases per 100,000 births. Between 1999 and 2015, the annual prevalence of vulvodynia or vaginismus rose from 2 to 16 cases per 100,000. Vulvodynia and vaginismus were associated with increased risks of eclampsia, chorioamnionitis, post-term pregnancy, cesarean delivery, instrumental vaginal delivery, blood transfusions, prolonged hospital stays, congenital anomalies and intrauterine growth restriction.

CONCLUSION

Vulvodynia and vaginismus in pregnancy appears underreported in pregnancy compared to reported population rates. Prevalence of reporting seems to have increased in the last decades and is associated with increased risks of maternal and newborn morbidities. Obstetrical caregivers should be aware of the underreporting of these conditions and the associated adverse effects when counseling obstetrical patients.

Fear Learning in Genital Pain: Toward a Biopsychosocial, Ecologically Valid Research and Treatment Model

Although fear learning mechanisms are implicated in the development, maintenance, exacerbation, and reduction of genital pain, systematic research on how fear of genital pain emerges, spreads, persists, and reemerges after treatment is lacking. This paper provides an overview of the literature on pain-related fear, integrates the ideas on learning and sexual arousal responding, and specifies the pathways through which compromised learning may contribute to the development and persistence of genital pain. In order to refine theories of genital pain and optimize treatments, we need to adopt a biopsychosocial framework to pain-related fear learning and uncover potential moderators that shape individual trajectories. This involves examining the role of physiological processes, subjective experiences, as well as partner and relational cues in fear acquisition, excessive generalization and impaired safety learning, extinction of fear, counterconditioning, and return of fear. Recent methodological advances in fear conditioning and sex research are promising to enable more symptom-specific and ecologically valid experimental paradigms.

Current Practices in Brazil on Diagnosis and Management of Women With Vulvodynia

OBJECTIVE

Vulvodynia (VVD) is a frequent and harrowing condition for which diagnosis and management remain insufficient. Our study aimed to describe and compare vulvovaginal signs and symptoms of Brazilian women with VVD and controls and describe previous medical assessment, past treatments, and vulvar pain relief among women with VVD.

METHODS

This cross-sectional descriptive study included Brazilian women with (n = 151) and without VVD (n = 106). All women were assessed for vaginal infection, vulvar pain intensity by means of a cotton swab test based on a numerical rate scale, and answered the Female Sexual Function Index questionnaire and a structured instrument about current vulvar symptoms. Previous treatments were assessed in the VVD group, and vulvar pain relief achieved with previous treatments was qualified through a 4-point Likert scale.

RESULTS

Volunteers were mainly White, with mean age of 30 years. Vulvovaginal signs and symptoms were significantly more frequent in women with VVD (p < .05), and vulvar pain duration was 5.8 (±4) years. More than 50% consulted with three or more physicians, and 49% remained without a conclusive diagnosis. Previous diagnosis and treatment of vulvovaginal infection were often reported by women with VVD. Most of the tried prescriptions were self-reported as providing only low vulvar pain relief.

CONCLUSIONS

Prolonged duration of vulvar pain, multiple visits to health care professionals, and poor relief of pain are common aspects in the clinical history of women with VVD. In addition to pain, vulvar fissure, edema, erythema, vaginal discharge, and foul odor are common and should be considered to avoid misdiagnosis. Appropriate treatments to VVD are still poorly reported.

Temporomandibular Joint Disorder Comorbidities

Comorbidity is a distinct additional condition that either existed or exists during the clinical course of a patient afflicted by the condition/entity in question. The clinician attempting to manage temporomandibular joint disorder (TMD) and TMD pain must realize that recognition and management of the comorbidities are essential to the successful management of the same with optimal pain control. When TMD presents with multiple comorbidities, the task for the clinician becomes more complex. It is the hope of the authors that this condensed version of TMD-associated comorbidities acts as a primer for understanding the significance of the same in pain management.

Chronic vulvar pain in gynecological outpatients

OBJECTIVES

Chronic vulvar pain (CVP) is pain in the vulvar area exceeding three months of duration. Previous studies have reported a prevalence of 7-8% in the general population and observed an association between CVP and other chronic pain, affective disorders and early life stressors. The aim of this study was to estimate the prevalence of CVP among gynecological outpatients and to explore its association with child sexual abuse, comorbid fibromyalgia and mental health.

METHODS

We conducted a questionnaire-based cross-sectional study among consecutive women attending an unselected general gynecological outpatient clinic at St Olav's University Hospital, Trondheim, Norway, during the period August 1st, 2017, to June 30th, 2018. CVP was defined as having experienced either vulvar burning, sharp pain or allodynia for three months or more within the previous year. Fibromyalgia was defined as widespread pain in the past six months in conjunction with a symptom severity score ≥5 on the fibromyalgia symptom severity score inventory, an ordinal scale from zero to 12. We collected information on sexual coercion experience and assessed mental health with the mental health inventory (MHI-5) of the SF-36 health survey, which yields a zero to five scale.

RESULTS

Of 1,125 questionnaires distributed, 810 (72%) were returned, and 762 (68%) included in final analyses. Among these, 130 (17.1%) reported CVP within the previous year and 92 (16.7%) were classified as suffering from fibromyalgia. Fibromyalgia was associated with CVP (adjusted OR of 1.8, 95% CI 1.1-3.1). Child sexual abuse was reported by 96 (13.1%) and was associated with CVP (adjusted OR 2.0, 95% CI 1.2-3.3). CVP and fibromyalgia were both associated with lower mental health scores; 0.51 and 0.58 points on the MHI-5 scale, respectively.

CONCLUSIONS

Chronic vulvar pain is common among women in a gynecological outpatient clinic and associated with child sexual abuse, comorbid fibromyalgia and worse mental health. Ethical committee number: REK Midt No. 2016/2150.

Chronic Vulvar Pain and Health-Related Quality of Life in Women with Vulvodynia

The aim of this study was to investigate the severity of chronic vulvar pain in women with vulvodynia and its impact on their health-related quality of life (QL). The study group consisted of 76 women aged 19 to 58. The study was carried out using the diagnostic survey method, i.e., (1) the questionnaire technique, comprising (A) the author's questionnaire (76 questions) and (B) the WHOQOL-BREF questionnaire, and (2) the VAS. When analyzing the severity of vulvar pain on the VAS, the highest proportion of women rated it at level 6 (23.68%). This was significantly determined by certain personal characteristics (age < 25 years old) and sociodemographic characteristics (marital status: unmarried women, divorcees, widows; high school education), each at p < 0.05. Vulvodynia causes a significant deterioration (64.47%) in QL, which is mainly caused by a reduction in the ability to perform activities of daily living (27.63%) and a decrease in sexual satisfaction (27.63%). The level of stress significantly exacerbates pain (p < 0.05). The severity correlates significantly (p < 0.05) and negatively (r < 0) with QL perception, which was rated worst in the physical domain. The use of treatment resulted in a significant improvement in the physical and psychological domains (p < 0.05), and the latter was particularly influenced by physiotherapy (p < 0.05).

Vestibular hyaluronic acid injection in provoked vestibulodynia patients and its effect on pain and sexual function: A preliminary report

OBJECTIVE

Provoked vestibulodynia (PVD) is a challenging and distressing problem for women. The aim of this study was to examine the effect of hyaluronic acid (HA) in the management of this condition.

METHOD

This is a retrospective review of 12 women diagnosed with PVD and treated with HA (19 mg/mL) applied, point-by-point, to the vestibular region at 2 mm intervals and at a depth of 0.5 mm. Women completed a pain VAS and a Female Sexual Function Index (FSFI) before and 45 days after treatment.

RESULTS

An improvement was observed both in mean FSFI scores (17.8 to 23.3; p = 0.003) and mean VAS scores (7.2 to 4.1; p = 0.002) after HA application respectively. However, on a telephone interview 3 months post treatment, five women (41.7 %) complained of recurrence of their dyspareunia.

CONCLUSION

HA is a promising management option in provoked vestibulodynia. However, further larger studies with possible alternative regimens and longer follow-up are required.

Validation of ICD-9 Codes for Identification of Chronic Overlapping Pain Conditions

Chronic overlapping pain conditions (COPCs) are a collection of chronic pain syndromes that often co-occur and are thought to share underlying nociplastic pathophysiology. Since they can manifest as seemingly unrelated syndromes they have historically been studied in isolation. Use of International Classification of Diseases (ICD) codes in medical records has been proposed as a means to identify and study trends in COPCs at the population level, however validated code sets are needed. Recently, a code set comprising ICD-10 codes as proxies for 11 COPCs was validated. The goal of this project was to validate a code set composed of ICD-9 codes for the identification of COPCs in administrative datasets. Data was extracted using the Electronic Medical Record Search Engine at the University of Michigan Health System from January 1st, 2011 to January 1st, 2015. The source population were patients with one of the candidate ICD-9 codes corresponding to various COPCs. Natural language searches were used as a reference standard. If code sets met a pre-specified threshold of agreement between ICD-9 codes and natural language searches (≥ 70%), they were retained and diagnostic accuracy statistics were calculated for each code set. Validated ICD-9 code sets were generated for 10 of the 11 COPCs evaluated. The majority had high levels of diagnostic accuracy, with all but one code set achieving ≥ 80% specificity, sensitivity, and predictive values. This code set may be used by pain researchers to identify COPCs using ICD-9 codes in administrative datasets.

Chronic Vulvovaginal Pain in Patients of Color: Benefits of Partner Supportiveness in Relation to Sexual Dissatisfaction and Distress

Within the social support literature, individuals who experience chronic pain have shown many positive outcomes and benefits when receiving the appropriate level of emotional support. In the current study, individuals who experience chronic vulvovaginal pain (CVVP) were asked about their partner’s supportiveness, other sources of emotional support, and their satisfaction and stress surrounding sexual activity. The participants (n = 333) also identified as people of color, with a majority identifying as African American or Black (n = 227). The participants indicated that their partners were overall supportive of their diagnoses and found other emotional support sources through medical professionals, vulvar/vaginal pain-specific medical information websites, and family or friends. After conducting linear regressions, results showed the partner supportiveness was associated with less distress and less dissatisfaction surrounding sexual activity. Future research is suggested to further examine social support’s role for minority patients who experience chronic vulvovaginal pain.

Exclusive manual perineal rehabilitation with lidocaine 2% gel in the treatment of provoked vestibulodynia: results from a single-arm interventional study

As of now, there is no adequate therapeutic strategy for provoked vestibulodynia (PVD). Pelvic Floor Muscle Therapy (PFMT) is a widely used technique in general pelvic floor rehabilitation. The objective of this study is to examine the effects of exclusive manual perineal rehabilitation with lidocaine 2% gel on PVD. During the first session, recruited patients (n = 68; mean age 31 ± 8.6; range: 18–52) received a questionnaire (Q1) on general well-being and health, pain of the genital area, sexual function, and symptoms during vaginal penetration. This questionnaire was based on a generalised questionnaire on the quality of life, the Medical Outcomes Study 36-item (SF-36), the Female Sexual Function Index (FSFI), and the Visual Analogue Scale (VAS). A second identical questionnaire with an additional set of open-ended questions concerning the assessment of the treatment was collected after treatment (Q2). A total of 45 questionnaires were completed. Statistical results showed a significant improvement of all items before and after treatment (p < 0.001): perceived general well-being and health, perceived vulvar pain, perceived sexual function, and perceived vaginal penetration. In conclusion, exclusive manual perineal rehabilitation using lidocaine 2% gel seems to be a safe and effective treatment option for vulvodynia in women.

The Biopsychosocial Puzzle of Painful Sex

Genital pain associated with sex is a prevalent and distressing problem with a complex research and clinical profile. This article reviews the historical context of the "sexual pain disorders" and the circuitous trajectory that has led from the first mention of painful sex in ancient documents to the latest diagnostic category of genito-pelvic pain penetration disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders as well as in other existing and proposed nomenclatures. Prominent etiologic research and emergent theoretical models are critically assessed, as is the latest treatment outcome research of note. Finally, the review points to a number of extant needs in the research and clinical effort, including an integrated biopsychosocial and multidisciplinary approach, randomized clinical trials, targeting of treatment barriers, and expansion of the entire enterprise to include populations that have not been considered. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Menstrual Cycle Characteristics and Vulvodynia

Objective: The menstrual cycle may influence vulvodynia through hormonal pathways or vulvar irritation due to menstruation or menstrual hygiene. We assessed menstrual cycle characteristics in those with and without clinically confirmed vulvodynia. Materials and Methods: Participants were recruited from the administrative database of a health care network serving ∼27% of Minneapolis-Saint Paul residents. For 220 clinically confirmed cases and 224 controls, menstrual cycle characteristics were retrospectively assessed at three time points: before age 18, the year before onset of vulvar pain, and 3 months before study participation. Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between menstrual characteristics at all three time points and vulvodynia. Models adjusted for prespecified confounders were evaluated against crude effect estimates. Results: Women with heavier menstrual flows had higher odds of vulvodynia compared with women with lighter menstrual flows during their adolescent years (OR 1.62, 95% CI 0.91-2.86), the year before onset of vulvar pain (OR = 2.11, 95% CI 1.10-4.02), and during the 3 months before study participation (OR = 1.67, 95% CI 0.91-3.06). Women with more severe cramps also had higher odds of vulvodynia compared with women with no or mild cramps during their adolescent years (OR = 2.45, 95% CI 1.45-4.15), the year before onset of vulvar pain (OR = 3.30, 95% CI 1.67-6.51), and during the 3 months before study participation (OR = 4.96, 95% CI 1.99-12.36). Women with specific premenstrual symptoms also reported higher odds of vulvodynia. Among those with vulvodynia, half reported a change in vulvar pain across the menstrual cycle, with 60% of these reporting greater pain just before and during menstruation. Furthermore, we observe a trend of decreased tampon use and increased use of sanitary pads as women with vulvodynia moved closer to their date of diagnosis. Conclusions: Menstrual cycle characteristics were associated with vulvodynia, and associations were consistent across different phases of the reproductive life cycle.

Temporal Relationships Between Pain During Intercourse (PDI), Loneliness, and Depressive Symptoms Among Women

Background

Painful sex can lead to increased psychological distress, including major depressive disorder, and the experience of loneliness may explain this association.

Aims

We aimed to investigate loneliness as a mediator between painful sex and depressive symptoms and hypothesized that women who experienced greater pain during intercourse (ie, more severe and more frequent pain) would endorse higher rates of loneliness and, in turn, higher rates of depressive symptoms at a 6-month follow-up.

Methods

Participants were 148 adults who were assigned female at birth (78.4% white, 77% partnered, 31.14 ± 10.9 years old) and completed an online, anonymous survey including the Female Sexual Function Index (FSFI), UCLA Loneliness Scale-3 (ULS), and demographic information.

Main Outcome Measure

Depressive symptoms, measured via the Patient Health Questionnaire-8 (PHQ8) at baseline (T1) and 6-month follow-up (T2) were used as the outcomes of the present study.

Results

Painful sex and ULS at T1 were significantly correlated with each other and with PHQ8 at T1 (r = 0.590). However, change in PHQ8 from T1 to T2 was not significantly correlated with ULS (r = 0.024) or any other key study variables, indicating that that ULS was not a significant mediator of the relationship between painful sex at T1 and change in PHQ8 (standardized indirect effect = 0.011; 99% CI = −0.114 to 0.188).

Conclusion

These findings are consistent with previous studies highlighting that painful sex is related to depressive symptoms through loneliness cross-sectionally, suggesting that future treatments for depressive symptoms among women who experience painful sex might target loneliness.

Stout ME, Hawkins MAW. Temporal Relationships Between Pain During Intercourse (PDI), Loneliness, and Depressive Symptoms Among Women. Sex Med 2021;9:100444.

Chronic Vulvar Pain After Female Genital Mutilation/Cutting: A Retrospective Study

INTRODUCTION

Chronic vulvar pain is a condition that affects many women during their lifetime, including women with Female Genital Mutilation/Cutting (FGM/C).

AIM

To study the prevalence and possible etiologies of chronic vulvar pain among women living with FGM/C.

METHODS

We conducted a retrospective review of consecutive medical files of 506 women who consulted our specialized clinic for women with FGM/C between April 1, 2010 and December 31, 2017. We collected sociodemographic and clinical data including information on the type of FGM/C and its complications. We focused on studying the prevalence, etiologies and characteristics of chronic vulvar pain.

MAIN OUTCOME MEASURES

Prevalence and etiologies of vulvar pain in women with FGM/C.

RESULTS

Chronic vulvar pain was present in 14 women (2.8%). Pain was unprovoked in one case (7.1%) and provoked in the 13 other cases (92.9%). In most of the cases, women presented vulvar pain related to scar complications such as clitoral or peri-clitoral adhesions or scar tissue (n = 3, 21.4%), bridle scars (n = 1, 7.1%), post-traumatic neuromas (n = 2, 14.3%) and vulvar cysts (n = 6, 42.9%), the latter being found more frequently in women with FGM/C type III. In 2 cases (14.3%) of chronic vulvar pain, no lesions other than FGM/C were visible at clinical examination. Among these 14 women, 12 suffered from superficial dyspareunia as well. The remaining ones had not had any sexual contact for several years. Dyspareunia was present in 126 women (24.9%), among which 75 patients (14.8%) suffered from superficial dyspareunia and 25 patients (4.9%) complained of deep dyspareunia. Fourteen women (2.8%) reported both superficial and deep dyspareunia. Twelve women (2.3%) reported dyspareunia with no specified localization documented in the medical charts. Dyspareunia was significantly more frequent among infibulated women compared to women with FGM/C different from type III (P = .014).

CONCLUSION

Chronic vulvar pain after FGM/C is probably associated with scar complications and FGM/C type III (infibulation). Dyspareunia is more frequent in women with FGM/C type III. Bazzoun Y, Aerts L, Abdulcadir J. Chronic Vulvar Pain After Female Genital Mutilation/Cutting: A Retrospective Study. Sex Med 2021;9:100425.

Treatment of Localized Vulvar Pain with Neural Therapy: A Case Series and Literature Review

BACKGROUND

Localized vulvar pain (LVP) is a common condition among fertile women, with physical and psychosexual implications. Treatment is complex with limited benefits. Neural therapy is a regulatory therapy that uses injections of local anesthetics in low concentrations in specific points to treat different conditions.

CASE PRESENTATION

We present the cases of 5 women, ages 33-44 years, with LVP treated with procaine 0.5% injections in painful points. Complete relief from pain occurred in 2 patients, and significant improvement in 3. Only 1 or 2 sessions were required. Initial VAS score was ≥70 and decreased to ≤30 after the intervention. The improvement was maintained over time, with a minimum follow-up period of 6 months. None of the patients were able to have sex or use tampons due to pain, but they were able to resume after the intervention.

CONCLUSIONS

In this case series, local injections of procaine showed a favorable outcome. Future randomized clinical trials could help elucidate the role of this intervention in LVP.

Evaluation of Gut Microbiota in Patients With Vulvovestibular Syndrome

Background

Vulvovestibular syndrome (VVS) or vulvodynia is a chronic, heterogeneous and multifactorial disease that dramatically affects women’s health and quality of life. Despite important advancements in understanding VVS etiology have been achieved in the past decades, VVS still remains an elusive and complex condition without identifiable causes and effective treatments. In the present observational, retrospective, case-control study, we sought to investigate whether gut dysbiosis developed in patients with VVS.

Methods

To this aim, we compared both bacterial and fungal composition in VVS patients (n = 74; 34.3 ± 10.9 years old) with those of women without gynecological symptoms (n = 13 healthy control; 38.3 ± 10.4 years old). Furthermore, to assess whether gut ecology may have an impact on gut function, the degree of intestinal inflammation (calprotectin levels) and gut permeability (zonulin levels) were also evaluated.

Results

VVS patient developed gut dysbiosis, mainly characterized by a significant increase of Escherichia coli along with increased colonization of mold/yeast compared to healthy controls. Furthermore, fecal levels of zonulin indicated that in VVS patients gut dysbiosis translated into increased gut permeability.

Conclusion

Our preliminary study, by demonstrating that alterations in gut microbiota and intestinal permeability are present in patients with VVS, highlights the novel notion that gut dysbiosis may be considered an important associated factor for VVS. These findings, if confirmed, may be clinically relevant and may help in choosing further diagnostic methods and more effective therapies for these patients.

Early Life Health in Women with Provoked Vestibulodynia and/or Vaginismus

Background: The lifetime prevalence of prolonged vulvar pain ranges from 3% to 28% among premenopausal women. Provoked vestibulodynia (PVD), often accompanied with various degrees of vaginismus, is the predominant cause. We explored the association between birth-related events and the risk of developing PVD/vaginismus during adulthood. Materials and Methods: We identified all women born in Sweden between 1973 and 2001 and categorized those with and without a diagnosis of PVD/vaginismus between 2001 and 2016 (during ages 15-43 years). Nationwide registry data were used to estimate the association between health during infancy (preterm birth, low birth weight, small for gestational age [SGA], Appearance, Pulse, Grimace, Activity and Respiration [APGAR] scores <7, and pain exposure during infancy) and the onset of PVD/vaginismus later in life using an event probability model. Results: Of the 1,359,315 women born in Sweden during 1973-2001, 9,247 were diagnosed with PVD (n = 6,648), vaginismus (n = 3,567), or both (n = 969). Preterm delivery <37 weeks (adjusted odds ratios [aOR]: 1.15, 95% confidence interval [CI]: 1.05-1.26), low birth weight <2,500 g (aOR: 1.24, 95% CI: 1.12-1.36), extremely low birth weight <1,500 g (aOR 1.41, 95% CI: 1.10-1.82), and SGA (aOR 1.20, 95% CI: 1.08-1.34) were factors associated with developing PVD/vaginismus. APGAR scores <7 or pain exposure during birth or infancy was not associated with PVD/vaginismus. Advanced maternal age, higher educational attainment, and being born in Sweden were associated with having a female offspring diagnosed with PVD/vaginismus. Conclusions: In a population of Swedish women 15-43 years of age, adverse health at birth was associated with developing PVD/vaginismus later on in life.

Psychological Inflexibility as a Predictor of Sexual Functioning Among Women with Vulvovaginal Pain: A Prospective Investigation

Objective

Persistent vulvovaginal pain affects many women and often has adverse effects on sexual functioning. Psychological inflexibility related to pain is associated with distress and functional disability across different types of chronic pain conditions, but little is known about the role of psychological inflexibility in vulvovaginal pain. The present study examines psychological inflexibility related to pain as a predictor of sexual functioning over time among women with vulvovaginal pain.

Methods

Questionnaires including measures of psychological inflexibility, pain severity, and sexual functioning were administered to female university students at two points in time. One hundred thirty women with vulvovaginal pain responded to the questionnaire at baseline and at follow-up after 10 months. A multiple regression model was used to explore psychological inflexibility and pain severity as predictors of sexual functioning at follow-up.

Results

Higher levels of psychological inflexibility and more severe pain at baseline were associated with poorer sexual functioning 10 months later. In analysis adjusting for baseline levels of sexual functioning, psychological inflexibility was the only significant predictor of sexual functioning at follow-up.

Conclusions

The findings provide preliminary evidence that psychological inflexibility is associated with sexual adjustment over time among women with vulvovaginal pain and point to the relevance of further examinations of the psychological inflexibility model in the context of vulvovaginal pain.

Characteristics of the vaginal microbiome in women with and without clinically confirmed vulvodynia

BACKGROUND

Vulvodynia (idiopathic vulvar pain) affects up to 8% of women by age 40 years, has a poorly understood etiology, and has variable treatment efficacy. Several risk factors are associated with vulvodynia from a history of yeast infections to depression and allergies. Recent work suggests an altered immune inflammatory mechanism plays a role in vulvodynia pathophysiology. Because the vaginal microbiome plays an important role in local immune-inflammatory responses, we evaluated the vaginal microbiome among women with vulvodynia compared with controls as 1 component of the immune system.

OBJECTIVE

The objective of the study was to characterize the vaginal microbiome in women with clinically confirmed vulvodynia and age-matched controls and assess its overall association with vulvodynia and how it may serve to modify other factors that are associated with vulvodynia as well.

STUDY DESIGN

We conducted a case-control study of 234 Minneapolis/Saint Paul-area women with clinically confirmed vulvodynia and 234 age-matched controls clinically confirmed with no history of vulvar pain. All participants provided vulvovaginal swab samples for culture-based and non-culture (sequencing)-based microbiological assessments, background and medical history questionnaires on demographic characteristics, sexual and reproductive history, and history of psychosocial factors. Vaginal microbiome diversity was assessed using the Shannon alpha diversity Index. Data were analyzed using logistic regression.

RESULTS

Culture and molecular-based analyses of the vaginal microbiome showed few differences between cases and controls. However, among women with alpha diversity below the median (low), there was a strong association between increasing numbers of yeast infections and vulvodynia onset, relative to comparable time periods among controls (age-adjusted odds ratio, 8.1, 95% confidence interval, 2.9-22.7 in those with 5 or more yeast infections). Also among women with low-diversity microbiomes, we observed a strong association between moderate to severe childhood abuse, antecedent anxiety, depression, and high levels of rumination and vulvodynia with odds ratios from 1.83 to 2.81. These associations were not observed in women with high-diversity microbiomes.

CONCLUSION

Although there were no overall differences in microbiome profiles between cases and controls, vaginal microbiome diversity influenced associations between environmental and psychosocial risk factors and vulvodynia. However, it is unclear whether vaginal diversity modifies the association between the risk factors and vulvodynia or is altered as a consequence of the associations.

Exploring Pain-Related Anxiety and Depression in Female Patients With Provoked Vulvodynia With Associated Overactive Pelvic Floor Muscle Dysfunction

Introduction

Vulvodynia is a chronic pain condition with potential associated factors, including musculoskeletal and psychosocial components.

Aim

This study explores the prevalence of pain-related anxiety and depression in women with provoked vestibulodynia with associated overactive pelvic floor muscle dysfunction (PVD-PFD).

Methods

A retrospective chart review of 352 women presenting to 2 urban vulvovaginal specialty clinics over the course of a year was conducted. Women presenting for initial evaluation completed validated questionnaires for pain-related anxiety and depression. Women who completed these questionnaires with a diagnosis of PVD-PFD independently confirmed by a women's health physical therapist were included in analysis. Information on previously attempted treatments was gathered.

Main Outcome Measures

Pain-related anxiety was measured with the Pain Anxiety Symptoms Scale-20 and depression with the Patient Health Questionnaire 8.

Results

Of 79 women with confirmed PVD-PFD, 22% met criteria for pain-related anxiety alone, 4% for depression alone, and 27% for both pain-related anxiety and depression, with a significant association between anxiety and depression (χ² (1) = 21.44, P < .0005, phi = 0.521). There was also a significant association between anxiety and/or depression and whether prior treatment was attempted (χ² (2) = 6.81, P = .03, phi = 0.294).

Conclusion

The study found that 49% of women with PVD-PFD experienced pain-related anxiety, with or without depression. In addition, there was a statistically significant association between attempts at prior treatment and greater pain-related anxiety and depression. This is the first study to report a rate of pain-related anxiety specifically in women with PVD-PFD. These findings are consistent with studies showing elevated pain-related anxiety in other chronic musculoskeletal conditions, including lower back pain and fibromyalgia.

Govind V, Krapf JM, Mitchell L, et al. Exploring Pain-Related Anxiety and Depression in Female Patients With Provoked Vulvodynia With Associated Overactive Pelvic Floor Muscle Dysfunction. J Sex Med 2020;8:517–524.

Vulvodynia

Vulvodynia is a condition that occurs in 8-10% of women of all ages and is characterized by pain at the vulva that is present during sexual and/or non-sexual situations. Diagnosis is established through careful medical history and pelvic examination, including the cotton-swab test. The onset and maintenance of vulvodynia involves a complex interplay of peripheral and central pain mechanisms, pelvic floor muscle and autonomic dysfunction, anxiety, depression and childhood maltreatment as well as cognitive-affective, behavioural and interpersonal factors. Given the absence of empirically supported treatment guidelines, a stepwise approach of pelvic floor physical therapy and cognitive behavioural therapy as well as medical management is suggested, with surgery as the last option. Vulvodynia has a negative effect on the quality of life of women and their partners, and imposes a profound personal and societal economic burden. In addition, women with vulvodynia are more likely to report other chronic pain conditions, which further alters their quality of life. Future efforts should aim to increase girls', women's and healthcare professionals' education and awareness of vulvodynia, phenotype different subgroups of women based on biopsychosocial characteristics among more diverse samples, conduct longitudinal studies and improve clinical trial designs.

Clinicians' Perceptions of Norwegian Women's Experiences of Infertility Diseases

BACKGROUND

Norway has one of the best health systems in the world. However, it has a low birth rate, which decreased by 21.2% between 2009 and 2018, and one of the highest rates of infertility prevalence. The aim of this study is to understand how Norwegian doctors perceive female infertility diseases, namely those that are more difficult to diagnose and to treat, and that are more common in their practice.

METHOD

Descriptive qualitative study was conducted with gynecologists and general practitioners. The sample resulted from the establishment of five criteria and on the doctors' acceptance to participate in this study. Our sample comprised thirteen highly qualified and experienced doctors. Qualitative content analysis was the method chosen to analyze the collected data.

RESULTS

Clinical diseases (polycystic ovary syndrome, endometriosis and vulvodynia) and consequences of these diseases were the pinpointed themes. These led to a set of sub-themes: the main symptoms and the treatment of the diseases, from the perspective of both women and doctors (stigmatization, disturbances in women's daily life, diagnostic delay, and governmental support).

CONCLUSIONS

The three most relevant disorders mentioned were polycystic ovary syndrome, endometriosis and vulvodynia. These diseases cause several impacts on the lives of women, because they feel stigmatized and limited in their daily life and sexuality, and the diagnosis of these diseases takes too much time. Governments should better redistribute the financing of women's health and allocate resources to specialized centers.

The association of vulvar pain and urological urgency and frequency: findings from a community-based case-control study

INTRODUCTION AND HYPOTHESIS

Vulvodynia is chronic debilitating burning vulvar pain or pain on contact. Although women who suffer from vulvodynia are more likely than others to experience co-morbid interstitial cystitis (IC) and urinary tract infections (UTIs), few studies have explored whether women with vulvodynia experience adverse urinary symptoms (lower urinary tract symptoms [LUTS]) in the absence of urological pain.

METHODS

Two hundred and eleven participants with and 226 participants without clinically confirmed vulvodynia completed the Pelvic Pain and Urgency/Frequency (PUF) questionnaire and were scored using all questions, and then a subset of questions relating only to their current frequency and bother of urination during day and night, and the frequency, severity and bother of urgency after voiding. Total, symptom, and bother scores were compared in women with and without vulvodynia, and regression models estimated adjusted odds ratios and 95% confidence intervals for the various LUTS symptoms.

RESULTS

As expected, 40% of women with vulvodynia met the criteria for IC (PUF > 12) compared with 2% without vulvodynia. After excluding questions related to bladder or vulvovaginal pain, women with vulvodynia, compared with those without, were skewed toward higher PUF scores, including being 2.4 times more likely to report usually or always bothered by night-time voiding (95% CI 1.22-4.74), and 18 times more likely to report moderate/severe urgency after urination (95% CI 5.48-64.12).

CONCLUSIONS

Women with vulvodynia are substantially more likely to report voiding dysfunction and symptoms of urgency than women with no history of vulvar pain. These findings are independent of comorbid interstitial cystitis or history of UTIs.

Exploring Hygienic Behaviors and Vulvodynia

OBJECTIVES

Vulvodynia is common and characterized by vulvar discomfort and pain. However, few studies have assessed hygienic practices in relation to onset. We investigated whether hygienic behaviors were associated with the onset of vulvodynia.

MATERIALS AND METHODS

We assessed a self-reported history of personal hygienic behaviors, including wearing tight-fitting clothing, vulva care and genital washing, pubic hair removal, douching, and powdering, a year before first reported onset of vulvar pain among 213 clinically confirmed cases and a similar time period among 221 general population controls.

RESULTS

Compared with women who reported never wearing tight-fitting jeans or pants, women wearing tight-fitting jeans or pants 4 or more times per week had twice the odds of vulvodynia (95% CI = 1.14-3.95). Relative to controls, women with vulvodynia were substantially less likely to report use of soaps and gels to cleanse the vulva (95% CI = 0.17-0.63). Among women who chose to remove pubic hair, those who removed pubic hair from the mons pubis compared with bikini-area only hair removal, were 74% more likely to have vulvodynia (95% CI = 1.05-2.89). Finally, compared with women who reported bikini-area only hair removal less than monthly, those who removed hair from the mons pubis weekly or more were nearly 2 times more likely to be vulvodynia cases (95% CI = 0.83-3.49).

CONCLUSIONS

Wearing tight-fitting jeans or pants and removing hair from the mons pubis area were associated with increased odds of vulvodynia. Research on how hygienic practices could influence vulvar pain in larger and more temporally addressed populations is warranted.

Prevalence of dyspareunia and vulvodynia in a Colombian clinic sample: A pilot survey

Objective:

The primary objective of our research was to determine the prevalence of dyspareunia and vulvodynia in a limited clinical sample of Colombian women.

Methods:

The study was composed of women who were seen in local Colombian medical clinics. A pilot survey was designed in Spanish to obtain patients’ demographic and medical history. Harlow’s validated questionnaire was incorporated into our survey to screen for dyspareunia and vulvodynia.

Results:

Five hundred and eighty-two women completed the survey and 96.2% (N = 560) reported being sexually active. The survey response rate was 96%. Among those who were initially screened and reported being sexually active, 51.8% (N = 290; 95% confidence interval: 47.7%–55.9%) described having pain with intercourse (dyspareunia) and 25.9% (N = 145; 95% confidence interval: 22.4%–29.7%) did not have pain. Of those who were sexually active, Harlow’s validated questionnaire was completed by 490 women: 27.6% (N = 135; 95% confidence interval: 23.7–31.75) described vulvar pain lasting longer than 3 months (vulvodynia); 51.9% (95% confidence interval: 43.1%–60.5%) had burning pain; 42.4% (95% confidence interval: 33.8%–51.0%) had sharp stabbing pain; 69.6% (95% confidence interval: 61.1%–77.2%) reported having pain during intercourse (dyspareunia).

Conclusion:

In this select population sample, the prevalence of dyspareunia ranged from 51.8% using a general survey to 69.6% using a validated questionnaire. The prevalence of vulvodynia was 27.6% (95% confidence interval: 23.7–31.75). This is higher than the prevalence of dyspareunia (45%) and vulvodynia (3%–16%) reported in the US general population.

Thermal and Mechanical Pain Thresholds of Women With Provoked Localized Vulvodynia: A Pilot Study

Context

Vulvodynia is a chronic pain condition defined as vulvar pain lasting at least 3 months in the absence of gross anatomic or neurologic findings. Provoked, localized vulvodynia (PLV), a subtype of vulvodynia, is characterized by vestibular pain in response to light touch. The cause of PLV remains largely unknown, and triggering events have yet to be determined.

Objective

To evaluate vestibular and peripheral experimental pain thresholds in patients with PLV to further define the somatosensory profile of these patients.

Methods

After informed consent was provided, eligible participants completed a questionnaire and underwent quantitative sensory testing at the forearm and posterior vestibule. Detection and pain thresholds to thermal (cold and heat) and mechanical (pressure) stimuli were measured.

Results

Seventeen participants with PLV and 16 control participants were included. Participants in the PLV group scored lower on the patient health questionnaire 9 (PHQ-9) compared with those in the control group (P<.05) and had higher ratings of self-reported genital pain with sex (P<.001) and daily activity (P<.05). Forearm pain thresholds to cold (P<.01) and heat (P<.01) stimuli were also lower in the PLV group compared with those in the control group. Vestibular pain thresholds to cold (P<.05) and pressure (P<.01) stimuli were also lower in the PLV group.

Conclusion

Lower scores on the PHQ-9 and higher self-reported genital pain ratings of patients with PLV highlight the significant impact of this poorly understood condition on quality of life. Quantitative sensory testing results demonstrated that vestibular cold allodynia may be a somatosensory feature of PLV. Reduced forearm pain thresholds in these patients suggest altered sensory processing at extrapelvic sites, although it is unclear whether these measurements are related to central sensitization.

Vulvodynia in adolescents: presentation, diagnosis and treatment options

PURPOSE OF REVIEW

Vulvodynia in adults is a significant source of genital and sexual pain with far reaching negative repercussions. Well designed studies with sufficient power in adults are limited and there are even fewer in adolescents. This review will help the clinician understand, diagnose and treat vulvodynia in adolescents based on current knowledge.

RECENT FINDINGS

Although research on vulvodynia in adolescents is lacking, studies suggest that it not only exists but also may negatively impact an adolescent's medical and sexual health. This review will look at both historical approaches to vulvodynia, as well as more current approaches. It is important to note that no treatment modalities have been specifically approved for use in vulvodynia.

SUMMARY

Vulvodynia in women is known to have significant impact on general health and sexual wellbeing. How early vulvodynia presents is unknown, but it appears that in at least some cases, it can be found in adolescents. Providers of adolescent care should have knowledge of this pain disorder so that they may appropriately diagnose and manage this multifactorial problem.

Patterns in Vulvodynia Treatments and 6-Month Outcomes for Women Enrolled in the National Vulvodynia Registry-An Exploratory Prospective Study

BACKGROUND

Vulvodynia is a poorly characterized condition with multiple treatment options that have been described as largely ineffective in research settings.

AIM

To describe treatment patterns in women enrolled in the National Vulvodynia Registry and determine if there is an association between selected treatments and patient-reported outcomes such as pain, sexual function, and psychological distress after 6 months of treatment.

METHODS

Participants completed questionnaires on general medical history and patient-reported outcomes using the short-form McGill Pain Questionnaire, the Female Sexual Function Index, the Short Form-12 quality-of-life questionnaire, the Coping Strategies Questionnaire, and the State-Trait Anxiety Inventory. The evaluation also included pain sensitivity assessment of the vaginal mucosa using a cotton-tipped applicator and the vaginal muscles using a single-digit. In this prospective cohort study, all measurements were collected at baseline and again at 6 months after treatment.

OUTCOMES

Type of treatment, number of treatments, self-reported pain intensity, dyspareunia, and pain-related psychological distress measures are reported at baseline and 6 months.

RESULTS

Of 344 women enrolled, 282 received treatment; 78 different treatments were identified and categorized by type (eg, topical, oral, physical therapy) and number. The most commonly used treatments were topical (85%, n = 241), physical therapy (52%, n = 147), and oral medications (45%, n = 128). Notably, 73% of participants received ≥2 treatments. There was no association between type or number of treatments and patient characteristics. At 6 months, women reported improvements in general pain (P = .001), pain during intercourse (P = .001), catastrophizing (P = .000), and anxiety (P = .000). The Short Form-12 quality-of-life questionnaire showed improvements in physical limitations (P = .024), emotional limitations (P = .003), well-being (P = .025), and social function (P = .010). However, all domains of the Female Sexual Function Index indicated worsening in sexual function (P = .000) except for pain.

CLINICAL TRANSLATION

Multi-modal treatments were most commonly used in clinical practice and improvements in patient-reported outcomes such as quality of life, distress, and pain were noted; however, participants who returned at 6 months continued to report poor sexual function.

CONCLUSIONS

Strengths include a prospective and long-term study design that evaluated women in clinical settings. Limitations include a high rate of loss to follow-up for certain measures and inability to evaluate efficacy of individual treatments. In a setting where women were receiving highly specialized care, we found wide variation in the type and number of treatments used to treat vulvodynia. Despite this heterogeneity in treatment selection, women reported significant improvements in all study measures except sexual function. Lamvu G, Alappattu M, Witzeman K, et al. Patterns in Vulvodynia Treatments and 6-Month Outcomes for Women Enrolled in the National Vulvodynia Registry-An Exploratory Prospective Study. J Sex Med 2018;15:705-715.

Recovering from provoked vestibulodynia: Experiences from encounters with somatocognitive therapy

Although provoked vestibulodynia (PVD) represents a significant challenge for many young women in the Western world, little is known about how these women experience therapeutic efforts. The aim of this paper is to enhance our knowledge of the way that the therapeutic process is experienced by women with PVD undergoing somatocognitive therapy (SCT). The study enhances insight into this recently developed therapy through a detailed description of the physiotherapy approach. The empirical data are based on interviews with six women who participated in SCT. The empirical data analysis is guided by thematic analysis. Our findings demonstrate how the women experience SCT as a bodily process of wholeness. The process of wholeness relates to new experiences in the women's own bodies, awareness of muscular and mental tension and relaxation, breathing patterns, and perceptions focusing on pain. The findings are presented as three interrelated themes: 1) sensitizing the body as an interconnected unit; 2) incorporating the painful pubic region into the body; and 3) developing a new understanding of oneself. The women who participated in this study found that SCT contributed significantly to the process of their recovery from PVD.

Vulvodynia: a consideration of clinical and methodological research challenges and recommended solutions

Vulvodynia, an idiopathic chronic vulvar pain, is a prevalent genital pain condition that results in significant impairment to sexual, relational, and psychological functioning of affected women and their romantic partners. Despite its high prevalence, there remain gaps in knowledge and health care access for women coping with vulvodynia, given its varied clinical presentation and no widely accepted treatment protocol. The past several decades have seen important advancements in understanding vulvodynia and developing effective treatments; however, progress has been impeded due to clinical and methodological challenges in conducting research with this vulnerable population. This review presents a brief overview of vulvodynia correlates, consequences, etiology, and treatment, and then turns its attention to considering the clinical and methodological challenges that hinder vulvodynia research. Identifying these barriers alongside potential mitigating solutions is essential to developing empirically supported treatments for all women affected by vulvodynia, across all age and minority groups. Potential solutions will require researchers to broaden eligibility criteria, examine subgroups of women, and expand definitions of treatment outcomes, and may be best facilitated by more active collaboration among research groups and across relevant disciplines. Engagement in these solutions may contribute to more representative findings and the development and dissemination of empirically based treatment options for this complex pain condition.

Recurrent Yeast Infections and Vulvodynia: Can We Believe Associations Based on Self-Reported Data?

OBJECTIVE

We determined whether self-reported new or recurrent yeast infections were a risk factor for and/or consequence of vulvodynia and then determined the extent to which various levels of misclassification of self-reported yeast infections influenced these results.

MATERIALS AND METHODS

In this case-control study we retrospectively assessed self-reported new and recurrent yeast infections prior and subsequent to first vulvar pain onset among 216 clinically confirmed cases and during a similar time period for 224 general population controls.

RESULTS

A history of >10 yeast infections before vulvodynia onset was strongly but imprecisely associated with currently diagnosed vulvodynia after adjustment for age, age at first intercourse, and history of urinary tract infections [adjusted odds ratio = 5.5, 95% confidence interval (CI) 1.7-17.8]. Likewise, a history of vulvodynia was associated with a twofold risk of subsequent new or recurrent onset of yeast infections after adjustment for age, age at first intercourse, and history of yeast infections before vulvodynia onset (comparable time period among controls, 95% CI 1.5-2.9). Bias analyses showed that our observed associations were an underestimation of the true association when nondifferential misclassification of self-reported yeast infections and certain differential misclassification scenarios were present. However, if women with vulvodynia more frequently misreported having them when they truly did not, our observed associations were an overestimate of the truth.

CONCLUSIONS

There appears to be a positive relationship between yeast infections preceding and following the diagnosis of vulvodynia, but this relationship varies from strong to nonexistent depending on the relative accuracy of the recalled diagnosis of yeast infections among cases and controls. To better understand the bidirectional associations between yeast infections and vulvodynia, future validation studies are needed to determine the extent to which misclassification of self-reported yeast infections differs between women with and without vulvodynia.

Clinical profile of persistent genito-pelvic postpartum pain

OBJECTIVE*: the primary aim was to describe the pain characteristics of persistent genito-pelvic postpartum pain (PPP) and compare these characteristics by mode of delivery. The secondary aim was to incorporate psychosocial variables into the conceptualization of PPP by exploring the relationship among postpartum depressive symptoms, fatigue, and PPP.

DESIGN

cross-sectional study design.

SETTING

online survey.

PARTICIPANTS

106 women recruited from the community who gave birth within twelve months prior to completing the survey.

MEASUREMENTS AND FINDINGS

questionnaire regarding sociodemographic information, pregnancy and childbirth variables, depressive symptoms (Edinburgh Postnatal Depression Scale), and fatigue (Fatigue Symptom Checklist). Women who were ≥3 months postpartum and indicated they were still experiencing any genito-pelvic pain from childbirth were provided questions about their current pain experience. Twenty-seven (25.5%) women were between 3-12 months postpartum and currently experiencing PPP. The intensity of pain was mild, and had multiple locations and triggers. Compared to women whose acute pain resolved after childbirth, women with PPP were more likely to have had a Caesarean section (15.2% versus 33.3%). Other birth-related (i.e., epidural/spinal anesthesia use during vaginal birth) and psychosocial variables (income) also differentiated women with PPP from women whose gentio-pelvic pain resolved. Postpartum fatigue independently predicted PPP (Odds ratio = 4.7), while postpartum depressive symptoms did not.

KEY CONCLUSIONS

PPP was quite prevalent in this sample, and while the intensity of pain was on average, mild, the pain was widespread in terms of location and triggers. Multiple biopsychosocial factors differentiated women with persistent postpartum pain from those women whose pain resolved.

IMPLICATIONS FOR PRACTICE

PPP is a common health concern for new mothers in the first year postpartum, and may be best addressed by health care professionals using a multidimensional approach, which focuses on the psychosocial aspects of pain.

Painful sex (dyspareunia) in women: prevalence and associated factors in a British population probability survey

Objective

To estimate the prevalence of painful sex among women in Britain, and to explore associated sexual, relationship and health factors that should be considered in assessment.

Design

Multi‐stage, clustered and stratified population probability sample survey, using computer‐assisted self‐interview. Sample frame was the British Postcode Address File.

Setting

Participants interviewed at home between 2010 and 2012.

Sample

A total of 15 162 adults aged 16–74 years (8869 women). Data reported from 6669 sexually active women.

Methods

Age‐adjusted logistic regressions to examine associations between painful sex and indicators of sexual, relational, mental and physical health.

Main outcome measure

Physical pain as a result of sex for ≥3 months in the past year, plus measures of symptom severity.

Results

Painful sex was reported by 7.5% (95% CI 6.7–8.3) of sexually active women, of whom one‐quarter experienced symptoms very often or always, for ≥6 months, and causing distress. Reporting painful sex was strongly associated with other sexual function problems, notably vaginal dryness (age adjusted odds ratio 7.9; 6.17–10.12), anxiety about sex (6.34; 4.76–8.46) and lacking enjoyment in sex (6.12; 4.81–7.79). It was associated with sexual relationship factors [such as not sharing same level of interest in sex (2.56; 1.97–3.33)], as well as with adverse experiences such as non‐volitional sex (2.17; 1.68–2.80). Associations were also found with measures of psychological and physical health, including depressive symptoms (1.68; 1.28–2.21).

Conclusion

Painful sex is reported by a sizeable minority of women in Britain. Health professionals should be supported to undertake holistic assessment and treatment which takes account of the sexual, relationship and health context of symptoms.

Tweetable abstract

Painful sex—reported by 7.5% of women in Britain—is linked to poorer sexual, physical, relational and mental health.

Painful sex–reported by 7.5% of women in Britain–is linked to poorer sexual, physical, relational and mental health.

This article includes Author Insights, a video abstract available at https://vimeo.com/rcog/authorinsights14518.