A psychosocial approach to female genital pain

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.

Role of sexuality in women with chronic pain: Results from an Italian cross-sectional study on chronic headache, fibromyalgia, and vulvodynia

Background/objectives

To compare sexual functioning, genital pain, and satisfaction among women diagnosed with various Chronic pain (CP) conditions. Additionally, it seeks to explore the role of sexual factors in predicting levels of central sensitization (indicative of CP-related mental and physical distress), physical, and mental quality of life (QoL) for each condition individually.

Methods

From April 2023 to January 2024, 1006 women categorized into five groups (Chronic Headache - CH; Fibromyalgia - FM, Vulvodynia - VU, Comorbidity group - CO, and Healthy Controls - HC) completed an online protocol.

Results

All groups reported sexual impairment: VU group exhibited the highest genital pain prevalence (97.93 %), followed by CO (74.29 %) and FM (55.91 %). ANCOVAs indicated lower sexual functioning scores for FM, VU, and CO compared to HC and CH. VU and CO reported lower satisfaction scores than other groups. Genital pain emerged as the primary predictor of central sensitization across all groups except controls. Regarding mental QoL, sexual satisfaction was significant for CH and CO, while genital pain and sexual satisfaction were significant for VU.

Conclusion

This study emphasizes the importance of integrating genito-pelvic pain assessment and addressing related sexual difficulties in CP diagnostics and care to enhance overall well-being and QoL.

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.

Pelvic floor physical therapy and mindfulness: approaches for chronic pelvic pain in women-a systematic review and meta-analysis

PURPOSE

Chronic pelvic pain (CPP) in women is a complex syndrome and symptoms are associated with sexual dysfunction, musculoskeletal and myofascial disorders, and comorbid psychiatric disorders. Its widespread prevalence results in substantial expense due to therapy and lost productivity, and it is perhaps one of the most urgent and neglected medical needs. This systematic review and meta-analysis aimed to estimate the role of mindfulness and pelvic floor physical therapy (PFPT) in the treatment or management of women with CPP.

METHODS

This systematic review (CRD42020204987) searched for relevant publications between January 2000 and November 2020 on MEDLINE/PubMed, Web of Science, One File GALE, and Technology Research databases using the following search terms: chronic pelvic pain, pelvic floor physical therapy/physiotherapy, mindfulness, and their variants. Risk of bias and quality of evidence were evaluated.

RESULTS

Seven clinical trials (n = 279) were included in the review, and five in the meta-analysis (n = 225). For the pain outcome and its catastrophizing, there was a statistical difference for the Pain Catastrophizing Scale after treatment and during follow-up with mindfulness and PFPT (MD = - 3.82 [- 6.97, - 0.68], p = 0.01, and MD = - 4.49 [- 7.61, - 1.37], p = 0.00, respectively). Sexual function, assessed by the female sexual function index, differed significantly during follow-up between PFPT and mindfulness (MD = - 0.72 [- 1.38, - 0.05], p = 0.03).

CONCLUSION

The small number of studies applying both PFPT and mindfulness to CPP suggests that a multidisciplinary approach is required to treat women with CPP, and further studies involving these therapeutic techniques throughout the CPP cycle are needed.

Non-pharmacological therapies for treating chronic pelvic pain in women: A review

Chronic pelvic pain (CPP) is an intricate condition with multiple etiologies that lead to indefinite pain mechanisms. Physicians and researchers are challenged in its treatment, and the combined therapy of pharmacologic and non-pharmacologic treatment has been recognized as a multidisciplinary approach cited by guidelines and adopted in clinical practice. As an alternative therapy for CPP, non-pharmacologic therapies benefit patients and deserve further study. This study reviews the literature published from January 1991 to April 2022 on non-pharmacologic therapies for CPP in adult women. Based on a survey, this review found that the most commonly used non-pharmacological therapies for CPP include pelvic floor physical therapy, psychotherapy, acupuncture, neuromodulation, and dietary therapy. By evaluating the efficacy and safety of each therapy, this study concluded that non-pharmacological therapies should be included in the initial treatment plan because of their high degree of safety and low rate of side effects. To fill the lack of data on non-pharmacologic therapies for CPP, this study provides evidence that may guide treatment and pain management.

Predictors of vaginal penetration in women with Provoked Vestibulodynia

This study examined whether time, treatment type, baseline individual differences, and treatment satisfaction affected the vaginal intercourse trajectories of women with Provoked Vestibulodynia (PVD) before and after psychological treatment. Women (N = 130) who received CBT or MBCT completed questionnaires prior to and 2-4 weeks, 6-, and 12-months following treatment. The odds of women engaging in vaginal penetration increased by 31% at each assessment. Baseline individual differences and treatment satisfaction predicted maintenance of or re-engagement in vaginal penetration at post-treatment. Findings suggest that women who refrain from vaginal intercourse after treatment differ from women who continue or resume this activity.

Clinical use and implications of sexual devices and sexually explicit media

Given that sexual pleasure is a core component of sexual health, devices that are designed to enhance and diversify sexual pleasure are particularly useful in clinical practice. Despite their growing popularity and widespread use in various biopsychosocial circumstances, many taboos still seem to exist, as indicated by the paucity of scientific literature on the prevalence, application and effectiveness of sexual devices for therapeutic use. However, sex toys and sexual devices are commonly used and have a variety of indications to expand individual and partnered sexuality and to treat sexual difficulties. Different devices are associated with specific advantages and potential risks, opportunities, barriers and ethical challenges when used in a clinical context. Increased knowledge about the aim and functional possibilities of sexual devices might help health-care professionals overcome potential embarrassment, preconceptions and other barriers, learn which patients might benefit from which products, consider their use in treatment programmes, educate about correct use and safety issues, and facilitate open communication about sexual pleasure with their patients.

Exploring the Effect of a Promotion and Prevention Regulatory Focus on Subjective Responses to Vaginal Sensations in a Laboratory Research Design

BACKGROUND

Self-regulation is an important process to explain sexual, emotional, and pain-related responses in the context of genital pain. Although highly relevant, self-regulatory focus theory is not well integrated into the literature on genital pain.

AIM

This study explored the impact of a promotion and prevention regulatory focus on genital pain responding. Sex would typically endorse a promotion focus, whereas pain during sex is likely to provoke a prevention focus oriented toward harm avoidance and safety.

METHOD

We induced gradually increasing vaginal pressure in a sample of 56 women using an intra-vaginal balloon that simulated potentially painful vaginal sensations. Women were first primed with a promotion vs prevention focus by making them list their ideals vs responsibilities as a sexual partner. We measured trait regulatory focus, pleasant and painful vaginal pressure sensations, sexual arousal, expectations, and approach-avoidance motivational tendencies.

MAIN OUTCOME

The effect of trait and state promotion and prevention regulatory focuses on the appraisal of vaginal pressure and sexual arousal.

RESULTS

When primed with a prevention compared with a promotion focus, women with a predominant prevention orientation reported less sexual arousal, less pleasant vaginal pressure appraisals, and lower approach tendencies regarding sexual stimuli. Women who experienced a match between their state and trait promotion focus appraised the vaginal pressure as less painful. No significant effects of regulatory focus were found on the expectancy measures.

STRENGTHS AND LIMITATIONS

We provided first evidence on self-regulatory motivation in the context of genital pain responses using an experimentally controlled laboratory design. Our sample was small and consisted of young students without (a clinical diagnosis of) genital pain, which limits our conclusions on the effect of promotion vs prevention regulation on genital pain responses.

CLINICAL IMPLICATIONS

Future research is needed to examine the clinical value of self-regulation and regulatory fit and to identify possible ways to target self-regulatory motivation in clinical interventions of genital pain.

CONCLUSION

Self-regulatory focus theory has clear potential to explain the sexual and motivational correlates of genital pain. Dewitte M and Kindermans H. Exploring the Effect of a Promotion and Prevention Regulatory Focus on Subjective Responses to Vaginal Sensations in a Laboratory Research Design. J Sex Med 2021;18:303-314.

Levels of Depression and Anxiety, Sexual Functions, and Affective Temperaments in Women With Lifelong Vaginismus and Their Male Partners

BACKGROUND

Depression and anxiety levels, sexual dysfunctions, and affective temperament characteristics of women with lifelong vaginismus (LLV) and their male partners may have important effects on the development, maintenance, and exacerbation of LLV.

AIM

We aimed to investigate depression and anxiety levels, sexual dysfunctions, and affective temperament characteristics of both women with LLV and their male partners.

METHODS

56 women with LLV, their 56 male partners, and 44 couples with no complaints of any sexual function as a control group were included in this study. Dyadic data were analyzed using the Actor-Partner Interdependence Model.

OUTCOMES

The Beck Depression Inventory, Beck Anxiety Inventory, Golombok Rust Inventory of Sexual Satisfaction, and Temperament Evaluation of Memphis, Pisa, Paris and San Diego Auto Questionnaire Scale were completed by all participants.

RESULTS

Women with LLV had higher levels of anxiety and depression and had more sexual dysfunctions except for avoidance than those of female controls. Temperament Evaluation of Memphis, Pisa, Paris and San Diego Auto Questionnaire Scale scores were significantly higher in women with LLV for depressive (odds ratio [OR] = 1.27, 95% CI = 1.09-1.49), cyclothymic (OR = 1.31, 95% CI = 1.15-1.49), anxious (OR = 1.22, 95% CI = 1.09-1.38), and irritable (OR = 1.22, 95% CI = 1.04-1.42) temperament than in female controls. It was found that anxiety levels of male partners of women with LLV were higher than those of male controls and that they experienced less sexual satisfaction. Depressive (OR = 1.31, 95% CI = 1.07-1.61) and cyclothymic (OR = 1.18, 95% CI = 1.04-1.34) temperament scores were significantly higher in male partners of women with LLV than in male controls. The Actor-Partner Interdependence Model analyses show that hyperthymic temperament in male partners of women with LLV and anxious and depressive temperament in women with LLV have a negative effect on their own sexual functions. In terms of partner effect, it was found that men with hyperthymic temperament had a negative effect on the sexual functions of women with LLV and men with depressive temperament had a positive effect.

CLINICAL IMPLICATIONS

The individual characteristics of both the women and their male partners have an impact on LLV.

STRENGTHS & LIMITATIONS

The sample size was relatively small to assess affective temperaments. The inclusion of male partners in the study contributed to our understanding of couples with LLV.

CONCLUSION

Our results indicate that affective temperaments detected in women with LLV (depressive, cyclothymic, anxious and irritable) and their male partners (depressive and cyclothymic) have an effect on the development, maintenance, and exacerbation of LLV, and affective temperaments have an effect on both their own and partner's sexual functions. Turan Ş, Usta Sağlam NG, Bakay H, et al. Levels of Depression and Anxiety, Sexual Functions, and Affective Temperaments in Women With Lifelong Vaginismus and Their Male Partners. J Sex Med 2020;17:2434-2445.

Cognitive behavioral therapy for the treatment of chronic pelvic pain

Chronic pelvic pain (CPP) in women is defined as noncyclical and persistent pain lasting more than six months perceived to be related to the pelvis. There are many etiologies that can cause CPP, including gynecologic, urologic, gastrointestinal, musculoskeletal, neurologic, and psychosocial. There is a strong association between psychological factors and CPP. It has been noted that almost half of women being treated for CPP report a history of sexual, physical, or emotional trauma. Women with CPP have been noted to have higher rates of psychological disorders in comparison to their peers. For men, the most common etiology for CPP is chronic prostatitis and there are also correlations with psychological disorders. There are many different treatment options for CPP: surgical, pharmacological, and non-pharmacological (alternative therapies). Cognitive-behavioral therapy may be another option when treating chronic pelvic pain syndrome and should be considered.

Genital Pain and Sexual Functioning: Effects on Sexual Experience, Psychological Health, and Quality of Life

BACKGROUND

Genital pain (GP) is a common symptom in women of reproductive age. The prevalence of GP is difficult to gauge as it has been underreported by both patients and clinicians and neglected in clinical studies despite wide recognition of the adverse effects to women's health.

AIM

The purpose of the present study was 3-fold: (i) to explore the self-reported presence and perception of GP and its association with sexual functioning, sexual distress, emotions, psychopathology, and quality of life (QoL); (ii) to explore if, controlling for the pain effect, women with Female Sexual Function Index (FSFI) scores indicating sexual dysfunction also reported worse outcomes regarding sexual distress, emotions, psychological health, and QoL than GP women with higher FSFI scores; and (iii) to evaluate the effects of GP duration, comparing women with GP with shorter (<6 months) duration of symptoms with women with longer (≥6 months) duration of symptom of GP on sexual functioning, distress, emotions, psychopathology and QoL.

METHODS

A total of 1,034 women (age ranges between 18 and 40 years) from the Italian general population completed a web survey on sexual health.

OUTCOMES

6 self-report questionnaires exploring different biopsychosocial factors were assessed: the FSFI, the Female Sexual Distress Scale, the Positive and Negative Affect Schedule, the Short Form McGill Pain Questionnaire adapted for GP, the Short Form 36, and the Symptom Check List-90-Revised.

RESULTS

Women who reported GP (n = 319) indicated generally lower sexual function than women without GP (n = 648; P = .036). They reported a higher level of sexual distress (P < .001), more negative emotions related to sexual experiences (P = .001), lower scores in all QoL domains (P < .001), and higher levels of psychopathological symptoms (P < .001). Controlling for pain effects, women whose FSFI scores indicated sexual dysfunction (n = 150) reported higher rates of sexual distress than women whose FSFI scores indicated normal sexual function (n = 169; P < .001). The scores also indicated fewer positive (P < .001) and more negative emotions (P < .001) related to sexuality, lower QoL (P < .001) and significantly higher psychological burden (P < .001). Moreover, women experiencing GP for ≥6 months reported significantly lower means on the FSFI total score (P < .05; especially in the desire, satisfaction, and pain domains), distress (P < .001), and emotions (P < .05) than women experiencing GP duration <6 months. No significant differences were found on the QoL and the psychopathological symptoms.

CLINICAL IMPLICATIONS

GP is significantly pervasive, but a high percentage of sexual problems and related emotional suffering is overlooked. Raising awareness about this issue is critical, both among clinicians and the general public.

STRENGTHS & LIMITATIONS

The present study highlighted important characteristics of GP from a community sample; the results indicate problems related to pain experiences and their repercussions on sexual, psychological, affective health, and QoL. Major limitations are related to the use of self-report measures via a web-based study.

CONCLUSION

The results provide evidence of a lack of awareness regarding pain experiences as they relate to sexual functioning in women; clinicians would be advised to more fully investigate sexual functioning and psychosocial variables associated with GP during routine consultation beginning with the first onset of the symptoms. Nimbi FM, Rossi V, Tripodi F, et al. Genital Pain and Sexual Functioning: Effects on Sexual Experience, Psychological Health, and Quality of Life. J Sex Med 2020; 17:771-783.

Extracorporeal shock wave therapy for treatment of vulvodynia: a prospective, randomized, double-blind, placebo-controlled study

BACKGROUND

Currently, there are no effective therapy strategies for idiopathic, non-organic vulvodynia in women. ESWT (extracorporeal shock wave therapy) is a nonsurgical/noninvasive technique widely used to treat musculoskeletal diseases, muscle spasticity and hypertonia, renal and biliary calculi and urological disorders.

AIM

We examined the effects of ESWT on vulvodynia in women.

DESIGN

A prospective, randomized, double-blind, placebo-controlled study was conducted between 2015 and 2018 following a feasibility study.

SETTING

Obstetrics and Gynecology Hospital departments.

POPULATION

The study included 62 women with vulvodynia for at least 3 months.

METHODS

The women were randomly assigned to either a treatment group (N.=31) or a placebo group (N.=31). The patients in the treatment group received perineally applied ESWT weekly (3000 pulses each for four consecutive weeks). The energy flux density was 0.25 mJ/mm2, frequency 4 Hz, focus zone 0-30 mm, therapeutic efficacy 0-90 mm, stand-off II. The device used was a standard electromagnetic shock wave unit with a focused shock wave handpiece. The position of the shock wave transducer was changed six times after every 500 pulses. Patients in the placebo group underwent the same treatment procedure, but the handpiece was provided with a placebo stand-off that disabled energy transmission. Subjective pain was self-evaluated by each patient using two tools before and after treatment: a 10 cm linear visual analogue scale (VAS, 0-10) and a cotton-swab test (CST, Goetsch scale 0-4). Follow-ups were done 1, 4, and 12 weeks post-ESWT.

RESULTS

In all, 61 women completed the study. We tested for differences in the VAS and CST within and between the treatment and placebo groups. The testing was between before treatment and particular follow-up. We found significant changes in the treatment group. Reductions in VAS (P<0.01) and CST (P<0.01) were observed at all three follow-ups. At all assessments, pain reduction was always >30%. In the placebo group there were no statistically significant changes between before and after treatment. There were no differences between the treatment and placebo groups before treatment but statistically significant differences at all three follow-ups (VAS P<0.01); CST P<0.01).

CONCLUSIONS

ESWT seems to reduce pain perception in our treatment group. Thus, we are encouraged to explore this technique further.

CLINICAL REHABILITATION IMPACT

The method is easily replicable, inexpensive, and without known side effects.

Relationship Context Moderates Couple Congruence in Ratings of Sexual Arousal and Pain During Vaginal Sensations in the Laboratory

Genital pain is a social experience that needs to be studied as a dyadic interaction between partners. The present study relied on a sample of 42 heterosexual couples to examine the level of congruence between both partners' ratings of pain and sexual arousal in response to experimentally induced vaginal pressure that served as a simulation of vaginal sensations during penetration. We also inferred the men's ability to estimate their partner's level of pain and sexual arousal. Because the relationship has shown to influence pain estimations, we considered the moderating role of perceived partner responsiveness and relationship satisfaction. We found higher disagreement in pain ratings when vaginal pressure was induced in the context of a sexual film compared to a neutral film, with men overestimating the level of pain in women. Also sexual arousal ratings diverged between partners, with men underestimating their partners' level of sexual arousal during the induction of vaginal pressure, regardless of whether they were watching a sexual or neutral film. Importantly, the level of congruence between actual and estimated ratings of pain and sexual arousal depended on how relationally satisfied men and women were and how validated and supported women felt by their male partner. These results make an important contribution to the growing literature on the social determinants of sexual pain experiences.

The Effects of Partner Presence and Sexual Stimulation on the Appraisal of Vaginal Pressure and Sexual Arousal

BACKGROUND

Sex research lacks experimental studies in which both partners participate in a laboratory procedure. This is relevant in the context of genital pain because painful vaginal sensations often occur in the presence of the partner.

AIM

To examine the effects of partner presence, sexual stimulation, and vaginal pressure on the appraisal of vaginal sensations and sexual arousal, ultimately aiming to increase the ecologic validity of laboratory designs.

METHODS

A community sample of 42 women and their male partners watched sexual and neutral films while separated or together. We induced gradually increasing vaginal pressure in the women using an intravaginal inflatable rubber balloon.

OUTCOMES

Women reported on pleasant and painful vaginal pressure and perceived genital arousal. Men and women reported on subjective sexual arousal. We also examined whether these appraisals were moderated by relationship satisfaction.

RESULTS

The appraisal of vaginal pressure varied as a function of relationship satisfaction. Less satisfied women reported more painful pressure than women who were highly satisfied and highly satisfied women appraised the pressure as more pleasant in the context of a sex film and in the presence (vs absence) of their partner. In men and women, although partner presence had a negative effect on subjective sexual arousal, the presence of the partner did increase women's perception of genital arousal when vaginal pressure was induced during a sex film, particularly when women felt highly satisfied with their relationship. Also, the effects on subjective sexual arousal were moderated by relationship satisfaction. For couples in which the woman was less satisfied, the induction of vaginal pressure resulted in higher subjective sexual arousal when the partner was absent compared with when he was present, whereas when the man felt less satisfied, partner presence had a positive effect on sexual arousal.

CLINICAL IMPLICATIONS

Interventions need to focus on the importance of sexual arousal during vaginal pressure stimulation and the way this is shaped by partner and relationship variables. Our results indicate that enhancing the relationship climate is an important target of intervention.

STRENGTHS AND LIMITATIONS

We did not include physical indices of genital arousal and did not use a clinical sample of women with genital pain.

CONCLUSIONS

The appraisal of vaginal sensations and sexual arousal are context-dependent responses that vary as a function of partner presence and sexual stimulation. Including both partners in the laboratory setting is important to create more valid models on sexual responding. Dewitte M, Schepers J, Melles R. The Effects of Partner Presence and Sexual Stimulation on the Appraisal of Vaginal Pressure and Sexual Arousal. J Sex Med 2018;15:539-549.