How young does vulvo-vaginal pain begin? Prevalence and characteristics of dyspareunia in adolescents

Do we want to know the enormity of women's severe menstrual disorders and chronic pelvic pain?

OBJECTIVE

The purpose of this paper is to call for a nationwide study to assess the prevalence and incidence of women health problems related to menstrual disorders and severe pelvic pain.

RATIONALE

The exact prevalence and incidence of endometriosis, adenomyosis, severe painful menstrual disorders, and of severe chronic pelvic pain are unknown. These issues severely impact women's quality of life and represent huge costs for our societies. Using adapted questionnaires, recent progresses in diagnosis and increased fundings announced by politicians, we can and should change this situation by performing a nationwide study to assess prevalence and incidence of these women problems in the French general population. The huge, anticipated costs of this study do appear quite reasonable when accounting for the enormous costs and societal consequences of endometriosis, menstrual disorders and severe pelvic pain.

CONCLUSION

These long-awaited data will improve our understanding of the causes, consequences, and natural history of endometriosis. These data will allow women to better understand that pain is not always related to endometriosis, thus preventing unjustified fears. Physicians will be able to adapt and improve medical managements, particularly the diagnosis. Politicians will have the tools to improve women's health and gender equality.

The Role of Vaginal Penetration Skills and Vaginal Penetration Behavior in Genito-Pelvic Pain/Penetration Disorder

Vaginal penetration skills and behavior are considered different aspects of vaginal penetration. Nevertheless, these terms are used interchangeably in most genito-pelvic pain/penetration disorder (GPPPD) intervention studies, possibly impacting the assessment and selection of intervention outcomes. This is the first theoretical essay on the relevance of nonsexual vaginal penetration skills in understanding and treating GPPPD symptoms, mainly for patients with vaginismus complaints. We aim to provide avenues for further empirical research and new perspectives for assessing, preventing, and treating GPPPD symptoms. We highlight the conceptual boundaries, overlaps, and commonalities between vaginal penetration skills and vaginal penetration behavior and the implications for measuring and selecting GPPPD treatment outcomes. We then briefly explain vaginal penetration skills as a self-learning process and review the impact of fear, anxiety, and cognitive factors on GPPPD symptoms. We also outline the role of the nonsexual genital self-exploration skills in later penetration behavior and offer implications for a new GPPPD patient-centered treatment approach.

Racialized differences across experiences and measurements of pain in genitopelvic pain/penetration disorder

BACKGROUND

Despite a growing body of research on genitopelvic pain/penetration disorder (GPPPD), few studies have examined racial and ethnic differences.

AIM

The goal of this study was to examine differences across racial groups pertaining to GPPPD with sexual vaginal intercourse in young college women at 2 public US universities.

METHODS

Data were collected from 1197 students from 2 public US universities. We limited our sample to 667 sexually active participants aged ≥18 years (mean, 19.21). Participants responded to survey items on their sexual history, wellness, and practices and to the Female Sexual Function Index. Data were analyzed through standard bivariate and regression analyses.

OUTCOMES

Participants were asked, "In general, do you feel pain with sexual intercourse?" and categorized into 1 of 3 pain groups: occasional (10%-25% of the time), frequent (≥50%), and no pain (<10%).

RESULTS

GPPPD was prevalent among young college women, with 162 (24.3%) reporting pain occasionally, 119 (17.8%) frequently, and 386 (57.9%) never or very seldom. While there were no differences in pain between Latina and non-Latina participants, our analysis indicated that pain was significantly higher among all other minoritized racial groups as compared with White women but particularly high in Black women, who had 2.15-higher odds of reporting pain than White women. Differences persisted when adjusting for socioeconomic status. Specific descriptors for pain sensation were more aligned with traditional descriptors of GPPPD (eg, burning, stinging, cramping, and pinching) in the White sample than among participants of color. Pain intensity did not differ among racial groups. We also found that a significant number of participants, particularly Black women, reported experiencing painful sex occasionally. No differences were noted across racial groups when assessing sexual function with the Female Sexual Function Index.

CLINICAL IMPLICATIONS

Existing surveys and physician intake forms should be critically examined for usability with patients of color. As evidenced, Black women's GPPPD seems to go underdetected/undetected by current measures.

STRENGTHS AND LIMITATIONS

This study is the first to explicitly compare racial differences among adolescents/young adults. The most notable limitation is the reliance on participant self-report and the absence of gynecologic examination to determine pain-contributing etiologies.

CONCLUSION

Painful intercourse affects young Black women at a higher rate than White women. Further research is needed into categories and metrics that capture their experiences of pain.

Anxiety Sensitivity in the Sexual Context: Links between Sexual Anxiety Sensitivity and Sexual Well-Being

Anxiety sensitivity, the fear of physiological arousal sensations, has been linked to lower sexual frequency, poorer sexual function, and greater sexual anxiety. The current study assessed whether anxiety sensitivity specific to the sexual context, termed sexual anxiety sensitivity, was linked to a wide range of indicators of sexual well-being over and above associations accounted for by general anxiety sensitivity. As a first step, we developed the Sexual Anxiety Sensitivity Inventory (SASI). Participants were 484 adults aged 19 to 60 years old who completed an on-line survey. To develop the SASI, we constructed parallel items to those on the Anxiety Sensitivity Scale-3 (ASI-3; Taylor et al., 2007). The SASI demonstrated the same three-factor structure as the ASI-3 and showed high internal consistency providing evidence for its reliability. As predicted, sexual anxiety sensitivity was significantly associated with all ten of the markers of the behavioral, cognitive-affective, and functional domains of sexual well-being assessed and six of these associations remained significant after controlling for general anxiety sensitivity. The results provide evidence that sexual anxiety sensitivity is an important construct for understanding individuals' sexual well-being and provide initial evidence that the specificity of the SASI has value as a reliable and valid measure for assessing sex-related anxiety sensitivity. Implications for clinicians and researchers are discussed.

Individual and Relationship Predictors of Trajectories of Sexual Function across Adolescent and Young Adult Relationships

Many young adults report poor sexual function, but research typically fails to consider relationship context and how problems might evolve over time. Research is needed to provide insights into how sexual problems are experienced across relationships, as well as the types of sexual function problems associated with various trajectories. We investigated retrospective trajectories of sexual problems across the multiple relationships of 688 young adults (18-24 years) as well as the individual and relationship factors associated with these trajectories. Both persistent suboptimal and optimal trajectories emerged for men and women. However, persistent and variable problematic function trajectories also emerged for women (and not men). Across all individual and relationship factors analyzed, multivariate multinomial regression analysis indicated that higher sexual esteem and more traditional gender beliefs best predicted membership in trajectories capturing better sexual function. Implications are discussed in terms of the need to provide substantive information regarding sexual function to young people as they transition to adulthood.

Secondary Dyspareunia After Childbirth: A Pilot Study for Comparison Between Group of Women With Episiotomy and Women Without Perineal Trauma

PROBLEM

Dyspareunia research following childbirth usually includes women who received an episiotomy during childbirth. Few studies have examined dyspareunia after childbirth in women who had no episiotomy or perineal trauma.

PURPOSE

The purpose of this study was to compare the incidence of dyspareunia in women with perineal trauma related to childbirth to women without perineal trauma related to childbirth. The second aim was to assess risk factors for dyspareunia after childbirth.

METHODS

A quantitative cross-sectional study was designed and data were collected from a questionnaire that were sent via the internet (online). The study was performed in Slovenia. The study design included purposive and snowball sampling. Participants were assured anonymity.

Analysis of data was conducted using SPSS 20.0. Factor analysis determined the validity and Cronbach's coefficient alpha determined the reliability of the questionnaire. The adequacy of a correlation matrix for factorization was assessed with the Kaiser–Meyer–Olkin (KMO) test and the Bartlett's test. To determine statistically significant differences, the chi-square (χ2) test was used. Kullback–Leibler divergence was used to measure how one probability distribution was different from the other probability distribution when the χ2 test was not satisfactory.

FINDINGS

There were 387 respondents to the online questionnaire and 22% of the women who received an episiotomy prior to childbirth reported dyspareunia after childbirth; 13.69% reporteddyspareunia when they had no perineal trauma associated with childbirth. Dyspareunia persisted up to 18 months in 11% of participants who had an episiotomy and in 8% of women who experienced no perineal trauma.

DISCUSSION

After an atraumatic childbirth, women can also experience dyspareunia. Pregnant women may benefit when their provider knows the risk factors for dyspareunia and limits episiotomy to those situations when there is a clear indication. Additional research may elucidate risk factors for dyspareunia following an atraumatic delivery.

Epistles of dyspareunia: storying Christian women's experiences of painful sex

Dyspareunia is painful attempted or completed vaginal-penile intercourse, and vaginal pain from other forms of touch. Because there is a persistent underlying message of shame and taboo surrounding female sexual pleasure in some Christian-informed cultural contexts, we sought to examine how self-identified Christian women in the Midsouthern USA conceptualise and experience dyspareunia. Data were collected through initial surveys and semi-structured interviews and analysed using incident-to-incident and in-vivo coding. Creative Analytic Practice was used to create composite character narratives from the data, storying five aspects of participants' experiences: (1) ignorance and abstinence at home, church, and school; (2) socially-informed expectations of sex and painful realities; (3) making sense of, coping with, and seeking help for painful sex; (4) validation, diagnosis, and treatment; and (5) sex mis-education and desire for a different future. Findings suggest that participants' understandings of and coping with their sexuality and the accompanying painful sex are shaped by implicit and explicit religious messages they encountered in their family upbringing, schooling, social and religious circles, and interactions with healthcare providers. Health professionals are urged to pre-screen women for symptoms of dyspareunia and include sexual wellness checks as routine procedure, and subsequently refer patients to pelvic health physical therapy when appropriate.

Exploring Relationships Between Genito-Pelvic Pain/Penetration Disorder, Sex Guilt, and Religiosity Among College Women in the U.S

INTRODUCTION

Despite a growing body of research on psychosocial factors in Genito-Pelvic Pain/Penetration Disorder (GPPPD) during sexual intercourse, there are few studies examining adolescent and young adult women's experiences with painful sex and the effects of religiosity, sexual education, and sex guilt.

AIM

The purpose of the study was to examine the occurrence of GPPPD among sexually active female college students, including psychosocial factors of religiosity and religious practice, sexual education, sex guilt, and sexual distress.

METHODS

Data were collected from 974 college women from a university in the Northeastern U.S. We limited our sample to sexually active women (n = 593, 60.9%; mean age: 18.96) who responded to the questionnaire item, "In general, do you feel pain with sexual intercourse?" Participants completed the Female Sexual Function Index (FSFI), Female Sexual Distress Scale (FSDS), Revised Mosher Sex Guilt Scale, Abbreviated Santa Clara Strength of Religious Faith Questionnaire, 10-item Gender Role Beliefs Scale, and measures on sexual wellness and practice and sexual education experiences. Data were analyzed using standard bivariate and regression analyses as well as path analysis.

MAIN OUTCOME MEASURES

Women were asked, "In general, do you feel pain with sexual intercourse?" and categorized into one of three pain groups: occasional (10%-25% of the time), frequent (50% or more), and no pain (less than 10%).

RESULTS

GPPPD with sex was prevalent among young college women, with 113 (19.1%) reporting frequent pain and 143 (24.1%) occasional pain (control n = 337, 56.8%). Numerous statistically significant factors were identified, including frequency of sex, ability to orgasm, sensations during intercourse, presence of a steady sexual partner, expectations of painful sex, sex guilt, and sexual distress. Sex guilt acted as full mediator between religiosity and painful sex.

IMPLICATIONS

Healthcare providers should proactively initiate conversations with young female patients about painful intercourse to identify issues and normalize language on pain with sex. Educators are urged to teach evidence-based information on pain-free and guilt-free sexual experiences inside and outside religious contexts.

CONCLUSION

Painful sex affects adolescent and young adult women at a similar rate as non-college adult women and while religiosity does not directly impact young women's GPPPD, religiosity does lead to painful sex if it causes sex guilt. Further research is needed into the mechanisms of religion-based sexual shaming and among religiously conservative women who practice abstinence until marriage. Azim KA, Happel-Parkins A, Moses A, et al. Exploring Relationships Between Genito-Pelvic Pain/Penetration Disorder, Sex Guilt, and Religiosity Among College Women in the U.S. J Sex Med 2021;18:770-782.

#ItsNotInYourHead: A Social Media Campaign to Disseminate Information on Provoked Vestibulodynia

Provoked Vestibulodynia (PVD) is a type of localized vulvodynia (or pain in the vulva). The estimated prevalence of this condition is about 12% of the general population and approximately 20% of women under the age of 19. Many women who live with PVD suffer in silence for years before receiving a diagnosis. Whereas cognitive behavioral therapy (CBT) was already known to be effective for managing symptoms of PVD, there has recently been a published head-to-head comparison of CBT versus mindfulness-based therapy for the primary outcome of pain intensity with penetration. The trial revealed that both treatments were effective and led to statistically and clinically meaningful improvements in sexual function, quality of life, and reduced genital pain, with improvements retained at both 6- and 12-month follow-ups. We then undertook an end-of-grant knowledge translation (KT) campaign focused on the use of social media to disseminate an infographic video depicting the findings. Social media was strategically chosen as the primary mode of dissemination for the video as it has broad reach of audience, the public can access information on social media for free, and it presented an opportunity to provide social support to the population of women with PVD who are characterized as suffering in silence by starting a sensitive and empowering dialogue on a public platform. In this paper, we summarize the social media reach of our campaign, describe how and why we partnered with social media influencers, and share lessons learned that might steer future KT efforts in this field.

The Prevalence and Educational Impact of Pelvic and Menstrual Pain in Australia: A National Online Survey of 4202 Young Women Aged 13-25 Years

STUDY OBJECTIVE

To explore the prevalence and impact of dysmenorrhea, pelvic pain and menstrual symptoms on young women at school or in tertiary education.

DESIGN AND SETTING

Cross-sectional online survey in Australia.

PARTICIPANTS

A total of 4202 adolescent and young women (13-25 years of age; median age 17 years), having reached menarche, living in Australia and currently attending school (n = 2421) or tertiary education (n = 1781).

INTERVENTIONS

Online survey hosted by Qualtrics between November 2017 to January 2018. Data were collected on sociodemographic data, menstrual cycle characteristics, dysmenorrhea, pelvic pain, and educational and social impact.

MAIN OUTCOME MEASURES

Information on menstrual and pelvic pain impact, academic absenteeism and presenteeism, impact on non-academic activities and interactions with teaching staff.

RESULTS AND CONCLUSIONS

Dysmenorrhea was reported by 92% of respondents. Dysmenorrhea was moderate (median 6.0 on a 0-10 numeric rating scale) and pain severity stayed relatively constant with age [r_s(3804) = 0.012, P = .477]. Noncyclical pelvic pain at least once a month was reported by 55%. Both absenteeism and presenteeism related to menstruation were common. Just under half of women reported missing at least one class/lecture in the previous three menstrual cycles. The majority of young women at school (77%) and in tertiary education (70%) reported problems with classroom concentration during menstruation. Higher menstrual pain scores were strongly correlated with increased absenteeism and reduced classroom performance at both school and in tertiary education. Despite the negative impact on academic performance the majority of young women at school (60%) or tertiary education (83%) would not speak to teaching staff about menstruation.

Primary Dysmenorrhea and Painful Sex: Canaries in the Coal Mine?

OBJECTIVE

Primary dysmenorrhea and provoked vestibulodynia (PVD) are common pain conditions in young women. The purpose of this study was to document the severity of dysmenorrhea in women with confirmed PVD to further clarify reports of comorbidity. Since central sensitisation (CS) of the nervous system is present in both conditions, diagnosis of either, but especially both conditions, may reflect past chronic stress.

METHODS

We investigated this comorbidity in a sample of 63 women who met diagnostic criteria for PVD, and a comparison group of 89 women with low sexual desire and arousal but no pain during sex. All women completed questionnaires about the history and severity of their dysmenorrhea.

RESULTS

Of the women with PVD, 28.6% recalled moderate and 34.9% severe dysmenorrhea. For women in the comparison group, these figures were 22.5% and 19.1%, respectively. Women with PVD reported that the periods they experienced as teenagers were more painful, longer, more debilitating, and persistently painful for more years than those recalled by women in the comparison group.

CONCLUSIONS

Our findings suggest that the origins of the early-onset CS require serious investigation. Research into the potential to reduce future chronic pain conditions through early effective treatment of primary dysmenorrhea is also needed.

Risk Factors for Sexual Pain Among Physically Active Women

INTRODUCTION

Sexual pain is common among women but little is known about associations with exercise and physical activity.

AIM

To determine the prevalence of sexual pain among physically active women and to evaluate cycling and other potential risk factors.

METHODS

This is a secondary data analysis of a study on the urinary and sexual wellness of physically active women recruited through sporting clubs and targeted social media advertising. We used multivariable logistic regression to assess the role of cycling and exercise in reporting any, frequent, or severe sexual pain, controlling for demographic, relationship, and health risk factors.

MAIN OUTCOME MEASURE

Sexual pain, including frequency and severity, was measured using the Female Sexual Function Index.

RESULTS

A total of 2,039 women were included, with 1,097 (54%) reporting any level of sexual pain, 364 (18%) experiencing frequent pain, and 378 (19%) reporting severe pain. Less than 5% of women reported diabetes or hypertension, and the cohort had a median body mass index of 23.3 (interquartile range 21.4-25.7). Increasing age and body mass index were protective against any sexual pain, as was cycling (odds ratio [OR] 0.73 [95% CI 0.59-0.90]). Participants who reported being "moderately satisfied" (OR 0.53 [95% CI 0.31-0.91]) or "very satisfied" (OR 0.33 [95% CI 0.19-0.56]) with their emotional closeness to a sexual partner had decreased odds of any sexual pain.

CONCLUSION

Experiencing any sexual pain is common in physically active women, with a prevalence of over 50%; however, weekly energy expenditure from exercise was not associated with sexual pain. Cycling participation and higher levels of emotional closeness and intimacy were associated with less pain. Patients between the ages of 18 and 30 years who were normal or underweight incurred the highest risk of sexual pain. Fergus KB, Cohen AJ, Cedars BE, et al. Risk Factors for Sexual Pain Among Physically Active Women. Sex Med 2020;8:501-509.

Vulval Pain in Pediatric and Adolescent Patients

STUDY OBJECTIVE

To describe the experience of a tertiary pediatric and adolescent gynecology service that provides care to children and adolescents who present with vulval pain. Their presentation, associated symptoms, and management is described.

DESIGN

A retrospective analysis of all girls younger than 18 years of age who presented to the gynecology clinic of our tertiary referral Children's Hospital between Jan 2010 and July 2016. Electronic medical records were reviewed and parameters recorded using a standardized data sheet.

SETTING

Gynecology clinic of a tertiary referral children's hospital and private rooms of our director of gynecology.

PARTICIPANTS

Young women younger than 18 years who presented with symptoms suggestive of vulvodynia.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Presenting symptoms, characteristics of associated features, treatment options, and treatment outcomes.

RESULTS

Forty-seven patients with a mean age of 11 years (range, 3-18 years) were identified. At the time of diagnosis 31/47 (65.9%) were premenarchal. Many presented with a symptom other than pain alone. In particular, 35/47 (74.4%) presented with coexisting or previous urinary symptoms. Of patients examined, most had positive cotton tip examination findings (16/17 (94.1%) and 11/13 (84.6%) for pre- and postmenarchal, respectively) with clinical inspection otherwise unremarkable.

CONCLUSION

Children and adolescents with vulval pain have varied presentations. Many of the pre- and postmenarchal patients had coexisting urinary tract symptomatology at the time of diagnosis. This review of patients seen over 5.5 years at a pediatric tertiary referral center provides information on the presenting symptoms, examination features, and response to clinical management.

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.

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.

Loneliness Mediates the Relationship Between Pain During Intercourse and Depressive Symptoms Among Young Women

Previous research suggests that women who experience pain during intercourse also experience higher rates of depressive symptoms. Loneliness might be one factor that contributes to this relationship. We hypothesized that women who experience more severe and interfering pain during intercourse would report higher rates of loneliness and higher rates of depressive symptoms. Further, we hypothesized that loneliness would mediate the relationship between pain during intercourse and depressive symptoms. A total of 104 female participants (85.6% white, 74.03% partnered, 20.9 [3.01] years old) completed an online survey including demographic information, PROMIS Vaginal Discomfort Measure, PROMIS Depression Measure, and Revised UCLA Loneliness Scale. Pearson correlations and bootstrapped mediation analysis examined the relationships among pain during intercourse, loneliness, and depressive symptoms. Pain during intercourse, loneliness, and depressive symptoms were all significantly correlated (p < .05). Results of the mediation analysis indicated that loneliness was a significant mediator of the relationship between pain during intercourse and depressive symptoms (indirect effect = 0.077; 95% CI 0.05-0.19). After accounting for loneliness, pain during intercourse was not significantly related to depressive symptoms, suggesting that loneliness fully mediated the relationship between pain during intercourse and depressive symptoms. These findings are consistent with previous studies highlighting that pain during intercourse is related to depressive symptoms. The current study adds to that literature and suggests that more frequent and severe pain during intercourse leads to more loneliness, which then leads to increased depressive symptoms. This line of work has important implications for treating women who experience depressive symptoms and pain during intercourse.

Antenatal Vulvar Pain Management, Labour Management, and Postpartum Care of Women With Vulvodynia: A Survey of Physicians and Midwives

OBJECTIVE

To examine maternity providers' recommendations for pregnant women with vulvodynia regarding management of vulvar pain and postpartum care, and to examine if, and how, a woman's chronic vulvar pain affects providers' examination and management during labour.

METHODS

This research was part of a larger study that invited physicians and midwives to answer a questionnaire regarding pregnancy and childbirth care in women with vulvodynia. To achieve the current objectives, the questionnaire included both dichotomous (yes or no) and open-ended items. The current sample (n = 116) consisted of 75 physicians and 41 midwives.

RESULTS

Over 60% of the sample reported making recommendations for vulvar pain management during pregnancy, and 32.8% of providers reported making special postpartum care recommendations for women with vulvodynia. Differences between physicians and midwives were noted for some of these recommendations. For example, to manage vulvar pain, only physicians recommended the use of/change in medications (P <0.001) and only midwives recommended complementary medicines (P = 0.02) and the use of lubricants (P = 0.006) and made recommendations for sexual well-being (P = 0.02). The majority of the sample (75%) reported that a woman having vulvodynia affected labour examination and management; providers most frequently reported minimizing exams and early use of epidural. Over 80% of midwives and 54% of physicians minimized exams during labour for women with vulvodynia (P= 0.01).

CONCLUSION

Further research is needed to understand the optimal provision of care for pregnant and postpartum women with vulvodynia. We advocate for increased education of vulvodynia aimed at providers of antenatal, labour, and postnatal care.

Evaluation and Treatment of Female Sexual Pain: A Clinical Review

Dyspareunia and vulvodynia are genital pain disorders that have devastating effects on women's quality of life. These disorders occur with high prevalence and place a significant financial burden on women and the health care system. Many women do not report genital pain, and most providers do not inquire about this type of pain. As a result, women also experience social isolation. Numerous treatments are thought to improve quality of life and decrease pain; however, more studies are needed. This review aims to provide an overview of clinical evaluation methods and to summarize treatment options for women suffering from dyspareunia and vulvodynia.

Efficacy of Internet-Based Guided Treatment for Genito-Pelvic Pain/Penetration Disorder: Rationale, Treatment Protocol, and Design of a Randomized Controlled Trial

INTRODUCTION

Genito-pelvic pain/penetration disorder (GPPPD) not only adversely affects women's sexuality and sexual satisfaction but is also associated with a wide range of psychosocial consequences such as reduced quality of life and well-being, mental health comorbidities, and relationship distress. Evidence for effective treatment options is scarce.

AIM

This article describes the rationale, treatment protocol, and study design for a randomized controlled trial examining the efficacy of an Internet-based guided intervention for GPPPD.

METHOD

Two hundred women who meet the criteria for GPPPD and have not been able to experience sexual intercourse for at least the last 6 months will be recruited and randomly assigned either to the intervention group (IG) or a 6-month waitlist control group. Assessments take place at baseline (T1), peritreatment after completion of Session 5 in IG (T2), after completion of Session 8 or 12 weeks after randomization (T3), and after 6 months (T4). Data will be analyzed on an intention-to-treat and a completer basis.

MAIN OUTCOME MEASURES

The primary outcome will be sexual intercourse involving the insertion of the partner's penis at posttreatment. Secondary outcomes include, e.g., improved non-intercourse penetration, sexual functioning, dyadic stress coping, reduced fear of sexuality and negative penetration-related cognitions. Fear of sexuality, penetration-related cognitions, and exercise intensity will be assessed as mediators of intercourse in the IG. Sexual dysfunctions of partners will be measured at baseline (T1) and investigated as a potential moderator of the primary treatment outcome.

DISCUSSION

Given the burden associated with GPPPD and the need for specialized treatment, there is a surprising lack of evidence-based treatment options. This study aims to assess whether Internet-based interventions could contribute to closing this treatment gap.

CLINICAL TRIAL REGISTRATION

German Register of Clinical Studies (DRKS): DRKS00010228.

Anxiety Mediates the Relation Between Childhood Sexual Abuse and Genito-Pelvic Pain in Adolescent Girls

Previous research has demonstrated associations between child sexual abuse, anxiety, and genito-pelvic pain, but no study to date has examined whether sexual abuse may be associated with genito-pelvic pain through victims' elevated anxiety. The present study aimed to determine whether anxiety mediates the relationship between child sexual abuse and genito-pelvic pain. Using self-report questionnaires, data were gathered from 218 sexually active adolescent girls recruited from seven metropolitan high schools. As expected, results revealed a significant indirect effect of sexual abuse on the development of genito-pelvic pain through trait anxiety. This study thus suggests that anxiety may be one of the mechanisms by which child sexual abuse leads to an increased risk of developing genito-pelvic pain in this population.

Vulvar Pain-Associations Between First-Time Vaginal Intercourse, Tampon Insertion, and Later Experiences of Pain

This study examines associations between the first experience of vaginal intercourse/tampon insertion and later experiences of vulvar pain. The study is based on questionnaire data from 1,259 Swedish female senior high-school students, aged 18 to 22 years old. Of these, 592 women reported present vulvar pain. Present vulvar pain was associated with first-time experiences of vaginal intercourse (pain, negative experience, against will) and with pain at tampon insertion. First-time experiences were also related to temporal aspects of present vulvar pain during vaginal intercourse (at the beginning, after a while during, and after). Implications of first-time experiences of vaginal intercourse for future symptoms of vulvar pain are discussed.

Dyspareunia in the Context of Psychopathology, Personality Traits, and Coping Resources: Results From a Prospective Longitudinal Cohort Study From Age 30 to 50

Although dyspareunia has a major impact on sexual and general wellbeing, there are few data on the longitudinal development of its prevalence in representative study groups. Therefore, it was the aim of the present study to fill this gap by evaluating the prevalence of dyspareunia in a representative sample at age 30, 35, 41, and 50. Additional aims were to determine the association between dyspareunia, psychopathological covariates, personality characteristics, and coping resources. Semi-structured interviews with single-item questions on sexual problems in general as well as dyspareunia were used to gain information on 1-year as well as long-time prevalence rates. Psychopathological covariates were explored with the SCL-90-R. The Freiburger Personality Inventory (Freiburger Persönlichkeits Inventar, FPI) assessed personality characteristics. Scales of sense of mastery and self-esteem were used to investigate coping resources. Twelve months prevalence of dyspareunia varied between 4.5 and 6.4 % with a mean of 5.6 % and a long-time risk of 19.3 %. No relation between age and the prevalence rates was found. Dyspareunia was related to psychopathological covariates, especially depression. With respect to personality traits as measured with the FPI only nervousness showed a significant association with dyspareunia, whereas coping resources were unrelated. As dyspareunia is experienced by about 20 % of all women, it represents a frequent sexual problem. Therefore, assessment of dyspareunia should be integrated into primary care of women at any age and diagnostic as well as therapeutic strategies should be based on physiological and psychological factors.

A Swiss Longitudinal Study of the Prevalence of, and Overlap Between, Sexual Problems in Men and Women Aged 20 to 50 Years Old

The aim of this study was to obtain data on the development and course of sexual problems and their interrelationships by investigating a representative sample of men and women over a period of 30 years. A representative sample of 299 women selected from the complete electoral register and 292 men selected from screening lists for military service in Zurich, Switzerland, answered questions about their sexuality as part of a series of seven interviews between ages 20 (1979) and 50 (2008). Of the initial sample of 591 participants, 43% (57% of them male) were lost to follow-up. Interviews were conducted using the Structured Psychopathological Interview and Rating of the Social Consequences of Psychological Disturbances for Epidemiology (SPIKE), a semistructured interview. Sexual problems were identified on the basis of the study participants' self-appraisal. One-year prevalence rates, lifetime risks, and overlap of functional, emotional, and sexual desire problems in men and women were evaluated. The findings confirmed higher lifetime risks in women than in men for any sexual problem (females 67.0%; males 46.0%) and for functional (39.3%; 22.1%), emotional (35.7%; 15.9%), and sexual desire problems (51.6%; 33.3%). While in general men's sexual problems increased with age, no such association was observed in women. The overlap of all three problems (functional, emotional, and sexual desire) was reported by 16.9% of women but only 5.0% of men. Although there are commonalities, the type but also the development and, in particular, the overlap of sexual problems in women and men are markedly different.

Feasibility, acceptability, and initial efficacy of an online sexual health promotion program for LGBT youth: the Queer Sex Ed intervention

Lesbian, gay, bisexual, and transgender (LGBT) youth experience multiple sexual health inequities driven, in part, by deficits in parental and peer support, school-based sex education programs, and community services. Research suggests that the Internet may be an important resource in the development of sexual health among LGBT youth. We examined the feasibility of recruiting youth in same-sex relationships into an online sexual health intervention, evaluated intervention acceptability, and obtained initial estimates of intervention efficacy. LGBT youth (16 to 20 years old) completed Queer Sex Ed (QSE), an online, multimedia sexual health intervention consisting of five modules. The final sample (N = 202) completed the pretest, intervention, and posttest assessments. The primary study outcomes were sexual orientation identity and self-acceptance (e.g., coming-out self-efficacy), sexual health knowledge (e.g., sexual functioning), relationship variables (e.g., communication skills), and safer sex (e.g., sexual assertiveness). Analyses indicated that 15 of the 17 outcomes were found to be significant (p < .05). Effect sizes ranged from small for sexual orientation (e.g., internalized homophobia) and relationship variables (e.g., communication skills) to moderate for safer sex (e.g., contraceptive knowledge) outcomes. This study demonstrated the feasibility, acceptability, and initial efficacy of QSE, an innovative online comprehensive sexual health program for LGBT youth.

Pelvic examination experiences in women with and without chronic pain during intercourse

INTRODUCTION

Although pelvic examinations (PEs) are an important component of women's health, some women experience difficulty during PEs due to anxiety and pain. These difficulties may be heightened in women with chronic pain during sexual intercourse. Some evidence suggests that this population experiences pain and distress during PEs, but their experiences in this context have not been empirically investigated from a multidimensional perspective.

AIMS

The aims of this study were to compare the PE experiences of women with and without pain during intercourse and to examine predictors of negative experiences in each group.

METHOD

Women with vulvovaginal pain (n = 90), pelvic pain (n = 89), and women without current intercourse pain (n = 207) completed an online survey including sections assessing demographics, gynecological and medical history, and PE experiences. Respondents completed questionnaires assessing vaginal penetration cognitions and body image.

MAIN OUTCOME MEASURES

Participants rated their most recent PE on numerical scales for pain, embarrassment, anxiety, and the overall quality of the experience.

RESULTS

Women with pelvic and vulvovaginal pain during intercourse reported significantly more pain and anxiety during their most recent PE compared with the no pain group, and women with a higher number of lifetime gynecological diagnoses reported significantly more pain. Multiple regression analyses indicated that various predisposing, examination-related, and psychological factors predicted specific PE ratings in each group.

CONCLUSIONS

The results provide empirical support that PEs are more physically and emotionally difficult for women who experience chronic pain during intercourse. These findings have important clinical implications, as PEs are a critical part of complete reproductive care and play an essential role in the assessment/management of sexual pain, including Genito-Pelvic Pain/Penetration Disorder.

Age, quality, and context of first sex: associations with sexual difficulties

INTRODUCTION

Research consistently indicates an association between a younger age at first sex and poorer sexual health outcomes. However, research addressing associations between age at first sex and sexual difficulties has produced mixed findings. Moreover, little is known about links between the context and quality of first sex and subsequent sexual difficulties.

AIMS

The aims of this study are to examine whether (i) age and (ii) context and quality at first sex are associated with sexual difficulties; (iii) examine whether age at first sex and context and quality variables are independently associated (after mutual adjustment) with sexual difficulties; and (iv) examine whether age at first sex has an indirect effect on sexual difficulties through an effect on context or quality.

METHODS

Data from 388 questionnaires were gathered from students aged 17-21 living in accommodation halls and by postal invitation to adults aged 25-35.

MAIN OUTCOME MEASURES

The main outcome measure was the Golombok-Rust Inventory of Sexual Satisfaction (GRISS), which assesses sexual difficulties via an overall score and seven subscales.

RESULTS

Appraising first sex as emotionally negative was associated with the majority of sexual difficulties. A less stable relationship at first sex was associated with sexual communication problems and dissatisfaction. Greater enjoyment and using substances were associated with a lower likelihood of anorgasmia for women. Age at first sex was directly associated with reduced sexual frequency only. A younger age at first sex was associated with a greater likelihood of negative appraisal and lower likelihood of a stable relationship and thereby indirectly associated with several sexual difficulties.

CONCLUSIONS

Experiencing first sex as emotionally negative was consistently associated with later sexual difficulties. When attending to sexual difficulties, understanding the quality and context of first sex may be more useful than knowing the age at first sex. This research is limited by the retrospective nature of the reports of first sex.

Prevalence and predictors of genito-pelvic pain in pregnancy and postpartum: the prospective impact of fear avoidance

INTRODUCTION

There is limited knowledge regarding the symptom profile of genito-pelvic pain in pregnancy and postpartum, and potential psychosocial predictors of this pain. Prior studies have reported a positive association between prepregnancy pain and postpartum genito-pelvic pain. Greater fear avoidance has been associated with increased genital pain intensity in women, unrelated to childbirth. This relationship has not been examined prospectively in a postpartum population.

AIMS

The study aims were to examine the symptom profile of genito-pelvic pain during pregnancy and at 3 months postpartum, and the impact of prepregnancy nongenito-pelvic pain and fear avoidance in pregnancy on genito-pelvic pain at 3 months postpartum.

METHODS

First-time expectant mothers (N = 150) completed measures of fear avoidance (pain-related anxiety, catastrophizing, hypervigilance to pain), prepregnancy nongenito-pelvic pain, childbirth-related risk factors (e.g., episiotomy), and breastfeeding.

MAIN OUTCOME MEASURES

Those reporting genito-pelvic pain in pregnancy and/or at 3 months postpartum answered questions about the onset (prepregnancy, during pregnancy, postpartum) and location (genital, pelvic, or both) of the pain and rated the intensity and unpleasantness of the pain on numerical rating scales.

RESULTS

Of 150 women, 49% reported genito-pelvic pain in pregnancy. The pain resolved for 59% of women, persisted for 41%, and 7% of women reported a new onset of genito-pelvic pain after childbirth. Prepregnancy nongenito-pelvic pain was associated with an increased likelihood of postpartum onset of genito-pelvic pain. Greater pain-related anxiety was associated with greater average genito-pelvic pain intensity at 3 months postpartum.

CONCLUSIONS

Results suggest that about half of women may develop genito-pelvic pain during pregnancy, which will persist for about a third, and a subset will develop this pain after childbirth. Prior recurrent nongenito-pelvic pain may enhance the risk of developing genito-pelvic pain postpartum, while greater pain-related anxiety in pregnancy may increase the risk for greater intensity of postpartum genito-pelvic pain.

The impact of vaginal penetration difficulties on the sexual functioning of women and their male partners

OBJECTIVES

To compare the sexual function of women with and without vaginal penetration difficulties (VPDs) and relate it to the sexual function of their male partners.

METHODS

All consenting women attending a sexual medicine centre during 2005-2007 completed the Female Sexual Function Index (FSFI) and answered questions about five VPDs (placement of a tampon, gynaecological examination, insertion of her or her partner's finger, and penile-vaginal intercourse). Male partners filled the International Index of Erectile Function (IIEF).

RESULTS

Full data were available for 223 women, and 118 male partners. Male partners of women with VPDs (n = 53) had lower sexual desire (p = 0.0225). The number of VPDs in the women concerned negatively correlated with their partners' desire (r = - 0.18339, p = 0.0468) and erectile function (r = - 0.19848, p = 0.0312). All women with at least one VPD (n = 109) reported significantly more sexual pain (p < 0.0001) and had worse sexual function scores (p = 0.014) than women with no VPDs (n = 114). Women with VPDs other than penile-vaginal penetration had worse orgasmic functioning (p = 0.0119).

CONCLUSIONS

The women's VPDs are correlated with worse sexual functioning for them and for their male partners. The five VPDs are a practical and useful tool for identifying impaired sexual functioning.

When sex hurts: Female genital pain with sexual consequences deserves attention: A position paper

Background and aims The problem of sexual pain is an area that has been shamefully ignored by both the pain community and the health service authorities. Although about 40% of women report such pain and 30% report it during their last intercourse, sexual pain has historically not even been considered a pain problem. The objectives of the present study was to present a background to the problem of female sexual pain, further elaborate on the problem and offer some direction for how advances might be concretely made. Discussion Genital pain is common and many women describe pain during several non-sexual activities. Therefore describing the pain strictly as a sexual problem, threatens to lose important information about the experience of pain which will be misleading both in assessment and treatment. Instead, seeing the problem as a multidimensional pain condition with debilitating sexual consequences is suggested. It has become apparent that although biological aspects are central in the experience of genital pain, psychological and social aspects may play a major role. The fear avoidance model which has played a major role in our understanding of the development of chronic musculoskeletal pain, also seems to be applicable in genital pain conditions. However, one has to be aware of certain differences when comparing genital pain from musculoskeletal conditions. In addition, there is a lack of established guidelines for assessing or treating unexplained genital pain conditions, and there is a risk of not acknowledging the role of socio-cultural context on how female sexuality is viewed. The problem of recurrent sexual pain is a highly volatile, personal, and socially weighted experience. Because of the lack of understanding of the mechanisms, it is a risk of over-emphasizing the role of vaginal penetration in the assessment and treatment of female sexual pain and clinicians may simply fail to investigate sexual function from a broader perspective. Conclusions and implications There is a growing interest in the problem of female genital pain and associated problems with sexual pain. However, research predominately refers to the field of sex research, and the involvement from the pain community has to date been relatively low. There is an immediate need to identify the psychosocial mechanisms involved in the transition from acute to chronic genital pain in women and to address these components in treatment using established methods. Since sexual pain is far more than pain during vaginal penetration, there is a risk of treatment interventions being oriented towards performance in terms of a narrowly defined sexual behavior instead of focusing on valued activities, meaning and pleasure for the individual. Assessment and treatment have to include a broad perspective on pain and on sex.

Living with genital pain: Sexual function, satisfaction, and help-seeking among women living in Sweden

Background and aims Female genital pain is a debilitating problem that negatively affects several aspects of the life of women. Several studies present figures of prevalence indicating that the problem affects nearly 20% of young women. However, many women fail to consult health care and the estimated prevalence therefore remains insecure. Historically, genital pain was commonly viewed as either physiological or psychosexual. Although the current field of research and clinical expertise in general agree upon a biopsychosocial conceptualization, less is known about the manifestation of the problem in everyday life and the experience of seeking health care among afflicted women. The objectives of the present study was to examine genital pain in a general female population living in Sweden cross-sectionally in terms of prevalence, sexual function, sexual satisfaction and help seeking, and to identify possible predictors of genital pain among women. Methods The study was a population-based study using a postal questionnaire administered to 4052 women (age 18--35). Of these 944 (response rate: 23%) took part in the study. Results Genital pain of six months duration was reported by 16.1% of the women. Women with pain more commonly reported fungal infections, other pain problems, sexual dysfunctions and symptoms of anxiety than pain-free women and in addition lower sexual satisfaction. There were no differences in sexual frequency. Pain was most commonly reported during sexual intercourse, but many women also experienced pain during non-sexual activities, with pain durations of several hours after the pain eliciting activity was interrupted. Of those reporting pain, 50% had sought care for their pain. The most common was to counsel a doctor and to receive topical treatment. However, the experienced effects of the treatments were on average low. In the explanatory model, fungal infections, and sexual dysfunctions were associated with genital pain. Conclusions The study had a low response rate, but still indicates that genital pain is common and negatively affects several aspects of women' life, not just sexual activities. Although many women report pro-longed pain experiences, many fail to consult health care and among those who seek care the effects of treatment are on average poor. There are strong associations between sexual dysfunctions (lack of sexual arousal, vaginal muscle tension hindering intercourse) and genital pain that, based on previous findings in this field of research, might be viewed in terms of circular maintaining processes. Implications Female genital pain is not just limited to the sexual context, but often negatively affects several situations in women' life. The size of the problem calls for immediate development of preventive interventions and treatment programs that focus on sexual education and to encourage a healthy sexuality among women and their partners. There is a need to identify methods in order to assemble evidence based interventions of female genital pain. Such methods are currently lacking, resulting in poor treatment options for women with pain.

Body image and genital self-image in pre-menopausal women with dyspareunia

With a prevalence of 15-21%, dyspareunia is one of the most commonly reported sexual dysfunctions in pre-menopausal women under the age of 40. Studies to date have focused primarily on clinical samples, showing that women with dyspareunia report overall sexual impairment, anxiety, and feelings of sexual inadequacy. However, little is known about their body image and genital self-image and few studies have sampled women exclusively from the general population. The aim of the present, controlled study was to investigate body image and genital self-image in a community sample of pre-menopausal women with self-reported dyspareunia. In total, 330 women completed an online survey, of which 192 (58%) had dyspareunia and 138 (42%) were pain-free control women. In comparison to pain-free control women, women with dyspareunia reported significantly more distress about their body image and a more negative genital self-image. Moreover, findings from a logistic regression, in which trait anxiety was controlled for, showed that a more negative genital self-image was strongly and independently associated with an increased likelihood of reporting dyspareunia. These results suggest that, in women with dyspareunia, body image and genital self-image are significantly poorer and would benefit from more attention from both clinicians and researchers.

Prioritizing the partner's enjoyment: a population-based study on young Swedish women with experience of pain during vaginal intercourse

The present study examines the prevalence of women who continue to have vaginal intercourse (VIC) despite pain, avoid telling the partner, and feign enjoyment. It also considers the reasons for this behavior. A sample of 1566 female senior high school students (aged 18-22 years) completed a questionnaire concerning their experiences and attitudes toward their body and sexuality. Forty-seven percent (270/576) of those women who reported pain during VIC continued to have VIC despite the pain. The most common reasons were that they did not want to spoil sex for or hurt the partner by interrupting VIC. Feigning enjoyment and not telling the partner about their pain were reported by 22 and 33%, respectively. Continuing to have VIC despite pain was associated with feelings of being inferior to the partner during sex, dissatisfaction with their own sex lives and feigning enjoyment while having pain. Pain during VIC is reported by every third young Swedish woman, and almost half of those still continue to have VIC. The major reason given is noteworthy - prioritizing the partner's enjoyment before their own - and indicates that young women who continue to have VIC despite pain take a subordinate position in sexual interactions.

A Psychological View of Sexual Pain among Women: Applying the Fear-Avoidance Model

Aim: The purpose of this paper is to examine how well research findings on dyspareunia (intercourse pain) fit the fear-avoidance (FA) model on pain. Results: The evidence suggests that the experience of pain in dyspareunia functions similarly to the pain reported in other pain conditions. There are also accumulating data showing that the central mechanisms of the FA model, such as catastrophizing, fear, hypervigilance and disability, are central to the experience of sexual pain. However, there are also some potential differences between sexual pain and other pain conditions that demand further attention in terms of the role of the partner, specific emotional consequences of avoidance and the effect of hypervigilance on sexual arousal. Conclusion: The results demonstrate the relevance of the FA model in sexual pain. They also imply that treatment methods for fear and avoidance in other pain conditions offer new avenues for treating sexual pain problems in the clinic. Future studies should focus on expanding how the mechanisms in the FA model contribute to sexual pain, as well as how treatments based on the model may be applied clinically.

Economic burden and quality of life of vulvodynia in the United States

OBJECTIVE

To explore the economic burden and quality of life of vulvodynia in the United States.

METHODS

We conducted a web-based survey from 2009 to 2010. Patients who responded to a National Vulvodynia Association advertisement completed the survey every month, recording their own costs and their employers' payments related to vulvodynia in the previous month. A total of 302 patients entered data for at least 1 month and among them, 97 patients had completed data for 6 months. We used multiple imputation to generate values for unobserved cost components. For insurance payments, we also extracted the average insurance payments for direct healthcare services relating to vulvodynia from a commercial insurance database. The total costs were disaggregated into direct healthcare costs, direct non-healthcare costs and indirect costs. We also assessed patients' quality of life by using Euro QOL 5 dimensions (EQ-5D) in a follow-up survey.

RESULTS

The total costs in 6 months were $8862.40 per patient, of which $6043.34 (68.19%) were direct healthcare costs, $553.81 (6.25%) were direct non-healthcare costs and $2265.25 (25.56%) were indirect costs. Based on the reported prevalence range of 3-7% in the US, our analysis yielded an annual national burden ranging from $31 to $72 billion in the US. However, the estimate should be viewed with caution as our study sample was non-probability. The average EQ-5D score was 0.74 ± 0.19 in vulvodynia patients.

CONCLUSION

Vulvodynia is associated with a huge economic burden to both individuals and society. It is also related to a relatively low quality of life.

Biopsychosocial factors associated with dyspareunia in a community sample of adolescent girls

Although various biopsychosocial factors have been associated with dyspareunia, research to date has focused on retrospective reports of adult women, and lack of consensus regarding etiology remains. By targeting girls at the beginning of their reproductive life, this study aimed to examine the biomedical, behavioral, and psychosocial correlates of chronic painful intercourse in sexually active adolescents compared to pain-free girls. With written informed consent, data were obtained from 1425 girls (12-19 year olds) from seven metropolitan high schools using self-report questionnaires pertaining to gynaecologic/biomedical history, physical/psychological/sexual abuse, anxiety, depression, attitudes towards sexuality, and social support. While the chronic painful intercourse (n = 51) and pain-free comparison group (n = 167) did not differ significantly on biomedical variables, painful intercourse was associated with significantly more pain during tampon insertion, and avoidance of tampons was linked to a fourfold risk of experiencing pain during sex. Cases also reported engaging in significantly more detrimental vulvar hygiene habits than pain-free girls, whereas no significant group differences were observed for self-treatment using over-the-counter antifungal preparations. Sexual abuse, fear of physical abuse, and trait anxiety were identified as significant psychosocial correlates of chronic painful intercourse. A logistic regression further identified pain during first tampon insertion and trait anxiety as statistical predictors of adolescent pain during intercourse. In addition to a possible intrinsic dysfunction in central pain processing, findings suggest that psychological variables, such as anxiety, play a significant role in painful intercourse's very first manifestations in adolescent girls.