A Psychophysiological Investigation of Sexual Arousal in Women with Lifelong Vaginismus

Vaginismus, Dyspareunia and Abuse History: A Systematic Review and Meta-analysis

BACKGROUND

Genito-pelvic pain/penetration disorder, which consists of a combination of vaginismus and dyspareunia, is considered a new diagnosis in the latest version of the Diagnostic and Statistical Manual of Mental Disorders. Although the etiology of this diagnosis is not well known, a history of abuse has been suggested to be a primary factor in the emergence of this disorder.

AIM

This systematic review and meta-analysis aimed to determine the association of abuse history with vaginismus and dyspareunia diagnosis.

METHODS

Related keywords were used to search articles in PubMed, PsycArticles, PsycINFO, Scopus, Web of Science, and the Turkish scientific information database (TRDizin). All articles published in English and Turkish until August 2020 were systematically reviewed. A total of 14 case-control studies, including 1428 participants, were included in the final analysis. The fixed-effects model was used to pool odd ratios (ORs) and 95% confidence intervals (CIs) of the studies. Heterogeneity was evaluated using the I² statistic.

OUTCOMES

Case-control studies that reported vaginismus or dyspareunia outcomes in individuals with or without a history of abuse.

RESULTS

A significant relationship was found between a history of sexual (1.55 OR; 95% CI, 1.14-2.10; 12 studies) and emotional abuse (1.89 OR; 95% CI, 1.24-2.88; 3 studies) and the diagnosis of vaginismus. A significant relationship was found between sexual abuse and dyspareunia (1.53 OR; 95% CI, 1.03-2.27; 6 studies). No statistically significant relationship was observed between physical abuse, vaginismus, and dyspareunia. No significant difference was found between sexual or physical abuse in terms of assessment methods for the diagnosis of vaginismus and dyspareunia.

CLINICAL IMPLICATIONS

This systematic review and meta-analysis points out that in the assessment of vaginismus patients, the risk of sexual and emotional abuse and in the assessment for dyspareunia patients, the risk of sexual abuse should be questioned and addressed in its treatment.

STRENGHT AND LIMITATIONS

The strength of the current meta-analysis is the inclusion of all forms of abuse, and studies published in Turkish and English with a broad and reproducible search strategy. The limitations of this meta-analysis are the exclusion of sources and design other than journal articles and case-control studies, including studies both childhood and adult abuse, which in some studies were not differentiated, having potential language and recall bias.

CONCLUSION

The study analysis suggests an association of vaginismus with sexual and emotional abuse and dyspareunia with sexual abuse. However, both disorders showed no association with physical abuse. S. Tetik, ÖY. Alkar, Vaginismus, Dyspareunia, and Abuse History: A Systematic Review and Meta-analysis. J Sex Med 2021;18:1555-1570.

Examination of Treatment Duration, Treatment Success and Obstetric Results According to the Vaginismus Grades

Introduction

In patients with vaginismus, the treatment becomes more challenging and the treatment may take longer as the grade of vaginismus is higher or worsens. However, the differences regarding treatment duration, success, and treatment methods by grades are not evident in the literature.

Aim

The aim of this study is to answer the question, “Does the number of treatment sessions, dilator requirement, treatment success, pre-& post-treatment FSFI scores and obstetric results of vaginismus patients change depending on the vaginismus-grade?”

Methods

The patients were divided into 4 grades according to the Lamont classification. They underwent stepwise treatment sessions by a single gynecologist. Treatment success, duration of treatment, mechanical dilator requirement, duration from marriage, pre- and post-treatment FSFI scores, pregnancy rates, and delivery types were compared between patients at different grades.

Main Outcome Measures

Assessment of the differences between vaginismus-grades by comparing clinical observations and FSFI-scores.

Results

Pain-free sexual intercourse occurred in 85 (93.4%) of 91 primary-vaginismus patients included in our study. The success rate was 100% in grade 1, 95.2% in grade 2, 92.1% in grade 3, and 92% in grade 4. Treatment session durations of the patients differed significantly by grades (P < .05). Same way the duration from marriage at the time of application differed significantly by the grade (P < .05). While there was a significant relationship between vaginismus grade and dilator requirement, there was no significant relationship between vaginismus grade and delivery type (P < .05). 54.5% of 44 patients, who got pregnant, delivered by cesarean-section. There was a significant increase in FSFI scores in all groups in the pre- and post-treatment third month (P < ,05).

Conclusion

Patients should be notified that as the grades of vaginismus progress, the duration of the treatment may extend, and its success may decrease, the requirement for mechanical dilators will increase in the advanced grade, and the grade may progress as the application period for treatment is delayed.

Kiremitli S, Kiremitli T. Examination of Treatment Duration, Treatment Success and Obstetric Results According to the Vaginismus Grades. Sex Med 2021;9:100407.

The role of personal factors in quality of life among Iranian women with vaginismus: a path analysis

Background

The aim of this study was to provide a path model for assessing the direct and/or indirect effects of psychological/behavioral parameters on health-related quality of life among women with vaginismus.

Methods

A cross-sectional study was conducted on a sample of 236 women with vaginismus disorder attending to sex clinics in Tehran, Iran from April 2017 to March 2018. Data were collected using a demographic questionnaire, the marital satisfaction scale, the hospital anxiety and depression scale, the rosenberg self-esteem scale, the body image concern inventory, the short-form health survey (SF-12) and the female sexual quality of life questionnaire. In addition to descriptive statistical data, the fitness of the proposed model was investigated using path analysis.

Results

The results of path analysis demonstrated that the final model had a good fit to the data (Chi-Square/degrees of freedom (Normed Chi²) = 2.12, root mean square error of approximation = 0.069, goodness fit index = 0.99, both comparative fit index = 0.99 and Tucker–Lewis index = 0.96). In this model, anxiety and depression significantly predicted health-related quality of life as measured by the SF-12.

Conclusions

Anxiety and depression are important components in predicting health-related quality of life among those suffering from vaginismus.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-021-01799-5.

Laser Doppler Imaging as a Measure of Female Sexual Arousal: Further Validation and Methodological Considerations

Laser Doppler imaging has recently been applied to the study of female sexual response, with promising results. The current study sought to provide further validation for its use in this capacity, as well as to examine the sexual psychophysiological concepts of genital non-response and return to baseline with this instrument. A sample of healthy heterosexual women without any sexual concerns (N = 24) participated in a single testing session design, which included self-report measures and genital imaging with the laser Doppler imager (LDI). During the imaging portion of the study, genital and subjective arousal data were collected while participants watched neutral and erotic film stimuli. The results support the validity of the LDI as a measure of female sexual arousal, and highlight its potential utility in research and clinical applications for sexual function and related difficulties.

A review of infrared thermography as applied to human sexual psychophysiology

Infrared thermography (IRT) is a non-contact technique that permits mapping and analysis of the temperature of the body's skin surface. This method has been applied to sexual psychophysiology since the 1980s and its use has been expanding ever since, mainly because it provides several advantages over existing genital response measures. This article presents a review of experimental studies employing IRT to investigate human sexual arousal, with the aim of summarizing the available procedures and evidence so far and to identify important caveats in the literature. The studies reviewed support the feasibility and validity of IRT as a real-time physiological measure of sexual arousal but varied substantially regarding methodology and procedures. The results of this review underscore the value and validity of IRT in sexual psychophysiology and point at the critical need for the standardization of IRT protocols to accommodate the specific needs of applying this methodology to sexual physiology.

Peripheral Female Genital Arousal as Assessed by Thermography Following Topical Genital Application of Alprostadil vs Placebo Arousal Gel: A Proof-of-Principle Study Without Visual Sexual Stimulation

Introduction

Female sexual arousal disorder is a pathophysiologic state characterized clinically by persistent or recurrent inability to attain or maintain an adequate lubrication-swelling response of sexual excitement until completion of sexual activity. Prior clinical experience with alprostadil products for men with erectile dysfunction supports its use in women with female sexual arousal disorder.

Aim

To compare the effect of topical alprostadil with over-the-counter (OTC) lubricant on female genital arousal in the absence of visual sexual stimuli.

Methods

Healthy premenopausal women without sexual dysfunction were recruited from the community to participate in the study. Of 17 women who consented, 10 were enrolled and completed the trial. The mean age of subjects was 32 years (range = 27–43). Study drug or placebo was applied topically to the genitals. Continuous temperature monitoring was performed. Participants completed questionnaires assessing genital sensation, effect, intensity, and duration.

Main Outcome Measures

Change in temperature from baseline in vestibule, clitoris and vulva.

Results

In all 10 subjects, topical alprostadil induced a statistically significant increase in temperature of the vestibule, clitoris, and vulva compared with the OTC lubricant. The most rapid difference in genital temperature between placebo and alprostadil was seen on the vulva, which demonstrated a significant difference at approximately 9 minutes. There was a significant difference in temperature seen for the vestibule and clitoris at 11 and 19 minutes, respectively. Sixty percent of women reported being aware or conscious of genital sensations with topical alprostadil, but not with OTC lubricant. Discordance was noted in 30% of subjects who reported being aware or conscious of genital sensations with the two treatments and 10% who reported not being aware or conscious of genital sensations with either treatment.

Conclusion

Topical alprostadil administered to healthy premenopausal women induced statistically significant, sustained increases in genital temperatures of the vestibule, clitoris, and vulva within 20 minutes compared with OTC lubricant.

Devices and Methods to Measure Female Sexual Arousal

INTRODUCTION

Multiple methods and devices are available for the assessment of female sexual response, each with strengths and limitations that can impact interpretation of research results. As such, it is important to have an understanding of available methodologies and instruments.

AIM

To review recent literature on the measurement of female sexual response, and to describe the methods and devices, and their strengths and limitations.

METHODS

A literature review was performed regarding methodology and instruments used to quantify female sexual response.

MAIN OUTCOME MEASURES

The description of currently available instruments and methods to quantify sexual response in women.

RESULTS

Methodologies used to examine female sexual arousal employ a variety of stimuli and instruments to elicit and record sexual response. The variation in research designs across studies highlights the importance of understanding (i) how sexual response is elicited in studies; (ii) what kinds of experimental designs are available for assessing sexual psychophysiology; and (iii) the various types of instrumentation used to collect data.

CONCLUSIONS

The physiological and self-reported measurement of female sexual response is crucial to our understanding of the mechanisms and factors involved with healthy sexual functioning. As such, it is important to understand the strengths and limitations associated with different stimuli, research designs, and instruments. Kukkonen TM. Devices and methods to measure female sexual arousal.

Female sexual pain disorders: dyspareunia and vaginismus

PURPOSE OF REVIEW

To analyze literature on sexual pain disorders and to review and summarize the articles published throughout 2013 which contribute to the current knowledge on this subject.

RECENT FINDINGS

By age 40, 7.8% of women reported vulvar pain. Diagnostic and Statistical Manual of Mental Disorders, fifth edition, has combined vaginismus and dyspareunia into the same diagnostic label. The research reviewed in this article seems to differently point toward two conditions, focusing on different aspects both on the etiological and on the treatment area. Higher levels of partner-perceived self-efficacy and lower levels of partner catastrophizing were associated with less pain intensity in women with entry dyspareunia, independent of women's pain perception and self-efficacy. Alexithymia and fear were found to be important etiological factors in vaginismus.

SUMMARY

The present findings did not provide clear evidence in support of the superiority of any treatment and highlight the need for randomized, placebo-controlled trials that compare treatments in the future. A lot of work remained to be done to understand such a complex and multifaceted disturbance as genital sexual pain, but the articles examined showed that we are slowly adding more knowledge on the etiological cause and treatment models for such conditions.

Fear Avoidance and Pain Catastrophizing among Women with Sexual Pain

Aim: Among women under 30 years of age, around 20% report recurrent sexual pain. Although the amount of studies investigating sexual pain has increased, little is known about the role of psychosocial factors. The present study used the fear-avoidance model from musculoskeletal pain as a theoretical frame of reference, and examined fear-avoidance beliefs, avoidance behaviors, pain catastrophizing and symptoms of anxiety and depression among women (18–35 years) reporting sexual pain. Methods: The study was cross-sectional, based on a sample of 133 women, where 37 women (27.8%) reported sexual pain often or always. Results: Women with pain reported higher levels of fear avoidance and pain catastrophizing as well as depression and anxiety, with fear avoidance and pain catastrophizing reaching similar levels as has been reported in other long-term pain populations. The level of anxiety and depression did not reach clinical levels. Fear-avoidance beliefs and pain catastrophizing were related to sexual pain and to pain intensity in the regression analysis. Conclusion: The data are in line with, and give further support to, a fear-avoidance perspective in female sexual pain, emphasizing the role of fear and avoidance of pain/sex.

Frontal alpha asymmetry and sexually motivated states

Anterior alpha asymmetry of electroencephalographic (EEG) signals has been suggested to index state approach (or avoidance) motivation. This model has not yet been extended to high approach-motivation sexual stimuli, which may represent an important model of reward system function. Sixty-five participants viewed a neutral and a sexually motivating film while their EEG was recorded, and reported their sexual feelings after each film. Greater alpha power in the left hemisphere during sexually motivated states was evident. A positive relationship between self-reported mental sexual arousal and alpha asymmetry was identified, where coherence between these indicators was higher in women. Notably, coherence was stronger when mental versus physical sexual arousal was rated. Alpha asymmetry appears to offer a new method for further examining this novel coherence pattern across men and women.

Brain processing of visual stimuli representing sexual penetration versus core and animal-reminder disgust in women with lifelong vaginismus

It has been proposed that disgust evolved to protect humans from contamination. Through eliciting the overwhelming urge to withdraw from the disgusting stimuli, it would facilitate avoidance of contact with pathogens. The physical proximity implied in sexual intercourse provides ample opportunity for contamination and may thus set the stage for eliciting pathogen disgust. Building on this, it has been argued that the involuntary muscle contraction characteristic of vaginismus (i.e., inability to have vaginal penetration) may be elicited by the prospect of penetration by potential contaminants. To further investigate this disgust-based interpretation of vaginismus (in DSM-5 classified as a Genito-Pelvic Pain/Penetration Disorder, GPPPD) we used functional magnetic resonance imaging (fMRI) to examine if women with vaginismus (n = 21) show relatively strong convergence in their brain responses towards sexual penetration- and disgust-related pictures compared to sexually asymptomatic women (n = 21) and women suffering from vulvar pain (dyspareunia/also classified as GPPPD in the DSM-5, n = 21). At the subjective level, both clinical groups rated penetration stimuli as more disgusting than asymptomatic women. However, the brain responses to penetration stimuli did not differ between groups. In addition, there was considerable conjoint brain activity in response to penetration and disgust pictures, which yield for both animal-reminder (e.g., mutilation) and core (e.g., rotten food) disgust domains. However, this overlap in brain activation was similar for all groups. A possible explanation for the lack of vaginismus-specific brain responses lies in the alleged female ambiguity (procreation/pleasure vs. contamination/disgust) toward penetration: generally in women a (default) disgust response tendency may prevail in the absence of sexual readiness. Accordingly, a critical next step would be to examine the processing of penetration stimuli following the induction of sexual arousal.

A comparative study of sexual function, behavior, and cognitions of women with lifelong vaginismus

Vaginismus is classified as a sexual dysfunction, yet limited research is available on the sexual function and behavior of women with this condition. Comparing women with lifelong vaginismus to women with lifelong dyspareunia and women with no pain during intercourse, this study explored sexual function, anxiety, and behavior along with cognitions related to vaginal penetration. A total of 152 women completed an online survey that included a series of validated questionnaires. Main findings indicated that, relative to both comparison groups, women in the vaginismus group reported a more limited range of sexual behavior across the lifespan and more maladaptive cognitions related to fear of losing control of one's body and the situation during penetration. Compared to the no-pain group, both symptomatic groups reported more difficulties across several indicators of sexual function, more limited sexual behavior in the past year and past month, and more maladaptive cognitions related to vaginal penetration. However, women with vaginismus reported more sexual desire and less difficulty with lubrication compared to women with dyspareunia. Numerous sexual problems extending beyond vaginal penetration difficulties were confirmed, suggesting a need for broader treatment approaches not limited to the experience of vaginal penetration. Results were discussed as they relate to the fear-avoidance model of vaginismus.