Listen to your sexual pain patients--really listen

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.

Examining the relationship between uterine fibroids and dyspareunia among premenopausal women in the United States

INTRODUCTION

Despite estimates of a high prevalence of deep dyspareunia (DD) among women in the United States, risk factors for this important area of sexual dysfunction have been largely understudied.

AIMS

The purpose of this study was to examine the relationship between uterine fibroids and the prevalence of DD.

METHODS

We used data from the Uterine Fibroid Study (enrollment 1996-1999 in a U.S. metropolitan area). Participating women were ages 35-49 and were randomly selected from the membership rolls of a prepaid health plan. Women were asked to provide detailed health information including a symptom questionnaire with questions about DD and to have a study ultrasound to screen for fibroids ≥ 0.5 cm in diameter. The analysis included 827 women, after restriction to participants who were premenopausal with an intact uterus, sexually active, completed the symptom questionnaire, and had fibroid status adequately assessed. Logistic regression was conducted to estimate the adjusted prevalence odds ratio (aPOR) for the association of DD with presence of fibroids after adjusting for age, ethnicity, education, depression, physical activity, parity, and pelvic pathology.

MAIN OUTCOME MEASURE

Our main outcome measures were the presence and severity of DD.

RESULTS

The presence of fibroids was significantly associated with DD (aPOR = 1.7 95% confidence interval [CI] 1.1, 2.5). The aPOR was stronger for severe DD, DD that interfered with normal activity "some" or "a lot" (aPOR = 3.1 95% CI 1.2, 8.2). However, there was not a significant dose response relationship between fibroid burden (measured by uterine volume) and DD. Fundal fibroids were more strongly associated with DD than other fibroids. Additional factors associated with significantly elevated odds of DD were parity, depression, younger age, and pelvic pathology.

CONCLUSION

Our results suggest that fibroids are associated with DD. The association may not be causal but may reflect shared etiology and/or pathologic pathways.