Body Image in Women with Primary and Secondary Provoked Vestibulodynia: A Controlled Study

The effectiveness of psychological interventions for reducing poor body image in endometriosis, PCOS and other gynaecological conditions: a systematic review and meta-analysis

Gynaecological conditions (e.g., endometriosis, PCOS) result in bodily changes that negatively impact body image. Psychological interventions (e.g., CBT, psychoeducation) have shown promise in reviews with the general population for alleviating body image concerns. This systematic review and meta-analysis aims to provide asynthesis of the impact of psychological interventions for reducing body image concerns for individuals with gynaecological conditions. Electronic databases were searched for relevant psychological intervention studies with body image outcomes. Twenty-one eligible studies were included in the systematic review (ten were included in a random-effects meta-analysis). Studies included participants (N = 1483, M = 71.85, SD = 52.79) with a range of gynaecological conditions, ages (Mage = 35.08, SD = 12.17) and cultural backgrounds. Most included studies reported at least one positive effect with the meta-analysis indicating psychological interventions were moderately superior to control conditions for reducing body image concerns (SMD -.41, 95% CI [-0.20 -0.62]). However, there was a high risk of bias and moderate heterogeneity. Results suggest psychological interventions may hold promise for reducing body image concerns among individuals gynaecological conditions in the short term. Further, preliminary support was found for the use of theory-guided psychological interventions delivered in group settings in particular, with further research needed on optimal intervention length and particular psychotherapeutic approach.

Do perfectionism, body image concerns, and intimacy predict genitopelvic pain in the postpartum? A prospective study of new mothers

BACKGROUND

Genitopelvic pain following childbirth is common and likely to challenge the psychological, relational, and sexual well-being of new mothers. While genitopelvic pain generally decreases during the postpartum period, personal and interpersonal characteristics may explain why genitopelvic pain persists beyond the period of physical recovery in some mothers. Body image concerns, increased stress, and relationship challenges would be particularly salient during pregnancy and the postpartum period, which could put new mothers at greater risk of sexual difficulties. Also, mothers may display a negative appraisal regarding genitopelvic pain and doubt their ability to cope with it, which may contribute to the pain.

AIM

The current study aimed to examine the role of perfectionism, body image concerns, and perceived intimacy in the occurrence and change in genitopelvic pain in new mothers in postpartum.

METHODS

A total of 211 new mothers and their partners were recruited for a larger prospective dyadic study on the transition to parenthood.

OUTCOMES

Mothers completed a single item assessing genitopelvic pain, in addition to brief validated questionnaires measuring perfectionism, body image concerns, and perceived couple intimacy during pregnancy and at 4, 8, and 12 months postpartum.

RESULTS

Five multilevel modeling analyses revealed that adaptive perfectionism, maladaptive perfectionism, and body image concerns were associated with a higher occurrence of genitopelvic pain from 4 to 12 months postpartum. Mothers' and partners' perceived intimacy was not significantly related to new mothers' genitopelvic pain. None of the predictors modified the trajectory of genitopelvic pain over time.

CLINICAL IMPLICATIONS

Raising awareness among health care professionals regarding the role of perfectionism and body image concerns in genitopelvic pain may help them identify new mothers at risk of chronic genitopelvic pain, while offering a new avenue of intervention.

STRENGTHS AND LIMITATIONS

There has been little research examining the role of perfectionism, body image concerns, and intimacy in postpartum genitopelvic pain. Based on a longitudinal prospective approach, this study identified perfectionism and body image concerns as significant predictors of postpartum genitopelvic pain. However, prepregnancy genitopelvic pain, genitopelvic pain intensity, and sexual distress were not measured.

CONCLUSION

Adaptive and maladaptive perfectionism and body image concerns are associated with new mothers' genitopelvic pain up to 12 months postpartum.

"The sound of silence" Giving voice to endometriosis-related positional dyspareunia

Deep dyspareunia is one of the main symptoms of endometriosis. It appears to be submerged by a two-way disconnection between patients and their physicians. The aim of our review is to provide clear, ready-to-use advice on how to manage deep dyspareunia overcoming the gap in communication. Sexual history should always be taken as part of routine health care in these regards, using a patient-centered approach. An educational pelvic examination, which actively includes patients in the identification of painful areas, may prove useful to improve patients' understanding of their condition. Correlating painful pelvic areas with sexual positions and inviting patients to adopt alternative positions may represent a simple but extremely effective coping strategy to mitigate pain. Revealing and explaining to partners the nature of the pain is essential to allow them to take part in shared research of coping mechanisms, empowering the couple to make choices and changes. Couples who do not feel comfortable talking about intimacy by themselves may find that including a psychotherapist or a sexual therapist, may be a good way to start communication. Investigating and managing dyspareunia during medical encounters is a medical and ethical duty all healthcare practitioners should pursue.

A conceptual model for managing sexual pain with somatocognitive therapy in women with provoked vestibulodynia and implications for physiotherapy practice

Somatocognitive therapy is a multimodal physiotherapy treatment developed in the early 2000s to alleviate the burden of chronic pelvic pain. In recent years, somatocognitive therapy has been further developed to treat women with provoked vestibulodynia. This prevalent gynecological pain condition is a subgroup of chronic pelvic pain and the most common form of vulvodynia. Provoked vestibulodynia is a neglected multifactorial pain condition of unknown cause, adversely affecting women's sexual life, relation to their partners and their psychological health. Pain is located at the vulvar vestibule and is provoked by touch or pressure such as sexual intercourse. In the management of sexual pain, somatocognitive therapy combines bodily exploration, pain education, cognitive coping strategies and structured homework to improve sexual function and reduce pain. To support these processes, developing a sound therapeutic alliance with the patient is essential. The aim of this article is to provide a conceptual model for managing provoked vestibulodynia with somatocognitive therapy, including a theoretical rational for this treatment. We base our conceptual model on the biopsychosocial model, i.e., considering the complex interplay of biomedical, emotional/cognitive, psychosexual and interpersonal factors in provoked vestibulodynia management. In addition, implications for practice and a detailed description of somatocognitive therapy for provoked vestibulodynia will be provided, to allow replication in clinical practice and in clinical trials.

"Anger, embarrassment, less than a woman": the emotional impact of Black women's sexual pain

Limited research has examined the emotions Black women report when thinking about sexual pain. To fill this gap in the literature, we explored the types of emotions that emerged when N = 126 premenopausal Black women thought about pain during sex. Open-ended responses to the following research question were analyzed: "What feelings emerge when you think about sexual pain?" Structural tabular thematic analysis was used to find commonalities in participants' responses. Findings indicated five families, or categories, of emotions: self-judgment, anger/disgust, sadness, anxiety, and emotions felt somatically. Additionally, women's reports were predominantly within the feeling state and cognitive appraisal components of emotion. Implications for health providers and therapists are discussed.

Pain Characteristics, Fear-avoidance Variables, and Pelvic Floor Function as Predictors of Treatment Response to Physical Therapy in Women With Provoked Vestibulodynia

OBJECTIVE

The aim was to investigate whether pretreatment pain characteristics, psychological variables, and pelvic floor muscle (PFM) function predict the response to physical therapy (PT) in women with provoked vestibulodynia (PVD).

MATERIALS AND METHODS

One hundred-five women diagnosed with PVD underwent 10 weekly sessions of individual PT comprising education, PFM exercises with biofeedback, manual therapy, and dilators. Treatment outcomes were evaluated at pretreatment, post-treatment, and 6-month follow-up and included pain intensity (numerical rating scale 0 to 10) and sexual function (Female Sexual Function Scale). Multilevel analyses were used to examine the potential predictors of response over time including pain characteristics (PVD subtype, pain duration), psychological variables (fear of pain, pain catastrophizing), and PFM function assessed with a dynamometric speculum (tone, flexibility, and strength).

RESULTS

PVD subtype and PFM tone were significant predictors of greater treatment response for pain intensity reduction. Secondary PVD (ie, pain developed after a period of pain-free intercourse) and lower PFM tone at baseline were both associated with greater reduction in pain intensity after PT and at follow-up. Among the psychological variables, fear of pain was the only significant predictor of better treatment response when assessed through improvement in sexual function, where higher fear of pain at baseline was associated with greater improvement after PT.

DISCUSSION

This study identified PVD secondary subtype, lower PFM tone, and higher fear of pain as significant predictors of better treatment response to PT in women with PVD.

A Network Analysis of Selected Psychosocial Factors in Vulvodynia and Its Subtypes

OBJECTIVE

Psychosocial factors are related to pain and sex-related outcomes in provoked vulvodynia and possibly in mixed and spontaneous vulvodynia. However, a broader behavioral framework, such as the psychological flexibility model, has received limited attention in this context. Recently, additional psychosocial variables have also emerged that appear relevant to vulvodynia, including perceived injustice, body-exposure anxiety during intercourse, and unmitigated sexual communion. The present study applied network analysis to explore relations between psychological flexibility, newly emerging psychosocial variables relevant to vulvodynia, and their associations with vulvodynia outcomes. The study also explored potential differences across vulvodynia subtypes.

DESIGN

An online cross-sectional study of 349 participants with vulvodynia (112 provoked, 237 spontaneous/mixed) was carried out.

METHODS

Participants completed self-report questionnaires, including questions on pain and sexual outcomes, depression, facets of psychological flexibility, body-exposure anxiety during intercourse, unmitigated sexual communion, and perceived injustice. Networks were computed for the total sample and for provoked and mixed/spontaneous vulvodynia subsamples.

RESULTS

Perceived injustice, pain acceptance, and depression were "central" factors among the included variables, in all models. Psychological flexibility processes were relevant for all networks. Depression was more central in the network for mixed/spontaneous vulvodynia; body-exposure anxiety during intercourse was most central for the provoked subtype.

CONCLUSIONS

Among the included variables, perceived injustice, pain acceptance, depression, and psychological flexibility appear to be important in vulvodynia. As different factors are significant across subtypes, tailored treatment approaches are suggested.

Transcranial direct current stimulation for provoked vestibulodynia: What roles do psychosexual factors play in treatment response?

There is growing evidence that provoked vestibulodynia (PVD), a frequent and debilitating condition, is characterized by central sensitization. This study aimed to examine predictive factors of transcranial direct current stimulation (tDCS) efficacy in this chronic pain population. Exploratory analysis derived from a randomized controlled trial was performed to assess predictors of pain reduction among 39 women with PVD who received 10 daily sessions of either active or sham tDCS. Clinical characteristics (e.g. pain intensity, duration and pain sensitivity) and psychosexual factors (e.g. pain catastrophizing, pain-related fear, anxiety, depressive symptoms and vaginal penetration cognitions) were assessed at baseline and used to predict tDCS response at 3-month follow-up. Analysis revealed that higher depressive symptoms and lower negative self-image cognitions were significant predictors of pain reduction at follow-up and accounted for 62.3% of the variance in the active tDCS group. Higher genital incompatibility cognitions were related to poorer response, regardless of treatment group. These findings suggest that women with PVD presenting higher depressive symptoms and lower levels of negative self-image cognitions could derive greater benefits from tDCS. These results suggest that tDCS could be effective in a subgroup of women with PVD - a possibility worth exploring with future prospective larger studies.

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

Background

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

Aims

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

Methods

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

Main Outcome Measure

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

Results

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

Conclusion

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

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

The role of psychological flexibility, perceived injustice and body image in Vulvodynia: A longitudinal study

BACKGROUND

Women with Vulvodynia experience pain, related impacts on sex and daily functioning, and depression. While psychosocial factors are associated with outcomes in Vulvodynia, longitudinal data are limited, especially in mixed/spontaneous Vulvodynia. Broad psychological models such as psychological flexibility (PF) and content-specific factors, such as body-exposure anxiety (BEA) and avoidance during sexual activities and perceived injustice, have not been adequately investigated in Vulvodynia. The aim of this study was to explore whether these factors assessed at baseline predict pain severity, pain interference, sexual functioning and satisfaction and depression 3 months later.

METHODS

A longitudinal study of 349 women with Vulvodynia was conducted. Participants completed online self-report measures of pain-related and sexual outcomes, depression, BEA, perceived injustice and facets of PF (present moment awareness, pain acceptance, committed action) at baseline and after 3 months, overlapping with the Coronavirus disease 2019 (COVID-19) pandemic.

RESULTS

Seventy percent of women responded at both assessments (n = 244). There were significant decreases in pain severity, pain interference, present moment awareness, committed action and a significant increase in depression at 3 months. All the baseline psychosocial factors significantly correlated with at least one outcome at 3 months. When adjusting for baseline outcome and demographics, committed action significantly positively predicted depression at 3 months and pain acceptance significantly positively predicted pain interference at 3 months.

CONCLUSIONS

Among women with Vulvodynia, pain acceptance and committed action are prospectively associated with pain interference and depression. The reliability and generalizability of these results needs to be established given the overlap with the COVID-19 pandemic. Future studies should investigate whether targeting these factors enhances outcomes in Vulvodynia.

SIGNIFICANCE

This longitudinal study explored the role of PF, perceived injustice and body image during sexual activities in predicting pain severity, pain interference, sexual functioning, sexual satisfaction and depression in women with Vulvodynia. The study findings reveal that two facets of PF (committed action and pain acceptance) predicted pain interference and depression over time. It may be important to incorporate these processes in treatments developed for Vulvodynia.

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.

Psychosocial factors associated with pain and sexual function in women with Vulvodynia: A systematic review

BACKGROUND AND OBJECTIVE

Vulvodynia is a prevalent chronic vulval pain condition affecting 10%-28% of women, and significantly impacting their health and quality of life. It is currently poorly understood and biomedical treatments achieve only modest benefits for pain and sexual functioning. A wider psychosocial conceptualization of this condition may improve outcomes. There is currently no coherent understanding of how psychosocial factors may contribute to outcomes in Vulvodynia. The aim of this review is to identify and systematically review psychosocial factors associated with pain and sexual outcomes and to inform a psychosocial model of Vulvodynia.

DATABASES AND DATA TREATMENT

Observational/experimental studies reporting on the association between psychosocial factors and pain/sexual outcomes in adult women with Vulvodynia were eligible. Two reviewers independently conducted eligibility screening, data extraction and quality assessment. Twenty-one studies were included, all focused on women with Provoked Vestibulodynia (PVD). Most of the studies were low-to-medium quality.

RESULTS/CONCLUSION

A range of general/pain-related distress and avoidance processes, and sex/intimacy avoidance or engagement processes were significantly associated with pain, sexual functioning or sexual distress and sexual satisfaction, supporting the role of a psychosocial approach to PVD. Depression, anxiety, catastrophizing, pain-anxiety, pain acceptance, body-exposure anxiety, attention to sexual cues, partner hostility and solicitousness, self-efficacy and penetration cognitions are highlighted as potentially important treatment targets in PVD. Due to the limited data available, developing a psychosocial model was not possible. Directions for future research include examining the replicability and generalizability of the factors identified, exploring differences/similarities across Vulvodynia subsets and testing tailored theoretically based treatments.

SIGNIFICANCE

The systematic review highlights the role of psychosocial factors associated with pain and sexual functioning in Vulvodynia. The review findings reveal that Vulvodynia presents both similar and unique cognitive, behavioural and interpersonal features compared to other chronic pain conditions. There may be important roles for negative sexual cues, body image-related factors during intercourse, partner factors, self-efficacy beliefs and penetration cognitions, in relation to pain and sexual functioning.

Genitopelvic pain: retrospective evaluation of a multimodal treatment efficacy

BACKGROUND

Genitopelvic and sexual pain penetration disorder (GPPD) recognizes a multifaceted etiology. As with syndromes of chronic pain, it responds poorly to medications and its management is difficult. Clinicians consequently favor a multimodal comprehensive approach to tackle the different aspects of the disorder. To treat GPPD women, we chose a multimodal regimen including topical and systemic medications associated with physical interventions and behavioral couple therapy. Our aim was to evaluate the regimen efficacy and the influence that demographic, clinical, and pain characteristics may have on the outcome.

METHODS

Sixty self -referred women requesting medical care for GPPD, who were free of debilitating illness, in stable heterosexual relationships and with healthy and sexually functional partners, were treated according with the multimodal regimen we tailored on the specific needs of these women. As said, it associated topical and systemic medications combined with physical exercises used in behavioral sex therapy, and behavioral couple therapy. Past sexual history, characteristics of pain, vestibular hyperreactivity, pelvic floor hypertonicity, general health, and couple harmony were evaluated and statistically analyzed to determine which characteristics were associated with therapy outcome.

RESULTS

The statistical analysis of an association between demographic, reproductive, pain and medical conditions on one hand and therapy outcome on the other did not find any significance.

CONCLUSIONS

The lack of association between the investigated characteristics and treatment outcome is disappointing; on the other hand, the statistically significant impact of couple harmony (evaluated as partner presence and participation) on the treatment results may be the answer to our search for factors predicting outcome.

Are Depressive Symptoms and Attachment Styles Associated with Observed and Perceived Partner Responsiveness in Couples Coping With Genito-Pelvic Pain ?

Partner responsiveness is thought to facilitate relationship adjustment in couples coping with genito-pelvic pain, such as provoked vestibulodynia (PVD). Recent studies suggest that attachment and depressive symptoms may act as a filter in the perception of partner responsiveness, and a barrier to the capacity of being responsive to a partner. Given studies suggesting higher depressive symptoms and relationship insecurities in women experiencing genito-pelvic pain compared to controls, investigating the role of these factors in partner responsiveness may help couples improve their wellbeing in the challenging context of PVD. The aim of this study was to examine the associations between depressive symptoms, attachment, and perceived and observed partner responsiveness in 50 couples coping with PVD. Participants took part in a videotaped discussion and completed self-report measures of depressive symptoms, attachment, and perceived partner responsiveness. Based on the actor-partner interdependence model, results indicated that when women and partners reported greater depressive symptoms and anxious attachment, they perceived each other as being less responsive. When partners experienced greater depressive symptoms, women and partners were rated, by a trained observer, as being less responsive to each other. Targeting depressive symptoms and relationship insecurity in couple therapy could increase responsiveness in couples coping with PVD.

Body image during sexual activity in the population of Polish adult women

Introduction

Recently it has been shown that body image during sexual activities is a better predictor of the diversity of sexual experience than body image as a psychological trait. To measure contextual body image (as a state) the Body Exposure During Sexual Activity Questionnaire (BESAQ) was developed.

Material and methods

845 women aged 18-55 years were included in the study. The original model was first translated into Polish and consulted to create the version to be further validated. The original model was tested using confirmatory factor analysis (CFA). The population was divided in two equal groups – group 1 was used for exploratory factor analysis. Discriminant and convergent validity were checked. Sexual function was assessed by the Changes in Sexual Function Questionnaire.

Results

The Polish model of BESAQ (BESAQ-PL) consisted of 28 items with 2 lower-order factors. It had a satisfactory goodness of fit – comparative fit index (CFI) = 0.93, Tucker-Lewis index (TLI) = 0.94, root-mean-square error of approximation (RMSEA) = 0.06 and χ² = 1360.0, df = 337, p< 0.001, excellent internal consistency measured by Cronbach’s α = 0.88 and satisfactory discriminate validity. State body image (BESAQ-PL) did not predict sexual functioning. Face was the most important for self-consciousness during sexual contact in the population of Polish women.

Conclusions

State body image correlates with sexual functions but is not a major factor influencing sexual performance. Women in Poland are not anxious about body exposure during sexual activity. The BESAQ-PL may be used in the population of Polish women between 18 and 55 years of age.

Genito-Pelvic Pain Through a Dyadic Lens: Moving Toward an Interpersonal Emotion Regulation Model of Women's Sexual Dysfunction

Researchers and clinicians alike widely acknowledge the inherently interpersonal nature of women's sexual dysfunctions given that both partners impact and are impacted by these difficulties. Yet theoretical models for understanding the role of interpersonal factors in women's sexual dysfunctions are severely lacking and have the potential to guide future research and inform more effective interventions. The most widely studied sexual dysfunction in women that has espoused a dyadic approach by including both members of affected couples is genito-pelvic pain/penetration disorder (GPPPD). In this article we use the example of GPPPD to introduce a novel interpersonal emotion regulation model of women's sexual dysfunction. We first review current knowledge regarding distal and proximal interpersonal factors in GPPPD. Then, we describe our theoretical model and consider relevant pain and sex-related research on emotion regulation processes-emotional awareness, expression, and experience-in the context of GPPPD, including sexual function, satisfaction, and distress. Next, we review how existing theories from the fields of chronic pain and sex and relationships research have informed our model and how our model further builds on them. Finally, we discuss the implications of our model and its applications, including to other sexual dysfunctions in women.