Psychological profiles among women with vulvar vestibulitis syndrome: a chart review

Immunohistochemical staining with CD117 and PGP9.5 of excised vestibular tissue from patients with neuroproliferative vestibulodynia

BACKGROUND

Neuroproliferative vestibulodynia (NPV), a provoked genital pain characterized by severe allodynia and hyperalgesia, is confirmed in excised vestibular tissue by immunohistochemical staining (>8 CD117-positive immunostained cells/100× microscopic field) rather than by hematoxylin and eosin staining.

AIM

In this study we sought to assess immunostaining of tissue samples obtained during vestibulectomy surgery and to correlate results with patient outcomes.

METHODS

Patients (n = 65) meeting criteria for NPV who underwent vestibulectomy during the period from June 2019 through December 2022 formed the study cohort. We performed assessment of pathology of vestibular tissues by use of immunohistochemical staining, including quantitation of mast cells by CD117 (mast cell marker) and nerve fibers by protein gene product (PGP) 9.5 (neuronal marker). We analyzed 725 photomicrographs of immunostained tissue sections (100× and 200×) by manual counting and computer-assisted histometry and correlated these data to clinical assessments.

OUTCOMES

Outcomes included density of CD117 and PGP9.5 immunostaining in the 1:00-11:00 o'clock and 12:00 o'clock vestibular regions, and patient-reported outcomes assessing sexual function, pain, distress, and symptom improvement.

RESULTS

All 65 NPV patients (median age 26 years), 45 with lifelong and 20 with acquired NPV, had severe pain documented by PROs and vulvoscopy and had >8 CD117-immunopositive cells/100× microscopic field. Median cell count values were similar in the 1:00-11:00 o'clock and 12:00 vestibular regions (28.5 and 29.5/100× field, respectively). Likewise, the marker) and nerve fibers by protein gene product (PGP) 9.5 (neuronal marker). We analyzed 725 photomicrographs of immunostained tissue sections (100× and 200×) by manual counting and computer-assisted histometry and correlated these data to clinical assessments.

OUTCOMES

Outcomes included density of CD117 and PGP9.5 immunostaining in the 1:00-11:00 o'clock and 12:00 o'clock vestibular regions, and patient-reported outcomes assessing sexual function, pain, distress, and symptom improvement.

RESULTS

All 65 NPV patients (median age 26 years), 45 with lifelong and 20 with acquired NPV, had severe pain documented by PROs and vulvoscopy and had >8 CD117-immunopositive cells/100× microscopic field. Median cell count values were similar in the 1:00-11:00 o'clock and 12:00 vestibular regions (28.5 and 29.5/100× field, respectively). Likewise, the median area of CD117 immunostaining was similar in both regions (0.69% and 0.73%). The median area of PGP9.5 immunostaining was 0.47% and 0.31% in these same regions. Pain scores determined with cotton-tipped swab testing were nominally higher in lifelong vs acquired NPV patients, reaching statistical significance in the 1:00-11:00 o'clock region (P < .001). The median score for the McGill Pain Questionnaire affective subscale dimension was also significantly higher in lifelong vs acquired NPV patients (P = .011). No correlations were observed between hematoxylin and eosin results and density of mast cells or neuronal markers. Of note, 63% of the patient cohort reported having additional conditions associated with aberrant mast cell activity.

CLINICAL IMPLICATIONS

The pathology of NPV is primarily localized to the vestibular epithelial basement membrane and subepithelial stroma with no visible vulvoscopic findings, making clinical diagnosis challenging.

STRENGTHS AND LIMITATIONS

Strengths of this study include the large number of tissues examined with what is to our knowledge the first-ever assessment of the 12:00 vestibule. Major limitations are specimens from a single timepoint within the disease state and lack of control tissues.

CONCLUSIONS

Performing immunohistochemical staining of excised vestibular tissue with CD117 and PGP9.5 led to histometric confirmation of NPV, indications that NPV is a field disease involving all vestibular regions, validation for patients whose pain had been ignored and who had experienced negative psychosocial impact, and appreciation that such staining can advance knowledge.

Self-compassion, perfectionism, impostor phenomenon, stress and anxiety in patients with localized provoked vulvodynia

Studies have shown that psychological distress has a role in the symptomology of localized provoked vulvodynia. Therefore, psychosocial support has been presented as a valuable part of the treatment. However, little is known about which psychological variables that coincide with localized provoked vulvodynia. The purpose of this study was to identify qualities of psychological distress in patients with localized provoked vulvodynia. Patients with localized provoked vulvodynia were consecutively recruited to participate in this cross-sectional questionnaire-based study. Participants completed a self-report questionnaire measuring perfectionism, impostor phenomenon, self-compassion, anxiety and perceived stress. A sample of 30 patients were included. Questionnaire results suggestive of perfectionism was seen in 63%, impostor phenomenon in 80%, low self-compassion in 27%, anxiety in 43% and perceived stress in 23% of the participants. The level of self-compassion was higher in patients in a committed relationship. The investigated qualities appear to be more common in patients with localized provoked vulvodynia than in comparable groups. Impostor phenomenon and perfectionism were particularly common, with more than half of the study population scoring above the cutoff for clinical significance. This motivates research to investigate if interventions targeting impostor phenomenon and perfectionism, may aid in the treatment of localized provoked vulvodynia.

Impact of a single-session psychosocial counseling intervention for women with vulvodynia

OBJECTIVE

To evaluate the impact of a single session of psychosocial counseling on patients with vulvodynia.

METHODS

Patients diagnosed with vulvodynia at a vulvovaginal specialty clinic were randomly assigned to receive either a one-on-one 30- to 45-min psychosocial counseling session with a psychosexual counselor plus written educational materials (intervention group) or written materials alone (control group). They completed a survey before and 6 weeks after randomization that included demographic information and validated measures of sexual function and illness perception.

RESULTS

Thirty-one of 38 (81.6%) women approached chose to participate; 26 of the 31 (83.9%) completed the 6-week follow-up survey. Only the intervention group showed improvement in knowledge about vulvovaginal and sexual health, as well as in most measures of improvement in illness perception, as measured by the Brief Illness Perception Questionnaire (P < 0.05). When compared directly with those in the control group, patients in the intervention group reported increased understanding of their vulvar symptoms (P < 0.005) and lessened emotional impact of these symptoms (P = 0.035).

CONCLUSION

Patients receiving one session of the one-on-one psychosocial counseling intervention reported improved understanding and lessened emotional impact of their vulvar symptoms, compared with the control group. This study suggests that improvement may occur following minimal intervention and supports the need for further study.

Protocol for double-blind RCT of acupuncture for vulvodynia

Background

Vulvodynia, vulvar pain of unknown origin lasting at least 3 months, affects 7% of American women. Dyspareunia, its frequent companion, renders sexual intercourse virtually impossible. Although few therapies are efficacious and rapid pain relief is rarely possible, there have been no sham/placebo-controlled studies of acupuncture for vulvodynia. Aims are to: 1) determine efficacy of acupuncture for vulvodynia, 2) explore duration of the acupuncture effect.

Methods

In a pretest/posttest randomized controlled, double-blind (practitioner-patient) efficacy trial of a standardized acupuncture protocol, we will randomize 80 participants 1:1 to either penetrating needle or skin-touch placebo needle groups. Both types of needles are designed to blind both the acupuncturist and participant. Participants with vulvodynia will insert and remove a tampon as a standardized stimulus and complete primary measures of vulvar pain (pain intensity) and secondary measures of dyspareunia (Female Sexual Function Index, FSFI dyspareunia subscale score) and sexual function (FSFI total score) pretreatment, after the 10th acupuncture session, and pain measures weekly until return to pretest levels. Upon study completion control group participants will be offered 10 free real acupuncture sessions.

Discussion

This is the first multi-needle multi-session RCT using double-blind acupuncture needles as a reliable sham. We hypothesize that controlling for baseline, at posttest there will be statistically significant less vulvar pain and dyspareunia and more sexual function over five weeks in the penetrating needle group compared to the skin touch placebo group.

Conclusion

This study is responsive to the need for efficacious pain management for women with vulvodynia.ClinicalTrials.gov Identifier: NCT03364127.

Assessing Psychodynamic Conflicts and Level of Personality Functioning in Women Diagnosed With Vaginismus and Dyspareunia

Knowledge on etiological and risk factors of genito-pelvic pain/penetration disorder, formerly classified as dyspareunia and vaginismus, is limited. The Operationalized Psychodynamic Diagnosis (OPD) system offers a valuable basis for developmental considerations, and has not yet been used to research sexual pain difficulties in women. We conducted an exploratory pilot study of psychodynamic motivational conflicts and level of personality functioning as defined by the OPD system by means of an anonymous online survey among 24 women who had been diagnosed with dyspareunia or vaginismus. We matched them with 24 healthy controls and compared groups using paired-samples t-tests and Wilcoxon tests. Effect sizes were calculated using Pearson's r. Large effect sizes were found for mean or median differences of several OPD Structure Questionnaire (OPD-SQ) scales (self-reflection, p = 0.002/r = 0.59; affect differentiation, p = 0.007/r = 0.53; self-perception, p = 0.002/r = 0.58; impulse control, p = 0.007/r = 0.53; self-worth regulation, p = 0.008/r = 0.52; self-regulation, p = 0.004/r = 0.56; experiencing affect, p = 0.009/r = 0.53; bodily self, p = 0.008/r = 0.54; OPD-SQ total score, p = 0.007/r = 0.52; internal communication, p = 0.001/r = 0.63) and OPD Conflict Questionnaire (OPD-CQ) scales (guilt conflict active, p = 0.004/r = 0.60; Oedipal conflict passive, p = 0.009/r = 0.51; individuation versus dependency conflict active, p = 0.01/r = 0.52; guilt conflict passive, p < 0.001/r = 0.70; self-worth conflict passive, p = 0.001/r = 0.70; passive mode, p < 0.001/r = 0.68). The problems with personality functioning and more pronounced types of conflicts participants displayed suggest proneness for self-invalidation, internalization and restricted self-perception.

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.

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.

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.

Psychological factors in genital pain: The role of fear-avoidance, pain catastrophizing and anxiety sensitivity among women living in Sweden

Objectives One in five women under the age of 30 report recurrent genital pain and pain during sexual intercourse. Female genital pain negatively affects sexual and general health, as well as dyadic function and quality of life. Although the current field of research and clinical expertise in general agree upon a biopsychosocial conceptualization, there is still a lack of theoretical models describing the psychosocial mechanisms involved in the development of genital pain. Originally developed to outline the transition from acute to chronic back pain, the fear avoidance (FA) model has lately been proposed as a possible tool in illustrating the mechanisms involved in genital pain. However, only few studies have empirically tested the components of the FA model empirically. The aim of the present study is to examine fear avoidance beliefs, pain catastrophizing, and symptoms of depression and anxiety among women reporting genital pain, and to relate these concepts to sexual satisfaction/function and the characteristics of pain. 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 reported elevated levels of symptoms of anxiety, fear avoidance beliefs, pain catastrophizing and anxiety sensitivity. Symptoms of anxiety also predicted pain in the explanatory model together with vaginal tension and fungal infection. Vaginal tension has previously been described as a fear-response to painful intercourse and the results thereby seem to give further support to viewing genital pain from a fear avoidance perspective. Furthermore, fear avoidance beliefs seem to be of similar importance as lack of desire for the experience of sexual satisfaction and could also predict pain during specific activities among women with pain. The results also indicate that sexual satisfaction is related to a specific pain-related fear, rather than a heightened level of general anxiety. Conclusions The study had a low response rate, but still indicates that genital pain is common and is associated with several aspects of fear and avoidance. In sum, the results support the FA model by giving strong support for fear reactions (vaginal tension) and fear avoidance beliefs, and moderate support for negative affect. In the model negative affect drives pain catastrophizing. Implications It seems that the experience of genital pain among women in the general population is common and could be associated with increased levels of anxiety and fear-avoidance beliefs. However, the associations should not be understood in isolation from physiological mechanisms but seem to indicate interactions between, e.g. fungal infections, negative appraisals of pain and symptoms, lack of sexual function and satisfaction and increased pain experience. It is possible that psychological mechanisms work in the transition from acute physiological pain to chronic psychologically maintained pain in terms of secondary reactions to, e.g. repeated fungal infections by adding emotional distress, fear of pain and avoidance behaviours.

Etiology, diagnosis, and clinical management of vulvodynia

Chronic vulvar pain or discomfort for which no obvious etiology can be found, ie, vulvodynia, can affect up to 16% of women. It may affect girls and women across all age groups and ethnicities. Vulvodynia is a significant burden to society, the health care system, the affected woman, and her intimate partner. The etiology is multifactorial and may involve local injury or inflammation, and peripheral and or central sensitization of the nervous system. An approach to the diagnosis and management of a woman presenting with chronic vulvar pain should address the biological, psychological, and social/interpersonal factors that contribute to her illness. The gynecologist has a key role in excluding other causes for vulvar pain, screening for psychosexual and pelvic floor dysfunction, and collaborating with other health care providers to manage a woman's pain. An important component of treatment is patient education regarding the pathogenesis of the pain and the negative impact of experiencing pain on a woman's overall quality of life. An individualized, holistic, and often multidisciplinary approach is needed to effectively manage the woman's pain and pain-related distress.

Do romantic partners' responses to entry dyspareunia affect women's experience of pain? The roles of catastrophizing and self-efficacy

INTRODUCTION

Entry dyspareunia is a sexual health concern which affects about 21% of women in the general population. Characterized by pain provoked during vaginal penetration, introital dyspareunia has been shown by controlled studies to have a negative impact on the psychological well-being, sexual function, sexual satisfaction, and quality of life of afflicted women. Many cognitive and affective variables may influence the experience of pain and associated psychosexual problems. However, the role of the partner's cognitive responses has been studied very little.

AIM

The aim of the present study was to examine the associations between partners' catastrophizing and their perceptions of women's self-efficacy at managing pain on one side and women's pain intensity, sexual function, and sexual satisfaction on the other.

METHODS

One hundred seventy-nine heterosexual couples (mean age for women = 31, SD = 10.0; mean age for men = 33, SD = 10.6) in which the woman suffered from entry dyspareunia participated in the study. Both partners completed quantitative measures. Women completed the Pain Catastrophizing Scale and the Painful Intercourse Self-Efficacy Scale. Men completed the significant-other versions of these measures.

MAIN OUTCOME MEASURES

Dependent measures were women's responses to (i) the Pain Numeric Visual Analog Scale; (ii) the Female Sexual Function Index; and (iii) the Global Measure of Sexual Satisfaction scale.

RESULTS

Controlled for women's pain catastrophizing and self-efficacy, results indicate that higher levels of partner-perceived self-efficacy and lower levels of partner catastrophizing are associated with decreased pain intensity in women with entry dyspareunia, although only partner catastrophizing contributed unique variance. Partner-perceived self-efficacy and catastrophizing were not significantly associated with sexual function or satisfaction in women.

CONCLUSIONS

The findings suggest that partners' cognitive responses may influence the experience of entry dyspareunia for women, pointing toward the importance of considering the partner when treating this sexual health problem.

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.

The recurrent pain and sexual sequelae of provoked vestibulodynia: a perpetuating cycle

INTRODUCTION

Optimal management of provoked vestibulodynia (PVD), thought to be the most common form of chronic dyspareunia, is unclear.

AIM

To integrate recent brain data on chronic pain circuitry with stress-induced neuroendocrine mechanisms in the skin and the stress burden (allostatic load) of women with PVD; to also clarify the typical chronicity and negative sexual sequelae associated with PVD; and then review modulation of pain circuitry by cognitive therapy and mindfulness practice and apply to PVD management. Methods.  Review of scientific publications in the areas of sexual medicine, pain, brain imaging, gynecology, stress response, mindfulness, and cognitive behavioral therapy (CBT).

MAIN OUTCOME MEASURES

(i) A model of PVD to reflect its etiology, typical chronicity, and the detrimental effects on sexual function; (ii) Interventions of sexual rehabilitation based on principles underlying changes associated with CBT and mindfulness practice.

RESULTS

A model emerges which reflects how stress-induced changes of pain amplification (central sensitization), characteristic of chronic pain conditions, may impair sexual response in addition to sexual dysfunction that arises from conscious pain avoidance and/or fear-related inattention to sexual cues. Stress from low self-acceptance may be a major component of the allostatic load present in women with PVD, only to be exacerbated by the sexual dysfunction precipitated by the pain of intercourse. Mindfulness-based CBT appears promising to target both the pain and sexual suffering from PVD.

CONCLUSION

New findings on brain activity associated with recurrent clinical pain, functional brain changes associated with CBT and mindfulness, plus new data on stress systems within the skin along with data on increased stress load in women with PVD, support the use of mindfulness-based CBT for the recurrent pain and sexual suffering from PVD.

A systematic review of relationship adjustment and sexual satisfaction among women with provoked vestibulodynia

The main objective of this article was to conduct a systematic review of the literature examining relationship adjustment and sexual satisfaction among women with provoked vestibulodynia (PVD). Although only a small number of studies have included partners, the literature regarding partner's relationship adjustment and sexual satisfaction was also examined. Relevant articles were identified by a literature search conducted between August 2008 and May 2010. Studies were included if they contained at least one group or subset of participants with PVD or dyspareunia (i.e., painful sexual intercourse), and if they assessed relationship adjustment or sexual satisfaction as a primary outcome measure. Within this review, the methodological quality of 33 studies was systematically rated, and effect sizes were calculated when possible. Methodological type and quality greatly varied across the studies, as did the pain samples included and the outcomes reported. Nevertheless, the results of controlled studies indicate that PVD is associated with decreased sexual satisfaction. The controlled results also suggest, however, that PVD is not necessarily associated with general relationship maladjustment for women and their partners. Future research, using various methodologies, is needed to further understand intimate relationships among women with PVD and the impact that this condition may have on couples.

Impact of educational seminars on women with provoked vestibulodynia

OBJECTIVE

Provoked vestibulodynia (PVD) is a common genital pain condition characterized by severe pain upon vaginal penetration. The treatment of women with PVD suggests variable efficacy across modalities. The emotional toll of PVD, because of the intimate and interpersonal nature of this sexually-provoked pain, and the relationship between PVD and anxiety, depression, and a host of subclinical emotional symptoms that may interfere with treatment, has been well documented. The role of the gynaecologist in identifying and managing these psychological symptoms has never been addressed. The goal of this study was to examine the efficacy of a brief, gynaecologist-led educational seminar on measures of psychological symptoms and sexual health.

METHODS

Twenty-nine women with PVD participated in three one-hour educational seminars led by a gynaecologist with expertise in the management of PVD. Participants completed questionnaires before, immediately after, and six months after the third session.

RESULTS

There were significant improvements in psychological symptoms of depression, anxiety, somatization, hostility, paranoid ideation, psychoticism, and the global severity index, both immediately post-seminar and at the six-month follow-up. Sexual arousal, orgasm, overall sexual function, and sexual distress also significantly improved in response to the seminars.

CONCLUSION

Gynaecologist-led educational seminars delivered in a group format have a significant positive impact on psychological symptoms and sexual functioning in women who suffer from PVD.

Current perspectives in vulvodynia

Vulvodynia, or chronic vulvar pain, is a common but poorly understood condition. Although its etiology is not well understood, it appears to be multifactorial. As such, treatment options are targeted to reduce singular symptoms in a piecemeal fashion. A number of randomized, controlled trials have been conducted and at least one paper on combination therapy has been published; however, further systematic research is needed in order to more fully inform clinical practice.

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

INTRODUCTION

Dyspareunia remains under-investigated despite recent population-based studies indicating that its prevalence ranges from 12% to 21% in adult women. Although clinical data suggest that dyspareunia can begin during adolescence, a large-scale epidemiological study has yet to be conducted with this population.

AIMS

To determine the prevalence and characteristics of dyspareunia in a large-scale sample of adolescents, in addition to the characteristics of vulvo-vaginal insertion pain in nonsexual contexts.

METHODS

With written informed consent, data were obtained from 1,425 girls (12-19-year-olds), from seven metropolitan high schools during regular school hours using a self-report questionnaire.

MAIN OUTCOME MEASURES

Dyspareunia prevalence was evaluated by asking sexually active participants whether or not they regularly (at least 75% of the time) experienced pain during intercourse. Pain duration, context of onset, location, intensity, and pain during tampon insertion and pelvic exams were evaluated.

RESULTS

Results revealed that 20% of sexually active girls (N = 251) reported having regular pain during intercourse for at least 6 months or more. A primary form of pain was reported by 67% of adolescents and significantly more girls with chronic dyspareunia identified the vaginal opening (39%; x=3.9/10) as being their most painful site compared with internal pain sites (18-29%; x=2.9-3.2/10) (P = 0.042). Chronic dyspareunia cases reported significantly more pain during first and usual tampon insertion (P = 0.003; P = 0.009) than pain-free controls, while no difference was found between groups regarding pelvic exams (P = 0.086). Experiencing severe pain at first tampon insertion was linked to a fourfold risk of reporting chronic dyspareunia (P = 0.001).

CONCLUSIONS

Results mirror prevalence estimates found in population-based studies with adult women and suggest that chronic dyspareunia is a significant sexual health problem in adolescent girls, with pain extending beyond intercourse to nonsexual contexts.

Negative affect and somatically focused anxiety in young women reporting pain with intercourse

After a long history of privileging psychosexual etiological factors over pain and physiological processes, dyspareunia has enjoyed 1 decade of pointed research focused on the presenting problem of pain. Although it is generally acknowledged that certain affective and cognitive styles may play a role in an individual's experience of pain in general, investigations into these questions specifically as they pertain to pain that occurs during sex are relatively scarce. To add to this growing body of knowledge, 759 women aged 18 to 29 completed questionnaires about current sexual functioning, gynecologic history, expectations about intercourse, and various personality and health-related anxiety measures. One-hundred-one women (14% of the sample) reported pain during intercourse on at least 50% of attempts. This group of women significantly differed from 536 women reporting pain on less than 10% of intercourse attempts on personality constructs related to emotional and relational well-being (e.g., neuroticism, extraversion, agreeableness), as well as anxiety sensitivity, anxiety related to physical health concerns, and the amplification of somatosensory experiences. This affective and cognitive profile is consistent with previous studies that have found an attentional hypervigilance to health and pain-related information in women with dyspareunia, all of which could prove germane to cognitive-behavioral treatments targeting this disorder.

Patient perceptions of vulvar vibration therapy for refractory vulvar pain

The objective of this study was to describe acceptability of vulvar vibration therapy (VVT), a novel treatment approach to vulvodynia. We included women with vulvodynia who attended the Pelvic Pain Clinic and had used VVT for at least two weeks. Participants completed a three-page, 65-item, questionnaire assessing demographics, VVT usage and responses to Likert statements regarding accessibility, comfort and symptom response to VVT. Of 69 qualifying patients, results from 49 (72%) were eligible for analysis. Participants were primarily white, married and well-educated, with a median age of 30 (range 19-68 years). Median duration of vulvar pain and dyspareunia was two years (0-23) and three years (0-30), respectively. Median duration of VVT was five months (1-18) and three days per week (0.5-7). Fully, 83% said that, "vibrator treatment is an acceptable treatment", 83% said that they were "satisfied with vibrator treatment", 76% endorsed vibrator as comfortable to use, 73% indicated that sex is less painful since starting vibration treatment and 88% would recommend VVT to others. We conclude that the therapeutic rationale for VVT is based on the anti-nocioceptive properties of vibration and on the favorable response of vulvodynia to physical therapy. Vulvar vibration therapy is safe, inexpensive and, in this survey, acceptable to most patients, many of whom described improvement in symptoms.

[Review of the literature on the psychoemotional reality of women with vulvodynia: difficulties met and strategies developed]

BACKGROUND

Within the past three decades, increased attention has been placed on the study of vulvodynia -- an unexplained chronic vulvular discomfort felt without any related pathology. In addition to its physical implications, vulvodynia has a psychosocial dimension.

OBJECTIVE

The purpose of the current article is to present a review of the literature on the psychoemotional reality of women with vulvodynia.

METHOD

A systematic literature review was conducted in the main social sciences databases, such as Dissertation Abstracts, Current Contents and PsycINFO.

RESULTS

Although some discrepancies were found in study results, the review of the literature revealed that women with vulvodynia are often confronted with identity and psychological difficulties, which are, in turn, influenced by social standards regarding sexuality and femininity. To cope with these difficulties, women develop different strategies to decrease the stress related to pain and enhance their psychological well-being.

CONCLUSION

The psychological and relational difficulties experienced by women with vulvodynia are not only due to the physical pain but also to the meaning they attribute to it, often influenced by social expectations related to heterosexuality and femininity. Hence, it is important to assist these women by increasing their knowledge on the psychosocial aspects of their experience while taking into account influences from the social context.

Vulvodynia

INTRODUCTION

Vulvodynia is increasingly recognized as a cause of sexual pain. Aim. The goal of this Continuing Medical Education article was to provide a comprehensive review of vulvodynia including terminology, possible etiologies, and offer treatment options.

METHODS

A Medline search was conducted using several terms related to and including the terms vulvodynia, vulvar vestibulitis, vestibulodynia, and pudendal neuralgia.

RESULTS

A thorough review of vulvodynia.

CONCLUSION

Vulvodynia most likely represents several disorders without an identifiable cause in many cases. The management of these patients requires a sensitive provider who can coordinate a multidisciplinary approach to their care. Despite the lack of large-scale, placebo-controlled trials, several new treatment options exist.

Vulvodynia: a psychophysiological profile based on electromyographic assessment

The objective of this study was to explore the relationship between psychological and physiological processes and how these interact in the case of vulvodynia. The study design consisted of a retrospective review of predominantly premenopausal women presenting with vulvodynia via analyses of questionnaires, psychometric tests, sexual history, surface electromyographic (sEMG) assessments, and clinical notes. Five hundred and twenty-nine patients with vulvodynia (mean age 27.7 years) were studied. The average age of symptom onset was 22.8 years and the average duration of symptoms was 5.0 years. Patients scored higher than the comparison group on global dimensions of the Symptom Checklist-90 Revised (SCL-90R), with anxiety and depression scores showing a significant but modest correlation with severity of pain. sEMG data confirmed an association with pelvic muscle dysfunction but there was no correlation with severity of vulvar pain. A negative correlation between sEMG readings and duration of pain was noted and may be due to progressive time-related quieting of electrical activity in muscle tissues, which is commonly associated with the development of a functional muscle contracture. In conclusion, it is important to view chronic pain syndromes like vulvodynia from a psychophysiological perspective which recognizes the potential contribution of psychological and physiological variables in the aetiology of chronic vulvar pain.

Assessment of vulvodynia symptoms in a sample of US women: a prevalence survey with a nested case control study

OBJECTIVE

Vulvodynia is a chronic pain syndrome of unknown origin with scant data on frequency. This study assessed the prevalence of vulvodynia symptoms in a sample of US women and compared health characteristics of symptomatic and asymptomatic women.

STUDY DESIGN

A phone survey contacted 2127 US households to identify 100 symptomatic women, who were matched on age and time zone to 325 asymptomatic controls. Odds ratios (ORs) and logistic regression were used to model associations between pain, medical conditions, and health care utilization variables.

RESULTS

Current vulvar pain of at least 6 months duration was reported by 3.8% of respondents, with a 9.9% lifetime prevalence. Forty-five percent of women with pain reported an adverse effect on their sexual life and 27% an adverse effect on their lifestyle. Cases more frequently reported repeated urinary tract infections (OR, 6.15; 95% CI, 3.51-10.77) and yeast infections (OR, 4.24; 95% CI, 2.47-7.28). Associations existed with chronic fatigue syndrome (OR, 2.78; 95% CI, 1.33-6.19), fibromyalgia (OR, 2.15; 95% CI, 1.06-4.36), depression (OR, 2.99; 95% CI, 1.87-4.80), and irritable bowel syndrome (OR, 1.86; 95% CI, 1.07-3.23).

CONCLUSION

Lifetime chronic vulvar pain was less prevalent in this national sample of women than previous data suggest and was correlated with several comorbid chronic medical conditions and substantial reduction in self-reported quality of life.

Vulvar vestibulitis syndrome: A review

Vulvar vestibulitis syndrome (VVS) is a perplexing disease involving pain limited to the vulvar vestibule without objective clinical findings to explain the symptoms. The condition impairs sexual function and creates significant psychological distress. Its cause is unknown, and few randomized studies exist on the efficacy of interventions. This article reviews disease characteristics, possible etiologies, and approaches to management.

Synergy between sexual abuse and cervical cancer in causing sexual dysfunction

Experiencing a sexual abuse creates a life-long traumatic memory. The life-long effect of such abuse on sexuality, well-being, the risk of contracting cervical cancer, or problems after treatment for cervical cancer is not known. A population-based follow-up study in 1996-97 that used an anonymous postal questionnaire for data collection, 256 women with stage IB-IIA cervical cancer registered in 1991-92 in Sweden, and 350 women without cervical cancer frequency matched for age and region of residence, provided information. Among the women with a history of cervical cancer and the control women, 46 (18%) and 50 (15%), respectively, reported a history of sexual abuse. The follow-up was 1-70 years after the sexual abuse. The relative risk (with 95% confidence interval) of decreased well-being was 2.4 (1.1-5.2) among controls and 2.7 (1.1-6.4) among former cervical cancer patients. A history of both sexual abuse and cervical cancer gave a relative risk of 30.0 (7.0-129.0) for superficial dyspareunia. Sexual abuse increased the risk of sexual problems after treatment. The sexually abused cervical cancer patients were generally less willing than other patients to trade off possible maximal survival and forgo parts of the treatment. A history of sexual abuse and cervical cancer are both independent risk factors for sexual dysfunction and decreased well-being, and there may be a large synergy when both factors are combined. Diagnosis and treatment of cervical cancer may be improved by recognition of a sexual abuse history.

Women's Sexual Pain and Its Management

INTRODUCTION

Approximately 15% of women have chronic dyspareunia that is poorly understood, infrequently cured, often highly problematic, and distressing. Chronic dyspareunia is an urgent health issue.

AIM

To provide recommendations/guidelines concerning state-of-the-art knowledge for the assessment and management of women's sexual pain disorders.

METHODS

An international consultation, in collaboration with the major sexual medicine associations, assembled over 200 multidisciplinary experts from 60 countries into 17 committees. One six-member committee focused on women's sexual pain disorders, developing recommendations over a 2-year period.

MAIN OUTCOME MEASURE

Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.

RESULTS

There is increasing evidence for the role of neuropathic pain mechanisms in the pathophysiology of sexual pain disorders. Empirical literature has demonstrated the comorbid presence of clinical psychopathology. With regard to the pathophysiologic role of the pelvic floor and sexual pain disorders, studies reveal that (i) differentiation between vaginismus and dyspareunia using clinical tools is difficult; (ii) vaginal spasms have not been identified; (iii) physical therapists can differentiate vaginismic women from matched controls based on muscle tone/strength differences; (iv) the traditional treatment of vaginismus with vaginal "dilatation" plus psycho-education, desensitization, and so forth is not evidence-based; (v) pelvic floor muscle tone/strength measures for women suffering from vulvar vestibulitis syndrome are intermediate between those of women with vaginismus and no-pain controls; and (vi) the pelvic floor musculature is indirectly innervated by the limbic system and highly reactive to emotional stimuli and states. Pelvic floor therapies for dyspareunia may be effective.

CONCLUSION

Recommendations include (i) revising the definitions of vaginismus and dyspareunia; (ii) integration of treatment approaches; (iii) validation of nonspecific treatment effects; (iv) controlled studies to test interventions; and (v) sexuality education to help prevent sexual pain.

Recent advances in women’s sexual function and dysfunction

Current reconceptualization of women's sexual response acknowledges that women have many reasons or incentives for engaging in sex over and beyond sexual desire. Normative changes in their sexuality across the life span, with reproductive events, and with duration of relationship are recognized. Psychophysiological and preliminary functional magnetic resonance imaging data clarify that women's subjective experience of arousal may correlate poorly with signals reflective of genital congestion and also correlate poorly with activation of areas of the brain involved in organizing the reflexive genital vasocongestion. These aspects have been incorporated into new models of sexual response. Definitions of women's sexual dysfunction have recently been revised and expanded in keeping with these concepts. Mental well-being and other psychological and biological factors modulating desire, arousability, and response are areas of active research. Current understanding of the pathophysiology of chronic pain can be applied to the chronic intermittent pain and allodynia of chronic dyspareunia.

Psychological difficulties within a group of patients with vulvodynia

This study reviews and reports on some of the psychological difficulties seen in a group of women with vulval pain (vulvodynia). The investigation involved 164 women (82 suffering with Vulvodynia and 82 women in a control group with general dermatology conditions) to establish the prevalence of psychological difficulties using validated questionnaires (SCL-90R and the IBQ) and reports on the possible effect these may have on sexual and relationship function and satisfaction. The level of psychological difficulties revealed significantly higher levels of psychological distress in the vulvodynia group within the domains of somatisation, obsessive-compulsive, depression, anxiety & phobic symptoms as well as with interpersonal sensitivity hostility and paranoia.