VESTIBULODYNIA AND VULVODYNIA
2013 Vulvodynia Guideline update
J Low Genit Tract Dis. 2014 Apr;18(2):93-100.
Stockdale CK1, Lawson HW.
Vulvodynia is a complex disorder that can be difficult to treat. Most
patients describe it as burning, stinging, irritation, or rawness.
Vulvodynia is a costly disease both economically and on its negative
impact on patient quality of life. Although many treatment options are
available, no one treatment is effective for all patients, thus the need to
individualize management. Measures such as gentle vulvar care,
medication, biofeedback training, physical therapy, sexual counseling and
surgery, as well as complementary and alternative therapies are available
to treat the condition with varying success.
Dyspareunia in women
Am Fam Physician. 2014 Oct 1;90(7):465-70.
Seehusen DA1, Baird DC2, Bode DV1.
Dyspareunia is recurrent or persistent pain with sexual activity that causes
marked distress or interpersonal conflict. It affects approximately 10% to
20% of U.S. women. Dyspareunia can have a significant impact on a
woman's mental and physical health, body image, relationships with
partners, and efforts to conceive. The patient history should be taken in a
nonjudgmental way and progress from a general medical history to a
focused sexual history. An educational pelvic examination allows the
patient to participate by holding a mirror while the physician explains
normal and abnormal findings. This examination can increase the
patient's perception of control, improve self-image, and clarify findings
and how they relate to discomfort. The history and physical examination
are usually sufficient to make a specific diagnosis. Common diagnoses
include provoked vulvodynia, inadequate lubrication, postpartum
dyspareunia, and vaginal atrophy. Vaginismus may be identified as a
contributing factor. Treatment is directed at the underlying cause of
dyspareunia. Depending on the diagnosis, pelvic floor physical therapy,
lubricants, or surgical intervention may be included in the treatment plan.
Vulvodynia
Best Pract Res Clin Obstet Gynaecol. 2014 Oct;28(7):1000-12. doi:
10.1016/j.bpobgyn.2014.07.009. Epub 2014 Jul 18.
Eppsteiner E1, Boardman L2, Stockdale CK3.
Vulvodynia is a complex disorder reported by up to 16% of women in the
general population. While most patients describe it as burning, stinging,
irritation, or rawness, it is underreported and underrecognized by
providers. Vulvodynia is costly both economically and psychologically
due to its negative impact on quality of life. Vulvodynia is a diagnosis of
exclusion with unknown etiology and may involve multiple sources of
pain in the same woman. Thus, there are no clinical or histopathologic
criteria for the diagnosis other than consideration and careful evaluation
to exclude other causes of pain. Successful therapy often requires a
multidisciplinary approach with more than one therapeutic intervention to
address the physical, psychological, psychosexual, and relationship
components.
Vulvodynia
Obstet Gynecol Clin North Am. 2014 Sep;41(3):453-64. doi:
10.1016/j.ogc.2014.05.005. Epub 2014 Jul 9.
Shah M1, Hoffstetter S2.
Vulvar pain and discomfort (vulvodynia) are common conditions that can
have a significant impact on a patient's quality of life. Vulvodynia is a
difficult condition to evaluate and treat. This article gives the primary
gynecologist a basic framework with which to identify, diagnose, and
begin treatment for these patients and refer if necessary. Initial evaluation
and physical examination are discussed in detail. Treatments ranging
from self-management strategies to nonpharmacologic and
pharmacologic therapies will be explored. Because vulvodynia is a
chronic pain disorder, diagnosis is the key to beginning treatment and
support for this patient population.
Vulvodynia: Current state of the biological science
Pain. 2014 Sep;155(9):1696-701. doi: 10.1016/j.pain.2014.05.010. Epub
2014 May 22.
.Wesselmann U1, Bonham A2, Foster D3. No abstract available
Etiology, diagnosis, and clinical management of vulvodynia
Int J Womens Health. 2014 May 2;6:437-49. doi: 10.2147/IJWH.S37660.
eCollection 2014.
Sadownik LA1.
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.
Chronic pelvic floor dysfunction
Best Pract Res Clin Obstet Gynaecol. 2014 Oct;28(7):977-90. doi:
10.1016/j.bpobgyn.2014.07.008. Epub 2014 Jul 17.
Hartmann D1, Sarton J2.
The successful treatment of women with vestibulodynia and its associated
chronic pelvic floor dysfunctions requires interventions that address a
broad field of possible pain contributors. Pelvic floor muscle
hypertonicity was implicated in the mid-1990s as a trigger of major
chronic vulvar pain. Painful bladder syndrome, irritable bowel syndrome,
fibromyalgia, and temporomandibular jaw disorder are known common
comorbidities that can cause a host of associated muscular, visceral,
bony, and fascial dysfunctions. It appears that normalizing all of those
disorders plays a pivotal role in reducing complaints of chronic vulvar
pain and sexual dysfunction. Though the studies have yet to prove a
specific protocol, physical therapists trained in pelvic dysfunction are
reporting success with restoring tissue normalcy and reducing vulvar and
sexual pain. A review of pelvic anatomy and common findings are
presented along with suggested physical therapy management.
Psychosexual aspects of vulvovaginal pain
Best Pract Res Clin Obstet Gynaecol. 2014 Oct;28(7):991-9. doi:
10.1016/j.bpobgyn.2014.07.007. Epub 2014 Jul 17.
Bergeron S1, Likes WM2, Steben M3.
Vulvovaginal pain problems are major health concerns in women of
childbearing age. Controlled studies have shown that vulvovaginal pain
can adversely affect women and their partners' general psychological
well-being, relationship adjustment, and overall quality of life. These
women have significantly lower levels of sexual desire, arousal, and
satisfaction, as well as a lower intercourse frequency than normal
controls. They also report more anxiety and depression, in addition to
more distress about their body image and genital self-image. Empirical
studies indicate that specific psychological and relationship factors may
increase vulvovaginal pain intensity and its psychosexual sequelae.
Randomized clinical trials have shown that psychosexual interventions,
namely cognitive-behavioral therapy (CBT), are efficacious in reducing
vulvovaginal pain and improving associated psychosexual outcomes.
Women reporting significant psychological, sexual, and/or relationship
distress should be referred for psychosexual treatment. A multimodal
approach to care integrating psychosexual and medical management is
thought to be optimal.
Can Fear, Pain, and Muscle Tension Discriminate Vaginismus from
Dyspareunia/Provoked Vestibulodynia? Implications for the New
DSM-5 Diagnosis of Genito-Pelvic Pain/Penetration Disorder.
Arch Sex Behav. 2014 Nov 15. [Epub ahead of print]
Lahaie MA1, Amsel R, Khalifé S, Boyer S, Faaborg-Andersen M, Binik
YM.
.
Fear has been suggested as the crucial diagnostic variable that may
distinguish vaginismus from dyspareunia. Unfortunately, this has not
been systematically investigated. The primary purpose of this study,
therefore, was to investigate whether fear as evaluated by subjective,
behavioral, and psychophysiological measures could differentiate women
with vaginismus from those with dyspareunia/provoked vestibulodynia
(PVD) and controls. A second aim was to re-examine whether genital
pain and pelvic floor muscle tension differed between vaginismus and
dyspareunia/PVD sufferers. Fifty women with vaginismus, 50 women
with dyspareunia/PVD, and 43 controls participated in an experimental
session comprising a structured interview, pain sensitivity testing, a
filmed gynecological examination, and several self-report measures.
Results demonstrated that fear and vaginal muscle tension were
significantly greater in the vaginismus group as compared to the
dyspareunia/PVD and no-pain control groups. Moreover, behavioral
measures of fear and vaginal muscle tension were found to discriminate
the vaginismus group from the dyspareunia/PVD and no-pain control
groups. Genital pain did not differ significantly between the vaginismus
and dyspareunia/PVD groups; however, genital pain was found to
discriminate both clinical groups from controls. Despite significant
statistical differences on fear and vaginal muscle tension variables
between women suffering from vaginismus and dyspareunia/PVD, a large
overlap was observed between these conditions. These findings may
explain the great difficulty health professionals experience in attempting
to reliably differentiate vaginismus from dyspareunia/PVD. The
implications of these data for the new DSM-5 diagnosis of Genito-Pelvic
Pain/Penetration Disorder are discussed.
Body Image in Women with Primary and Secondary Provoked
Vestibulodynia: A Controlled Study.
J Sex Med. 2014 Nov 13. doi: 10.1111/jsm.12765. [Epub ahead of print]
Maillé DL1, Bergeron S, Lambert B.
INTRODUCTION: Provoked vestibulodynia (PVD) is a women's genitopelvic pain condition associated with psychosexual impairments,
including depression. Body image (BI) has been found to be different in
women with primary (PVD1) and secondary (PVD2) PVD. No controlled
study has compared BI in women with PVD1 and PVD2 and investigated
its associations with sexual satisfaction, sexual function, and pain.
AIMS: The aims of this study were to (i) compare BI in women with
PVD1, PVD2, and asymptomatic controls and (ii) to examine
associations between BI and sexual satisfaction, sexual function, and pain
during intercourse in women with PVD.
METHODS: Fifty-seven women (20 with PVD1, 19 with PVD2, and 18
controls) completed measures of BI, sexual satisfaction, sexual function,
pain during intercourse, and depression.
MAIN OUTCOME MEASURES: The main outcome measures were (i)
Global Measure of Sexual Satisfaction Scale, (ii) Female Sexual Function
Index, and (iii) pain numerical rating scale.
RESULTS: Controlling for depression, women with PVD1 reported more
body exposure anxiety during sexual activities than women with PVD2
and controls F(2,51) = 4.23, P = 0.02. For women with PVD, more
negative BI during sexual activities was associated with lower sexual
satisfaction (β = -0.45, P = 0.02) and function (β = -0.39, P = 0.04) and
higher pain during intercourse (β = 0.59, P = 0.004). More positive body
esteem was associated with higher sexual function (β = 0.34, P = 0.05).
CONCLUSIONS: Findings suggest that women with PVD1 present more
body exposure anxiety during sexual activities than women with PVD2
and asymptomatic women. Body esteem and general attitudes toward
women's genitalia were not significantly different between groups.
Higher body exposure anxiety during sexual activities was associated
with poorer sexual outcomes in women with PVD. Further studies
assessing interventions targeting BI during sexual activities in this
population are needed, as improving BI during sexual interactions may
enhance sexual outcomes in women with PVD.
Transcutaneous Electrical Nerve Stimulation as an Additional
Treatment for Women Suffering from Therapy-Resistant Provoked
Vestibulodynia: A Feasibility Study.
J Sex Med. 2014 Nov 12. doi: 10.1111/jsm.12740. [Epub ahead of print]
Vallinga MS1, Spoelstra SK, Hemel IL, van de Wiel HB, Weijmar
Schultz WC.
INTRODUCTION: The current approach to women with provoked
vestibulodynia (PVD) comprises a multidimensional, multidisciplinary
therapeutic protocol. As PVD is considered to be a chronic pain disorder,
transcutaneous electrical nerve stimulation (TENS) can be used as an
additional therapy for women with otherwise therapy-resistant PVD.
AIMS: The aims of this study were to evaluate whether TENS has a
beneficial effect on vulvar pain, sexual functioning, and sexually-related
personal distress in women with therapy-resistant PVD and to assess the
effect of TENS on the need for vestibulectomy.
METHODS: A longitudinal prospective follow-up study was performed
on women with therapy-resistant PVD who received additional
domiciliary TENS. Self-report questionnaires and visual analog scales
(VASs) were completed at baseline (T1), post-TENS (T2), and follow-up
(T3).
MAIN OUTCOME MEASURES: Vulvar pain, sexual functioning, and
sexually-related personal distress were the main outcome measures.
RESULTS: Thirty-nine women with therapy-resistant PVD were
included. Mean age was 27 ± 5.6 years (range: 19 to 41); mean duration
between TENS and T3 follow-up was 10.1 ± 10.7 months (range: 2 to 32).
Vulvar pain VAS scores directly post-TENS (median 3.4) and at followup (median 3.2) were significantly (P < 0.01) lower than at baseline
(median 8.0). Post-TENS, sexual functioning scores on the Female
Sexual Functioning Index questionnaire had improved significantly
(P = 0.2); these scores remained stable at follow-up. Sexually-related
personal distress scores had improved significantly post-TENS (P = 0.01).
Only 4% of the women who received TENS needed to undergo
vestibulectomy vs. 23% in our previous patient population.
CONCLUSION: The addition of self-administered TENS to
multidimensional treatment significantly reduced the level of vulvar pain
and the need for vestibulectomy. The long-term effect was stable. These
results not only support our hypothesis that TENS constitutes a feasible
and beneficial addition to multidimensional treatment for therapyresistant PVD, but also the notion that PVD can be considered as a
chronic pain syndrome.
Impact of a Multidisciplinary Vulvodynia Program on Sexual
Functioning and Dyspareunia
J Sex Med. 2014 Oct 30. doi: 10.1111/jsm.12718. [Epub ahead of print]
Brotto LA1, Yong P, Smith KB, Sadownik LA.
INTRODUCTION: For many years, multidisciplinary approaches, which
integrate psychological, physical, and medical treatments, have been
shown to be effective for the treatment of chronic pain. To date, there has
been anecdotal support, but little empirical data, to justify the application
of this multidisciplinary approach toward the treatment of chronic sexual
pain secondary to provoked vestibulodynia (PVD).
AIM: This study aimed to evaluate a 10-week hospital-based treatment
(multidisciplinary vulvodynia program [MVP]) integrating psychological
skills training, pelvic floor physiotherapy, and medical management on
the primary outcomes of dyspareunia and sexual functioning, including
distress.
METHOD: A total of 132 women with a diagnosis of PVD provided
baseline data and agreed to participate in the MVP. Of this group, n = 116
(mean age 28.4 years, standard deviation 7.1) provided complete data at
the post-MVP assessment, and 84 women had complete data through to
the 3- to 4-month follow-up period.
RESULTS: There were high levels of avoidance of intimacy (38.1%) and
activities that elicited sexual arousal (40.7%), with many women (50.4%)
choosing to focus on their partner's sexual arousal and satisfaction at
baseline. With treatment, over half the sample (53.8%) reported
significant improvements in dyspareunia. Following the MVP, there were
strong significant effects for the reduction in dyspareunia (P = 0.001) and
sex-related distress (P < 0.001), and improvements in sexual arousal
(P < 0.001) and overall sexual functioning (P = 0.001). More modest but
still statistically significant were improvements in sexual desire,
lubrication, orgasmic function, and sexual satisfaction. All improvements
were retained at 2- to 3-month follow-up.
CONCLUSION: This study provides strong support for the efficacy of a
multidisciplinary approach (psychological, pelvic floor physiotherapy,
and medical management) for improving dyspareunia and all domains of
sexual functioning among women with PVD. The study also highlights
the benefits of incorporating sexual health education into general pain
management strategies for this population
Concurrent Deep-Superficial Dyspareunia: Prevalence, Associations,
and Outcomes in a Multidisciplinary Vulvodynia Program.
J Sex Med. 2014 Oct 27. doi: 10.1111/jsm.12729. [Epub ahead of print]
Yong PJ1, Sadownik L, Brotto LA.
INTRODUCTION: Little is known about women with concurrent
diagnoses of deep dyspareunia and superficial dyspareunia.
AIM: The aim of this study was to determine the prevalence,
associations, and outcome of women with concurrent deep-superficial
dyspareunia.
METHODS: This is a prospective study of a multidisciplinary vulvodynia
program (n = 150; mean age 28.7 ± 6.4 years). Women with superficial
dyspareunia due to provoked vestibulodynia were divided into two
groups: those also having deep dyspareunia (i.e., concurrent deepsuperficial dyspareunia) and those with only superficial dyspareunia due
to provoked vestibulodynia. Demographics, dyspareunia-related factors,
other pain conditions, and psychological variables at pretreatment were
tested for an association with concurrent deep-superficial dyspareunia.
Outcome in both groups was assessed to 6 months posttreatment.
MAIN OUTCOME MEASURES: Level of dyspareunia pain (0-10) and
Female Sexual Distress Scale were the main outcome measures.
RESULTS: The prevalence of concurrent deep-superficial dyspareunia
was 44% (66/150) among women with superficial dyspareunia due to
provoked vestibulodynia. At pretreatment, on multiple logistic regression,
concurrent deep-superficial dyspareunia was independently associated
with a higher level of dyspareunia pain (odds ratio [OR] = 1.19 [1.011.39], P = 0.030), diagnosis of endometriosis (OR = 4.30 [1.16-15.90],
P = 0.022), history of bladder problems (OR = 3.84 [1.37-10.76],
P = 0.008), and more depression symptoms (OR = 1.07 [1.02-1.12],
P = 0.007), with no difference in the Female Sexual Distress Scale. At 6
months posttreatment, women with concurrent deep-superficial
dyspareunia improved in the level of dyspareunia pain and in the Female
Sexual Distress Scale to the same degree as women with only superficial
dyspareunia due to provoked vestibulodynia.
CONCLUSIONS: Concurrent deep-superficial dyspareunia is reported by
almost half of women in a multidisciplinary vulvodynia program. In
women with provoked vestibulodynia, concurrent deep-superficial
dyspareunia may be related to endometriosis or interstitial cystitis, and is
associated with depression and more severe dyspareunia symptoms.
Standardized multidisciplinary care is effective for women with
concurrent dyspareunia
Psychological Treatment for Vaginal Pain: Does Etiology Matter? A
Systematic Review and Meta-Analysis
J Sex Med. 2014 Oct 20. doi: 10.1111/jsm.12717. [Epub ahead of print]
Flanagan E1, Herron KA, O'Driscoll C, Williams AC.
INTRODUCTION: Classification of vaginal pain within medical or
psychiatric diagnostic systems draws mainly on the presumed presence or
absence (respectively) of underlying medical etiology. A focus on the
experience of pain, rather than etiology, emphasizes common ground in
the aims of treatment to improve pain and sexual, emotional, and
cognitive experience. Thus, exploring how vaginal pain conditions with
varying etiology respond to psychological treatment could cast light on
the extent to which they are the same or distinct.
AIM: To examine the combined and relative efficacy of psychological
treatments for vaginal pain conditions.
METHODS: A systematic search of EMBASE, MEDLINE, PsycINFO,
and CINAHL was undertaken. Eleven randomized controlled trials were
entered into a meta-analysis, and standardized mean differences and odds
ratios were calculated. Effect sizes for individual psychological trial arms
were also calculated.
MAIN OUTCOME MEASURES: Main outcome measures were pain and
sexual function.
RESULTS: Equivalent effects were found for psychological and medical
treatments. Effect sizes for psychological treatment arms were
comparable across vaginal pain conditions.
CONCLUSIONS: Effectiveness was equivalent regardless of presumed
medical or psychiatric etiology, indicating that presumed etiology may
not be helpful in selecting treatment. Research recommendations and
clinical implications are discussed
Polymorphisms of the androgen receptor gene and hormonal
contraceptive induced provoked vestibulodynia.
J Sex Med. 2014 Nov;11(11):2764-71. doi: 10.1111/jsm.12668. Epub
2014 Sep 4.
Goldstein AT1, Belkin ZR, Krapf JM, Song W, Khera M, Jutrzonka SL,
Kim NN, Burrows LJ, Goldstein I.
AIM: Women who developed vestibulodynia (vulvar vestibulitis) while
taking combined hormonal contraceptives (CHCs) and a control group of
women were tested for polymorphisms of the gene coding for the
androgen receptor (AR) that is located on the X chromosome.
STUDY DESIGN: DNA from 30 women who developed vestibulodynia
while taking CHCs and 17 control women were tested for the number of
cytosine-adenine-guanine (CAG) trinucleotide repeats in the AR. In
addition, serum-free testosterone was tested in both groups.
RESULTS: The mean number of CAG repeats in the study group was
significantly greater than the control group (22.05 ± 2.98 vs. 20.61 ± 2.19,
respectively; P = 0.025). This significant difference persisted when
analyzing the CAG repeats from the longer allele from each subject.
Among those who were taking drospirenone-containing CHCs, the mean
calculated free testosterone was 0.189 ± 0.115 ng/dL in the study group
and 0.127 ± 0.054 ng/dL in the control group, all of whom were taking
drospirenone-containing CHCs (P = 0.042).
CONCLUSION: In the study cohort, women who developed
vestibulodynia while taking CHCs are more likely to have longer CAG
repeats in the AR than women who took the same type of CHC but did
not develop vestibulodynia. We speculate that the risk of developing
CHC-induced vestibulodynia may be due to lowered free testosterone
combined with an inefficient AR that predisposes women to vestibular
pain
Prevalence of vulvodynia and risk factors for the condition in
Portugal
Int J Gynaecol Obstet. 2014 Dec;127(3):283-7. doi:
10.1016/j.ijgo.2014.05.020. Epub 2014 Jul 17.
Vieira-Baptista P1, Lima-Silva J2, Cavaco-Gomes J2, Beires J2.
OBJECTIVE: To investigate the prevalence of vulvodynia in Portugal
and factors associated with this condition.
METHODS: In a cross-sectional study, an online survey was distributed
by email and posted on a website and social networks. Women aged at
least 18years who were living in Portugal were eligible to complete the
survey between June 1 and November 30, 2013. Participants had to have
had symptoms for at least 6months to be deemed to have vulvodynia.
RESULTS: Overall, 1229 questionnaires were included in analyses. A
total of 80 (6.5%) women had vulvodynia at the time of the survey, and
117 (9.5%) had had it previously; lifetime prevalence was 16.0%.
Pregnancy and type of delivery were not associated with vulvodynia.
Women who had ever taken oral contraceptives were significantly more
likely to have ever had vulvodynia (P<0.010). Candidiasis, genital herpes,
urinary tract infections, depression, and premenstrual syndrome were
associated with ever having had vulvodynia (P<0.01). Pain syndromes
were associated with ever having had vulvodynia, especially fibromyalgia
and bladder pain syndrome (P<0.001). Scoliosis and hysterectomy were
also significantly associated (P<0.01).
CONCLUSION: The prevalence of vulvodynia in Portugal is similar to
that elsewhere. Three main groups of factors might lead to vulvodynia:
local inflammatory factors, general pain susceptibility, and pelvic nerve
interference.
Milnacipran in Provoked Vestibulodynia: Efficacy and Predictors of
Treatment Success
J Low Genit Tract Dis. 2014 Aug 1. [Epub ahead of print]
.Brown C1, Bachmann G, Foster D, Rawlinson L, Wan J, Ling F.
OBJECTIVE: This study aimed to collect preliminary evidence on the
efficacy of milnacipran in reducing pain in women with provoked
vestibulodynia (PVD) and to identify which patient characteristics predict
treatment success.
MATERIALS AND METHODS: A 12-week open-label trial was
conducted in 22 women with PVD. The Pain Rating Index of the McGill
Pain Questionnaire was the primary outcome measure. Other outcome
measures included daily diaries, Beck Depression Inventory, State-Trait
Anxiety Inventory, Female Sexual Function Index, Brief Pain Inventory,
a personal or family history of fibromyalgia, and PVD subtype.
RESULTS: Milnacipran (50-200 mg/d) significantly reduced pain
severity on the Pain Rating Index (p = .001), coital pain (p = .001),
tampon pain (p = .003), and mean vulvar pain (p ≤ .001). Scores were
also decreased on the Beck Depression Inventory (p = .015), State-Trait
Anxiety Inventory (p = .046), and Brief Pain Inventory (p = .019) and
increased on the Female Sexual Function Index (p = .004). Fibromyalgia
history, PVD subtype, presence of depression or anxiety, and level of
impairment did not affect treatment response. By logistic regression
analysis, it was noted that the odds of treatment success was 3 times
higher among women who, at pretreatment, had a sexually satisfying
relationship compared to those who did not (odds ratio = 3.30, confidence
interval = 1.04-10.50, p = .043).
CONCLUSIONS: Milnacipran significantly reduced vestibular pain in
women with PVD. Treatment success was predicted by pretreatment
sexual satisfaction. A larger randomized controlled trial is necessary to
confirm the efficacy of milnacipran in PVD and to identify other possible
predictors of treatment outcome.
Pregnancy-related needs of women with vulvovaginal pain
syndromes
BJOG. 2014 Aug 4. doi: 10.1111/1471-0528.13027. [Epub ahead of
print]
Veasley C1, Witkin S. No abstract available
Feasibility and preliminary effectiveness of a novel cognitivebehavioral couple therapy for provoked vestibulodynia: a pilot study
J Sex Med. 2014 Oct;11(10):2515-27. doi: 10.1111/jsm.12646. Epub
2014 Jul 24.
Corsini-Munt S1, Bergeron S, Rosen NO, Mayrand MH, Delisle I.
INTRODUCTION: Provoked vestibulodynia (PVD), a recurrent,
localized vulvovaginal pain problem, carries a significant psychosexual
burden for afflicted women, who report impoverished sexual function and
decreased frequency of sexual activity and pleasure. Interpersonal factors
such as partner responses to pain, partner distress, and attachment style
are associated with pain outcomes for women and with sexuality
outcomes for both women and partners. Despite these findings, no
treatment for PVD has systematically included the partner.
AIMS: This study pilot-tested the feasibility and potential efficacy of a
novel cognitive-behavioral couple therapy (CBCT) for couples coping
with PVD.
METHODS: Couples (women and their partners) in which the woman
was diagnosed with PVD (N = 9) took part in a 12-session manualized
CBCT intervention and completed outcome measures pre- and posttreatment.
MAIN OUTCOME MEASURES: The primary outcome measure was
women's pain intensity during intercourse as measured on a numerical
rating scale. Secondary outcomes included sexual functioning and
satisfaction for both partners. Exploratory outcomes included pain-related
cognitions; psychological outcomes; and treatment satisfaction,
feasibility, and reliability.
RESULTS: One couple separated before the end of therapy. Paired t-test
comparisons involving the remaining eight couples demonstrated
significant improvements in women's pain and sexuality outcomes for
both women and partners. Exploratory analyses indicated improvements
in pain-related cognitions, as well as anxiety and depression symptoms,
for both members of the couple. Therapists' reported high treatment
reliability and participating couples' high participation rates and reported
treatment satisfaction indicate adequate feasibility.
CONCLUSIONS: Treatment outcomes, along with treatment satisfaction
ratings, confirm the preliminary success of CBCT in reducing pain and
psychosexual burden for women with PVD and their partners. Further
large-scale randomized controlled trials are necessary to examine the
efficacy of CBCT compared with and in conjunction with first-line
biomedical interventions for PVD.
Is chronic stress during childhood associated with adult-onset
vulvodynia?
J Womens Health (Larchmt). 2014 Aug;23(8):649-56. doi:
10.1089/jwh.2013.4484. Epub 2014 Jul 21.
Khandker M1, Brady SS, Stewart EG, Harlow BL.
BACKGROUND: Vulvodynia is an unexplained chronic vulvar pain
condition. Case-control studies provide opportunities to examine potential
mechanisms by which vulvodynia may develop. Findings inform
etiological models that can be tested in subsequent prospective studies.
METHODS: A survey of interpersonal relationships and the Structured
Clinical Interview for DSM-IV Axis I Disorders was administered to 215
case-control pairs of women with and without vulvodynia. Conditional
logistic regression was used to examine associations between affect-based
chronic stressors (i.e., living in fear of abuse, perceived abuse, and
antecedent mood disorders) with vulvodynia. These associations were
then examined among women with and without a history of childhood
abuse.
RESULTS: Among women with a history of severe childhood abuse,
those with vulvodynia had three times the odds of living in fear of any
abuse compared to women without vulvodynia (95% confidence interval:
1.0, 11.0), after adjustment for childhood poverty. Among women with
no history of childhood abuse, those with vulvodynia had over six times
the odds of antecedent mood disorder compared to women without
vulvodynia (95% confidence interval: 1.9,19.6).
CONCLUSION: Our findings suggest that affect-based chronic stressors
may be important to the psychobiological mechanisms of vulvodynia.
Prospective studies are recommended to test biopsychosocial models of
the etiology of vulvodynia.
Trends in pharmacy compounding for women's health in North
Carolina: focus on vulvodynia
South Med J. 2014 Jul;107(7):433-6.
Corbett SH1, Cuddeback G1, Lewis J1, As-Sanie S1, Zolnoun D1.
OBJECTIVES: To identify trends in compounding pharmacies with a
focus on women's health and, more specifically, the types and
combinations of medications used in the treatment of vulvodynia.
METHODS: This survey study was conducted with 653 nonchain
pharmacies that compound medications. Each pharmacy was asked to
complete a 19-item online survey assessing general practice and common
compounding indications, focusing on women's health.
RESULTS: Of the 653 pharmacies contacted, 200 (31%) responded to
our survey. Women's health issues ranked third (19%) among the
common indications for compounding, preceded by otolaryngology
(30%) and dermatology (28%). Of the medications compounded for
women's health, the most common indication was bioidentical hormone
therapy (73%) followed closely by vaginal dryness (70%) and low libido
(65%). Vulvodynia, or vulvar pain, was the fourth most common
indication for compounding medication for women's health issues (29%).
Vulvovaginal infections were reported as an indication for compounding
medications by 16% of respondents.
CONCLUSIONS: Vulvovaginal symptoms are a common indication for
compounding medications in women's health. Further research in
understanding the rationale for using compounded medications, even
when standard treatments are available for some of these symptoms (eg,
vaginal dryness, vulvovaginal infections), is warranted.
Feasibility of collecting vulvar pain variability and its correlates
using prospective collection with smartphones
Pain Res Treat. 2014;2014:659863. doi: 10.1155/2014/659863. Epub
2014 Jun 10.
Nguyen RH1, Turner RM1, Sieling J2, Williams DA3, Hodges JS4,
Harlow BL1.
Context. Vulvar pain level may fluctuate in women with vulvodynia even
in the absence of therapy; however, there is little evidence suggesting
which factors may be associated with variability. Objective. Determine
the feasibility of using smartphones to collect prospective data on vulvar
pain and factors that may influence vulvar pain level. Methods. 24
clinically confirmed women were enrolled from a population-based study
and asked to answer five questions using their smartphones each week for
one month. Questions assessed vulvar pain level (0-10), presence of pain
upon wakening, pain elsewhere in their body, treatment use, and
intercourse. Results. Women completed 100% of their scheduled surveys,
with acceptability measures highly endorsed. Vulvar pain ratings had a
standard deviation within women of 1.6, with greater variation on average
among those with higher average pain levels (P < 0.001). On the weeks
when a woman reported waking with pain, her vulvar pain level was
higher by 1.82 on average (P < 0.001). Overall, average vulvar pain level
was not significantly associated with the frequency of reporting other
body pains (P = 0.64). Conclusion. Our smartphone tracking system
promoted excellent compliance with weekly tracking of factors that are
otherwise difficult to recall, some of which were highly associated with
vulvar pain level.
Reproduction and mode of delivery in women with vaginismus or
localised provoked vestibulodynia: a Swedish register-based study
BJOG. 2014 Jul 3. doi: 10.1111/1471-0528.12946. [Epub ahead of print]
Möller L1, Josefsson A, Bladh M, Lilliecreutz C, Sydsjö G.
OBJECTIVE: To compare sociodemographics, parity and mode of
delivery between women diagnosed with vaginismus or localised
provoked vestibulodynia (LPV) to women without a diagnosis before first
pregnancy.
DESIGN: Retrospective, population-based register study.
SETTING: Sweden.
SAMPLE: All women born in Sweden 1973-83 who gave birth for the
first time or remained nulliparous during the years 2001-09.
METHODS: Nationally linked registries were used to identify the study
population. Women diagnosed with vaginismus or LPV were compared
to all other women. Odds ratios for parity and mode of delivery were
calculated using multinominal regression analysis and logistic regression.
MAIN OUTCOME MEASURES: Parity and mode of delivery.
RESULTS: Women with vaginismus/LPV were more likely to be
unmarried (P = 0.001), unemployed (P = 0.012), have a higher
educational level (P < 0.001), a lower body mass index (P < 0.001) and
use nicotine during pregnancy (P = 0.008). They were less likely to give
birth (adjusted odds ratio [OR] 0.61, 95% confidence interval [95% CI]
0.56-0.67). Women with vaginismus/LPV more often delivered by
caesarean section (P < 0.001) especially for maternal request (adjusted
OR 3.48, 95% CI 2.45-4.39). In women having vaginal delivery, those
with vaginismus/LPV were more likely to suffer a perineal laceration
(adjusted OR 1.87, 95% CI 1.56-2.25).
CONCLUSIONS: Women with vaginismus/LPV are less likely to give
birth and those that do are more likely to deliver by caesarean section and
have a caesarean section based upon maternal request. Those women
delivering vaginally are more likely to suffer perineal laceration. These
findings point to the importance of not only addressing sexual function in
women with vaginismus/LPV but reproductive function as well.
A Prospective Two-year Examination of Cognitive and Behavioral
Correlates of Provoked Vestibulodynia Outcomes
Clin J Pain. 2014 Jun 26. [Epub ahead of print]
Davis SN1, Bergeron S, Bois K, Sadikaj G, Binik YM, Steben M.
BACKGROUND:: Provoked vestibulodynia (PVD) is a common genital
pain disorder in women, which is associated with sexual dysfunction and
lowered sexual satisfaction. A potentially applicable cognitive-behavioral
model of chronic pain and disability is the fear-avoidance model (FAM)
of pain. The FAM posits that cognitive variables, such as pain
catastrophizing, fear, and anxiety lead to avoidance of pain-provoking
behaviors (intercourse), resulting in continued pain and disability.
Although some of the FAM variables have been shown to be associated
with PVD pain and sexuality outcomes, the model as a whole has never
been tested in this population. An additional protective factor, pain selfefficacy, is also associated with PVD, but has not been tested within the
FAM model. AIM:: Using a two-year longitudinal design, we aimed to
examine (1) whether initial levels (T1) of the independent FAM variables
and pain self-efficacy were associated with changes in pain, sexual
function and sexual satisfaction over the two-year time period, (2) the
prospective contribution of changes in cognitive-affective (FAM)
variables to changes in pain, and sexuality outcomes and (3) whether
these were mediated by behavioral change (avoidance of intercourse).
METHODS:: A sample of 222 women with PVD completed self-report
measures of FAM variables, self-efficacy, pain, sexual function and
sexual satisfaction at Time 1 and at a two-year follow-up. Structural
equation modeling with latent difference scores was used to examine
changes and to examine mediation between variables.
MAIN OUTCOMES:: Questionnaires included the Pain Catastrophizing
Scale, McGill Pain Questionnaire, Trait Anxiety Inventory, Pain Self-
Efficacy Scale, and Global Measure of Sexual Satisfaction, Female
Sexual Function Index.
RESULTS:: Participants who reported higher self-efficacy at T1 reported
greater declines in pain, greater increases in sexual satisfaction, and
greater declines in sexual function over the two time points. The overall
change model did not support the FAM using negative cognitive-affective
variables. Only increases in pain self-efficacy were associated with
reductions in pain intensity. The relationship between changes in selfefficacy and changes in pain was partially mediated through changes in
avoidance (more intercourse attempts). The same pattern of results was
found for changes in sexual satisfaction as the outcome, and a partial
mediation effect was found. There were no significant predictors of
changes in sexual function other than T1 self-efficacy.
DISCUSSION:: Changes in both cognitive and behavioral variables were
significantly associated with improved pain and sexual satisfaction
outcomes. However, it was the positive changes in self-efficacy that
better predicted changes in avoidance behavior, pain and sexual
satisfaction. Cognitive behavioral therapy is often focused on changing
negative pain-related cognitions to reduce avoidance and pain, but the
present results demonstrate the potential importance of bolstering positive
self-beliefs as well. Indeed, before engaging in exposure therapies, selfefficacy beliefs should be assessed and potentially targeted to improve
adherence to exposure strategies.
Understanding and treating vaginismus: a multimodal approach
Int Urogynecol J. 2014 Dec;25(12):1613-20. doi: 10.1007/s00192-0142421-y. Epub 2014 Jun 4.
Pacik PT1.
INTRODUCTION AND HYPOTHESIS: This clinical opinion was
written to bring attention to the understanding and treatment of
vaginismus, a condition that is often under diagnosed and therefore
inadequately treated, yet affects millions of women worldwide. Despite
its description more than a century ago, vaginismus is rarely taught in
medical school, residency training, and medical meetings. The DSM 5
classification stresses that vaginismus is a penetration disorder in that any
form of vaginal penetration such as tampons, finger, vaginal dilators,
gynecological examinations, and intercourse is often painful or
impossible. Compared with other sexual pain disorders such as
vulvodynia and vestibulodynia, the treatment of vaginismus has the
potential for a high rate of success. Stratifying the severity of vaginismus
allows the clinician to choose among numerous treatment options and to
better understand what the patient is experiencing. Vaginismus is both a
physical and an emotional disorder. In the more severe cases of
vaginismus women (and men) complain that attempted intercourse is like
"hitting a wall" suggestive of spasm at the level of the introitus. The
emotional fallout resulting from this needs to be addressed in any form of
treatment applied.
METHODS: This article is based on lessons learned in the treatment of
more than 250 patients and evaluation of more than 400 inquiries, and
was written to make vaginismus more widely understood, to aid in the
differential diagnosis of sexual pain, suggest a variety of effective
treatments, and explain how Botox can be used as part of a multimodal
treatment program to treat vaginismus.
CONCLUSIONS: With greater awareness among clinicians it is hoped
that medical schools, residency programs, and medical meetings will
begin teaching the understanding and treatment of vaginismus.
Remission of Vulvar Pain Among Women With Primary Vulvodynia
J Low Genit Tract Dis. 2014 May 22. [Epub ahead of print]
.Nguyen RH1, Mathur C, Wynings EM, Williams DA, Harlow BL.
OBJECTIVE: To determine whether rates of remission differed among
women with primary versus secondary vulvodynia.
METHODS: Using a community-based observational study based in
Minneapolis/St. Paul, 138 clinically confirmed cases of vulvodynia
between 18 and 40 years old were classified as primary (vulvar pain
starting at the time of sexual debut or first tampon insertion) or secondary
(vulvar pain starting after a period of pain-free intercourse) and queried
regarding their pain history to determine whether they had ever
experienced any vulvar pain-free time (remission) or pain-free time
lasting 3 months or longer.
RESULTS: Remission prevalence was 26% (9/34) for women in the
shortest quartile of duration of vulvar pain (<3.8 y) and 38% (13/34) for
the longest quartile of duration (≥13 y). After adjusting for vulvar pain
duration, generalized vestibular pain, medical treatment, body mass
index, and history of pregnancy, women who had primary vulvodynia
were 43% less likely to report remission (95% CI = 0.33-0.99) than
women with later onset (secondary cases). The association was
strengthened when restricting to only remissions lasting 3 months or
longer (adjusted risk ratio = 0.43, 95% CI = 0.22-0.84). Generalized
vestibulodynia and obesity also reduced the likelihood of remission.
CONCLUSIONS: Our study underscores the heterogeneity of vulvodynia
and provides evidence that primary vulvodynia may have a less wavering
course and, as such, a potentially different underlying mechanism than
that of secondary vulvodynia.
Attachment, Sexual Assertiveness, and Sexual Outcomes in Women
with Provoked Vestibulodynia and Their Partners: A Mediation
Model
Arch Sex Behav. 2014 Apr 29. [Epub ahead of print]
Leclerc B1, Bergeron S, Brassard A, Bélanger C, Steben M, Lambert B.
Provoked vestibulodynia (PVD) is a prevalent women's sexual pain
disorder, which is associated with sexual function difficulties. Attachment
theory has been used to understand adult sexual outcomes, providing a
useful framework for examining sexual adaptation in couples confronted
with PVD. Research to date indicates that anxious and avoidant
attachment dimensions correlate with worse sexual outcomes in
community and clinical samples. The present study examined the
association between attachment, pain, sexual function, and sexual
satisfaction in a sample of 101 couples in which the women presented
with PVD. The actor-partner interdependence model was used in order to
investigate both actor and partner effects. This study also examined the
role of sexual assertiveness as a mediator of these associations via
structural equation modeling. Women completed measures of pain
intensity and both members of the couple completed measures of
romantic attachment, sexual assertiveness, sexual function, and
satisfaction. Results indicated that attachment dimensions did not predict
pain intensity. Both anxious and avoidant attachment were associated
with lower sexual satisfaction. Only attachment avoidance predicted
lower sexual function in women. Partner effects indicated that higher
sexual assertiveness in women predicted higher sexual satisfaction in
men. Finally, women's sexual assertiveness was found to be a significant
mediator of the relationship between their attachment dimensions, sexual
function, and satisfaction. Findings highlight the importance of
examining how anxious and avoidant attachment may lead to difficulties
in sexual assertiveness and to less satisfying sexual interactions in
couples where women suffer from PVD.
Relationship satisfaction moderates the associations between male
partner responses and depression in women with vulvodynia: a
dyadic daily experience study
Pain. 2014 Jul;155(7):1374-83. doi: 10.1016/j.pain.2014.04.017. Epub
2014 Apr 23.
Rosen NO1, Bergeron S2, Sadikaj G3, Glowacka M4, Baxter ML5,
Delisle I6.
Vulvodynia is a prevalent vulvovaginal pain condition that interferes with
women's psychological health. Given the central role of sexuality and
relationships in vulvodynia, relationship satisfaction may be an important
moderator of daily partner responses to this pain and associated negative
sequelae, such as depression. Sixty-nine women (M age=28.12 years,
SD=6.68) with vulvodynia and their cohabiting partners (M age=29.67
years, SD=8.10) reported their daily relationship satisfaction, and male
partner responses on sexual intercourse days (M=3.74, SD=2.47) over 8
weeks. Women also reported their depressive symptoms. Relationship
satisfaction on the preceding day moderated the associations between
partner responses and women's depressive symptoms in several
significant ways: (1) On days after women reported higher relationship
satisfaction than usual, their perception of greater facilitative male partner
responses was associated with their decreased depression; (2) on days
after women reported lower relationship satisfaction than usual, their
perception of greater negative male partner responses was associated with
their increased depression; (3) on days after men reported higher
relationship satisfaction than usual, their self-reported higher negative
responses were associated with decreased women's depression, and
higher solicitous responses were associated with increased women's
depression, whereas (4) on days after men reported lower relationship
satisfaction than usual, their self-reported higher negative responses were
related to increased women's depression, and higher solicitous responses
were associated with decreased women's depression. Targeting partner
responses and relationship satisfaction may enhance the quality of
interventions aimed at reducing depression in women with vulvodynia.
Assessing severity of pain in women with focal provoked vulvodynia:
are von Frey filaments suitable devices?
J Reprod Med. 2014 Mar-Apr;59(3-4):134-8.
Donders GG, Bellen G.
OBJECTIVE: To determine whether von Frey filaments are effective in
the standardized assessment of the severity of focal provoked vulvodynia
(FPV) syndrome.
STUDY DESIGN: The data of 30 women with FPV attending monthly at
our vulvovaginal disease clinic, for a collective total of 141 visits over 6
months, were analyzed. At each visit sensitivity tests at the vulvar
vestibule were performed at the 5 and 7 o'clock area, totaling 282
measurements. A questionnaire, blinded to the examining physician, and
a visual analogue score (VAS) of pain ranging from 1 (no pain) to 10
(maximal pain) was obtained of the discomfort felt when attempting
sexual intercourse.
RESULTS: The VAS, the investigator assessment of redness, and the 1 to
10 score result of the cotton swab touch test at 5 and 7 o'clock were
superior diagnostic tools for assessing the severity of the pain when
compared to the use of von Frey filaments.
CONCLUSION: Although elegant because of the promise of objective,
semiquantitative measurements, von Frey filaments are less suitable
devices to assess severity of disease and response to treatment than are
cotton swab 1 to 10 pain scores and clinical parameters like subjective
pain (VAS) and objective focal redness.
Localized provoked vestibulodynia: outcomes after modified
vestibulectomy
J Reprod Med. 2014 Mar-Apr;59(3-4):121-6.
Swanson CL, Rueter JA, Olson JE, Weaver AL, Stanhope CR.
OBJECTIVE: To describe and estimate both short-term and long-term
effectiveness of a large cohort of women treated with modified
vestibulectomy in a single surgical service.
STUDY DESIGN: A total of 202 patients who were treated with
modified vestibulectomy for localized provoked vestibulodynia at Mayo
Clinic in Rochester, Minnesota, were mailed a questionnaire to document
severity of vulvar pain or discomfort before and after the surgery.
RESULTS: In total, 115 patients returned the questionnaire. Of the 71
patients who before surgery reported pain when inserting a tampon, 52
reported attempting to insert a tampon after surgery. Of these 52 patients,
47 (90.4%) noticed moderate to substantial improvement. Pain with
sexual intercourse occurred in 97.3% (107/ 110) of patients before
surgery. After surgery, 90 (84.1%) of those 107 patients noted moderate
to substantial improvement in their pain with intercourse.
CONCLUSION: Modified vestibulectomy was a successful treatment for
patients with localized provoked vestibulodynia and resulted in strong
patient satisfaction, long-term effectiveness, minimal scarring, and few
postoperative complications.
The value of histology in predicting the effectiveness of vulvar
vestibulectomy in provoked vestibulodynia
J Low Genit Tract Dis. 2014 Apr;18(2):109-14. doi:
10.1097/LGT.0b013e31829fae32.
Brokenshire C1, Pagano R, Scurry J.
OBJECTIVE: This study aimed to determine whether histology can
predict response to vestibulectomy in the management of provoked
vestibulodynia.
MATERIALS AND METHODS: Inflammatory cell, mast cell, and nerve
fiber counts were determined in prospectively collected vulvar
vestibulectomy specimens from 30 women treated surgically for
provoked vestibulodynia.
RESULTS: Twenty-three subjects (77%) had a complete early response
to surgery. At 3 years of follow-up, this had increased to 28 (93%), with a
29th showing some improvement. No subject had gotten worse after
surgery or in the 3 years of follow-up. When comparing patients with an
early complete response with those patients who still had symptoms, no
difference in lymphocyte counts (27.6 vs. 37.8 per mm), mast cell counts
(110.4 vs. 97.8 per mm), or stromal nerve fiber counts (16.4 vs. 16.4 per
mm) was found.
CONCLUSIONS: Vestibulectomy is a very effective treatment option in
women with provoked vestibulodynia who have had failed conservative
treatment. Histology is unable to predict which patients will respond to
surgery.
Management of pudendal neuralgia
Climacteric. 2014 Dec;17(6):654-6. doi: 10.3109/13697137.2014.912263.
Epub 2014 Jul 4.
Pérez-López FR1, Hita-Contreras F.
Pelvic pain is a frequent complaint in women during both reproductive
and post-reproductive years. Vulvodynia includes different
manifestations of chronic vulvar pain with no known cause. Many
women do not receive a diagnosis and appropriate treatment. Pudendal
neuralgia is a painful condition caused by inflammation, compression or
entrapment of the pudendal nerve; it may be related to or be secondary to
childbirth, pelvic surgery, intense cycling, sacroiliac skeletal
abnormalities or age-related changes. Clinical characteristics include
pelvic pain with sitting which increases throughout the day and decreases
with standing or lying down, sexual dysfunction and difficult with
urination and/or defecation. To confirm pudendal neuralgia, the Nantes
criteria are recommended. Treatment includes behavioral modifications,
physiotherapy, analgesics and nerve block, surgical pudendal nerve
decompression, radiofrequency and spinal cord stimulation.
Provoked vestibulodynia: inflammatory, neuropathic or
dysfunctional pain? A neurobiological perspective
J Obstet Gynaecol. 2014 May;34(4):285-8. doi:
10.3109/01443615.2014.894004. Epub 2014 Mar 20.
Micheletti L1, Radici G, Lynch PJ.
This paper aims to clarify the nature of the pain in provoked
vestibulodynia (PV). It reviews published data about the nature of the
pain in PV, employing a recent pain classification, which divides pain
from a neurobiological perspective, into nociceptive, inflammatory and
pathological pain, with the latter subdivided into neuropathic and
dysfunctional pain. Nociceptive pain is high-threshold pain provoked by
noxious stimuli; inflammatory pain is adaptive, low-threshold pain
associated with peripheral tissue inflammation; pathological pain is
maladaptive, low-threshold pain caused by structural damage to the
nervous system (neuropathic) or by its abnormal function (dysfunctional).
Most of the published data show that in PV, there is no active peripheral
tissue inflammation. Similarly, no neural damage has been demonstrated.
It is reasonable to consider PV as dysfunctional pain induced by exposure
to acute physical or psychological precipitating events in the presence of
an individual predisposition to produce or maintain abnormal central
sensitisation.
Pain Symptoms in Fibromyalgia Patients with and without Provoked
Vulvodynia
Pain Res Treat. 2014;2014:457618. doi: 10.1155/2014/457618. Epub
2014 Jan 29.
Ghizzani A1, Di Sabatino V2, Suman AL3, Biasi G1, Santarcangelo EL4,
Carli G3.
Objective. The aim of the study was to compare the pain symptoms of
fibromyalgia patients exhibiting (FMS+PVD) and not exhibiting (FMS)
comorbidity with provoked vulvodynia. Study Design. The case control
study was performed in 39 patients who had been diagnosed with FMS
and accepted to undergo gynaecological examination and in 36 healthy
women (C). All patients completed standardized questionnaires for pain
intensity, pain area, and psychological functioning. The gynaecological
examination included vulvar pain pressure reactivity (Q-tip), pelvic tone
assessment (Kegel manoeuver), and a semistructured interview collecting
detailed information about pelvic symptoms and sexual function. Results.
FMS+PVD patients displayed a higher number of associated symptoms
than FMS patients. The vulvar excitability was significantly higher in
FMS+PVD than in FMS and in both groups than in Controls. Half of
FMS+PVD patients were positive to Kegel manoeuver and displayed
higher scores in widespread pain intensity, STAI-Y2, and CESD levels
than Kegel negative patients. Conclusions. The study reveals that
increased vulvar pain excitability may occur in FMS patients
independently of the presence of coital pain. Results suggest that coital
pain develops in patients with higher FMS symptoms severity due to the
cooperative effects of peripheral and central sensitization mechanisms.
Sexual function, relationship adjustment, and the relational impact
of pain in male partners of women with provoked vulvar pain
J Sex Med. 2014 May;11(5):1283-93. doi: 10.1111/jsm.12484. Epub
2014 Feb 26.
Smith KB1, Pukall CF.
INTRODUCTION: Despite the impact of provoked vulvar pain on
women's sexuality and the partnered sexual context in which the pain
typically occurs, partners have not been included widely in research.
AIMS: To examine sexual and relationship functioning of male partners
of women with provoked vulvar pain symptoms using a controlled design
and to assess the impact of the pain on their relationship.
METHODS: Fifty male pain partners and 56 male controls completed
questionnaires to assess sexual communication, sexual
functioning/satisfaction, sexual esteem, relationship adjustment, and
psychological health. Participants also completed numeric rating scales to
assess the importance of sex to them and the extent to which they felt
their relationship matched a satisfying relationship. To assess the
relational impact of vulvar pain, pain partners were asked to indicate
whether the pain had impacted their relationship, and, if yes, rated this
impact.
MAIN OUTCOME MEASURES: Main outcome measures included the
Dyadic Sexual Communication Scale, the International Index of Erectile
Function, the Sexuality Scale, the Dyadic Adjustment Scale, the 12-Item
Short-Form Health Survey, and numeric rating scales.
RESULTS: Pain partners reported significantly poorer sexual
communication and erectile function and less sexual satisfaction
compared with controls. They also reported significantly less affectional
expression within their relationships and were more likely than controls
to report a discrepancy between their relationship and their idea of a
satisfying relationship. Almost 73% (n = 32/44) of pain partners reported
a negative relational impact of vulvar pain. No significant differences in
sexual desire, orgasmic function, sexual esteem, relationship satisfaction
and consensus, psychological health, or importance of sex were found
between groups.
CONCLUSIONS: Provoked vulvar pain partners appear negatively
impacted with regard to some sexual and physical aspects of their
relationship. As one of the few controlled studies to investigate partner
functioning in the context of provoked vulvar pain, this study has future
research implications and supports the involvement of partners in
treatment.
Natural history of comorbid orofacial pain among women with
vestibulodynia
Clin J Pain. 2015 Jan;31(1):73-8. doi: 10.1097/AJP.0000000000000087.
Bair E1, Simmons E, Hartung J, Desia K, Maixner W, Zolnoun D.
OBJECTIVES: We evaluated the stability of the comorbidity between
vulvodynia and orofacial pain (OFP) and its associated clinical
characteristics over a 2-year follow-up period.
MATERIALS AND METHODS: In an earlier study of vestibulodynia
patients, we administered questionnaires assessing demographic data,
self-reported pain, anxiety, somatic awareness, and presence of signs and
symptoms suggestive of clinical and subclinical OFP. The present study
readministered the same surveys to a subset of the original cohort after a
2-year follow-up period.
RESULTS: Of the 138 women in the previous study, 71 (51%) agreed to
participate in the present study. We confirmed our earlier findings that (1)
OFP is a highly prevalent (66%) condition among women with
vestibulodynia, and (2) compared with women with no OFP symptoms,
those with OFP symptoms experience higher levels of anxiety (P=0.005)
and somatic awareness (P<0.001). Although OFP symptoms showed
improvement in many of the vestibulodynia patients (33%) with OFP
symptoms at baseline, 13% had either developed new symptoms or
transitioned from subclinical to clinical OFP classification. Intercourserelated pain decreased in 69% of patients and increased in 24% of
patients. Consistent with our earlier report, we did not observe significant
differences with respect to demographics or severity of pain during
intercourse among the subgroups.
DISCUSSION: OFP is a common comorbidity among women with
vestibulodynia, although the presence of OFP can vary over time. The
comorbidity between vestibulodynia and OFP suggests that common
underlying mechanisms may mediate both conditions.
To say or not to say: Dyadic ambivalence over emotional expression
and its associations with pain, sexuality, and distress in couples
coping with provoked vestibulodynia
J Sex Med. 2014 May;11(5):1271-82. doi: 10.1111/jsm.12463. Epub
2014 Feb 19.
Awada N1, Bergeron S, Steben M, Hainault VA, McDuff P.
INTRODUCTION: Provoked vestibulodynia (PVD) is a highly prevalent
and taxing female genital pain condition. Despite the intimate nature of
this pain and the fact that affective factors such as anxiety have been
shown to modulate its manifestations, no study has yet explored the
emotional regulation of couples in which the woman suffers from PVD.
AIM: Ambivalence over emotional expression (AEE) is an emotional
regulation variable that quantifies the extent to which a person is
comfortable with the way she or he expresses emotions. We examined
whether the dyadic AEE of couples in which the woman suffers from
PVD was differentially associated with women's pain and couples'
psychological, sexual, and relational functioning.
METHODS: Couples (N = 254), in which the woman suffered from PVD,
completed the AEE questionnaire. A couple typology of dyadic AEE was
created.
MAIN OUTCOME MEASURES: Dependent measures for both members
of the couple were the global measure of sexual satisfaction scale, the
Beck depression inventory II, and the revised dyadic adjustment scale.
The female sexual function index and the sexual history form were used
to assess the sexual function of women and men, respectively. Women
also completed the pain rating index of the McGill pain questionnaire.
RESULTS: Couples, in which both partners were considered low on
AEE, had the highest scores on sexual satisfaction (P = 0.02) and function
(P < 0.01), the lowest depression scores (P < 0.01), and the best dyadic
adjustment (P = 0.02). No difference in pain intensity was found between
couples.
CONCLUSIONS: Findings suggest that, for couples in which the woman
suffers from PVD, an emotional regulation that is low in ambivalence in
both partners is associated with better psychological, sexual, and
relational outcomes. Results indicate that emotional regulation may be
important to consider in the assessment and treatment of couples coping
with PVD.
Factors associated with vulvodynia incidence
Obstet Gynecol. 2014 Feb;123(2 Pt 1):225-31. doi:
10.1097/AOG.0000000000000066.
Reed BD1, Legocki LJ, Plegue MA, Sen A, Haefner HK, Harlow SD.
OBJECTIVE: To assess incidence rates of and risk factors for
vulvodynia.
METHODS: We conducted a longitudinal population-based study of
women in southeast Michigan (Woman-to-Woman Health Study) using a
validated survey-based screening test for vulvodynia that was repeated at
6-month intervals over 30 months. Unadjusted incidence rates were
determined using Poisson models. Demographic and symptom-related
risk factors for incidence were assessed using discrete time survival
analysis.
RESULTS: Women who screened negative for vulvodynia at baseline
and were followed through at least one additional survey (n=1,786) were
assessed for onset of vulvodynia. The incidence rate was 4.2 cases per
100 person-years, and rates per 100 person-years were greater in women
who were younger (7.6 cases per 100 person-years at age 20 years,
compared with 3.3 cases per 100 person-years at age 60 years), Hispanic
(9.5 cases per 100 person-years), married, or living as married (4.9 cases
per 100 person-years); had reported symptoms of vulvar pain but did not
meet vulvodynia criteria on the initial survey (11.5 cases per 100 personyears); or had reported past symptoms suggesting a history of vulvodynia
(7.5 cases per 100 person-years). Increased risk of new-onset vulvodynia
also included baseline sleep disturbance, chronic pain in general, specific
comorbid pain disorders, and specific comorbid psychological disorders.
CONCLUSIONS: The incidence rates of vulvodynia differ by age,
ethnicity, and marital status. Onset is more likely among women with
previous symptoms of vulvodynia or those with intermediate symptoms
not meeting criteria for vulvodynia and among those with pre-existing
sleep, psychological, and comorbid pain disorders. This suggests
vulvodynia is an episodic condition with a potentially identifiable
prodromal phase.
Morphometry of the pelvic floor muscles in women with and without
provoked vestibulodynia using 4D ultrasound
J Sex Med. 2014 Mar;11(3):776-85. doi: 10.1111/jsm.12367. Epub 2013
Nov 6.
Morin M1, Bergeron S, Khalifé S, Mayrand MH, Binik YM.
INTRODUCTION: It has been suggested that pelvic floor muscles
(PFMs) play an important role in provoked vestibulodynia (PVD)
pathophysiology. Controversy in determining their exact contribution
may be explained by methodological limitations related to the PFM
assessment tools, specifically the pain elicited by the measurement itself,
which may trigger a PFM reaction and introduce a strong bias.
AIM: The aim of this study was to compare PFM morphometry in women
suffering from PVD to asymptomatic healthy control women using a
pain-free methodology, transperineal four-dimensional (4D) ultrasound.
METHODS: Fifty-one asymptomatic women and 49 women suffering
from PVD were recruited. Diagnosis of PVD was confirmed by a
gynecologist following a standardized examination. All the participants
were nulliparous and had no other urogynecological conditions. The
women were evaluated in a supine position at rest and during PFM
maximal contraction.
MAIN OUTCOME MEASURES: Transperineal 4D ultrasound, which
consists of a probe applied on the surface of the perineum without any
vaginal insertion, was used to assess PFM morphometry. Different
parameters were assessed in sagittal and axial planes: anorectal angle,
levator plate angle, displacement of the bladder neck, and levator hiatus
area. The investigator analyzing the data was blinded to the clinical data.
RESULTS: Women with PVD showed a significantly smaller levator
hiatus area, a smaller anorectal angle, and a larger levator plate angle at
rest compared with asymptomatic women, suggesting an increase in PFM
tone. During PFM maximal contraction, smaller changes in levator hiatus
area narrowing, displacement of the bladder neck, and changes of the
anorectal and of the levator plate angles were found in women with PVD
compared with controls, which may indicate poorer PFM strength and
control.
CONCLUSION: Using a reliable and pain-free methodology, this
research provides sound evidence that women with PVD display
differences in PFM morphometry suggesting increased tone and reduced
strength.
Impact of male partner responses on sexual function in women with
vulvodynia and their partners: a dyadic daily experience study
Health Psychol. 2014 Aug;33(8):823-31. doi: 10.1037/a0034550. Epub
2013 Nov 18.
Rosen NO1, Bergeron S2, Sadikaj G3, Glowacka M1, Delisle I4, Baxter
ML5.
OBJECTIVE: There is a paucity of research investigating the role of
interpersonal variables in vulvodynia--a prevalent, chronic, vulvo-vaginal
pain condition that negatively affects many aspects of women's sexual
health, emotional well-being and intimate relationships. Cross-sectional
studies have shown that male partner responses to painful intercourse are
associated with pain and sexual satisfaction in women with vulvodynia.
Partner responses can be solicitous (attention and sympathy), negative
(hostility and frustration), and facilitative (encouragement of adaptive
coping). No research has assessed the influence of daily partner responses
in this population. Further, there is limited knowledge regarding the
impact of partner responses on sexual function, which is a key measure of
impairment in vulvodynia.
METHODS: Using daily diaries, 66 women (M age = 27.91, SD = 5.94)
diagnosed with vulvodynia and their cohabiting male partners (M age =
30.00, SD = 8.33) reported on male partner responses and sexual function
on days when sexual intercourse occurred (M = 6.54, SD = 4.99).
Drawing on the Actor-Partner Interdependence model (APIM), a
multivariate multilevel modeling approach was adopted.
RESULTS: A woman's sexual functioning improved on days when she
perceived greater facilitative and lower solicitous and negative male
partner responses, and when her male partner reported lower solicitous
responses. A man's sexual functioning was poorer on days when he
reported greater solicitous and negative responses.
CONCLUSIONS: Findings suggest that facilitative male partner
responses may improve sexual functioning whereas solicitous and
negative responses may be detrimental. Partner responses should be
targeted in psychological interventions aimed to improve the sexual
functioning of affected couples.
Prevalence of symptoms consistent with a diagnosis of vulvodynia:
population-based estimates from 2 geographic regions
Am J Obstet Gynecol. 2014 Jan;210(1):40.e1-8. doi:
10.1016/j.ajog.2013.09.033. Epub 2013 Sep 28.
Harlow BL1, Kunitz CG1, Nguyen RH1, Rydell SA1, Turner RM1,
MacLehose RF1.
OBJECTIVE: We used validated sensitive and specific questions
associated with clinically confirmed diagnoses of unexplained vulvar pain
(vulvodynia) to compare the cumulative incidence of vulvar pain and
prevalence of care-seeking behavior in Boston metropolitan area (BMA)
and in Minneapolis/Saint Paul metropolitan area (MSP) from 2001
through 2005 using census-based data, and 2010 through 2012, using
outpatient community-clinic data, respectively.
STUDY DESIGN: We received self-administered questionnaires from
5440 women in BMA and 13,681 in MSP, 18-40 years of age, describing
their history of vulvar burning or pain on contact that persisted >3 months
that limited/prevented intercourse.
RESULTS: By age 40 years, 7-8% in BMA and MSP reported vulvar
pain consistent with vulvodynia. Women of Hispanic origin compared to
whites were 1.4 times more likely to develop vulvar pain symptoms (95%
confidence interval, 1.1-1.8). Many women in MSP (48%) and BMA
(30%) never sought treatment, and >50% who sought care with known
health care access received no diagnosis.
CONCLUSION: Using identical screening methods, we report high
prevalence of vulvar pain in 2 geographic regions, and that access to
health care does not increase the likelihood of seeking care for chronic
vulvar pain.
Decreased concentration of protease inhibitors: possible contributors
to allodynia and hyperalgesia in women with vestibulodynia
Am J Obstet Gynecol. 2014 Jul 25. pii: S0002-9378(14)00729-7. doi:
10.1016/j.ajog.2014.07.029. [Epub ahead of print]
Jayaram A1, Esbrand F1, Dulaveris G1, Orfanelli T1, Sobel R2, Ledger
WJ1, Witkin SS3.
OBJECTIVE: Women with vestibulodynia exhibit increased pain
sensitivity to contact with the vaginal vestibule as well as with vaginal
penetration. The mechanism(s) responsible for this effect remains
incompletely defined. Based on reports of a possible role for proteases in
induction of pain, we compared levels of proteases and protease
inhibitors in vaginal secretions from women with vestibulodynia and
controls.
STUDY DESIGN: Vaginal secretions from 76 women with
vestibulodynia and from 41 control women were assayed by an enzymelinked immunosorbent assay for the protease inhibitors, secretory
leukocyte protease inhibitor (SLPI) and human epididymis protein-4 (HE4), and the proteases, kallikrein-5 and cathepsins B and S. Concentrations
between subjects and controls were compared and levels related to
clinical and demographic variables.
RESULTS: Concentrations of HE-4 and SLPI were markedly reduced in
vaginal samples from women with vestibulodynia compared with controls
(P ≤ .006). All other compounds were similar in both groups. HE-4 (P =
.0195) and SLPI (P = .0033) were lower in women with secondary, but
not primary, vestibulodynia than in controls. Subjects who had constant
vulvar pain had lower levels of HE-4 and SLPI than did healthy control
women (P ≤ .006) or women who experienced vulvar pain only during
sexual intercourse (P ≤ .0191). There were no associations between HE-4
or SLPI levels and event associated with symptom onset, duration of
symptoms, age, number of lifetime sexual partners, or age at sex
initiation.
CONCLUSION: Insufficient vaginal protease inhibitor production may
contribute to increased pain sensitivity in an undefined subset of women
with secondary vestibulodynia who experience constant vulvar pain.
CD4-positive T-cell recruitment in primary-provoked localized
vulvodynia: potential insights into disease triggers
J Low Genit Tract Dis. 2014 Apr;18(2):195-201. doi:
10.1097/LGT.0b013e3182a55591.
Leclair CM1, Leeborg NJ, Jacobson-Dunlop E, Goetsch MF, Morgan TK.
OBJECTIVE: To better understand the potential disease triggers of
neurogenic inflammation in provoked localized vulvodynia (PLV), our
objective was to determine whether the types of infiltrating lymphocytes
were different in vestibular biopsies from women with primary PLV,
secondary PLV, and unaffected controls.
METHODS: Secondary retrospective analysis of archived vestibular
biopsies from a series of adult premenopausal women with primary PLV
(n = 10), secondary PLV (n = 10), and unaffected controls (n = 4) was
performed. All study patients had severe entry dyspareunia for more than
1 year. Subjects were excluded if pregnant, or they had a known
infection, or history of generalized vulvodynia. Biopsies were performed
during the midfollicular phase. Lymphocyte subtypes were highlighted in
histologic sections using antibodies against CD3, CD4, and CD8 and
scored as the mean number of T-cell subtypes per high-power field. Flow
cytometry was also used to test fresh biopsies from a de novo prospective
series of primary PLV (n = 4) and unaffected controls (n = 2).
RESULTS: Unaffected control biopsies showed more CD8-positive than
CD4-positive T cells, similar to previous reports of the gynecologic tract.
In contrast, biopsies from women with primary PLV showed significantly
more CD4-positive T cells than those from women with secondary PLV
and unaffected controls (p = .003). This observation was further
supported by flow cytometry.
CONCLUSIONS: CD4-positive T cells are more numerous in vestibular
biopsies from premenopausal women with primary PLV. This may be
important because subtypes of CD4-positive T cells are specifically
recruited by infectious, allergic, or autoimmune triggers. Future studies
distinguishing these subtypes may lead to new insights into this common
disease.
Serotonin Receptor Gene (5HT-2A) Polymorphism is Associated with
Provoked Vestibulodynia and Comorbid Symptoms of Pain
J Sex Med. 2014 Dec;11(12):3064-71. doi: 10.1111/jsm.12685. Epub
2014 Sep 1.
Heddini U1, Bohm-Starke N, Grönbladh A, Nyberg F, Nilsson KW,
Johannesson U.
INTRODUCTION: Provoked vestibulodynia (PVD) is a common type of
dyspareunia among young women. The patho-physiology remains largely
unclear. Women with PVD have general pain hypersensitivity and often
report additional pain symptoms. Signs point towards PVD being a
chronic pain disorder similar to other syndromes of longstanding pain,
including a common comorbidity of anxiety and depression.
Polymorphism in the serotonin receptor gene, 5HT-2A, has been
associated with other chronic pain disorders such as fibromyalgia but has
not been investigated in PVD patients.
AIM: We aimed to investigate a possible contribution of polymorphism
in the 5HT-2A gene to the etiology of PVD as well as a potential
influence on pain sensitivity.
METHODS: In this case-control study 98 women with PVD and 103
healthy controls between 18 and 44 years and in the same menstrual cycle
phase completed questionnaires and underwent quantitative sensory
testing. Venous blood samples were collected for DNA isolation.
MAIN OUTCOME MEASURES: Concomitant pain was reported, a
bodily pain score was created and pressure pain thresholds (PPTs) on the
arm, leg, and in the vestibule were measured. Intensity of coital pain was
rated on a visual analog scale, range 0-100. The T102C (rs6313) and A1438G (rs6311) single nucleotide polymorphisms (SNPs) in the 5HT-2A
gene were analyzed.
RESULTS: The probability of PVD was elevated in participants carrying
the 1438G- and 102C-alleles of the 5HT-2A gene (OR 2.9). The G-/Cgenotypes were also associated with more concomitant bodily pain in
addition to the dyspareunia, but not with experimental PPTs or coital pain
ratings. PVD patients reported more concomitant bodily pain and had
lower PPTs compared with controls.
CONCLUSION: The results indicate a contribution of alterations in the
serotonergic system to the patho-genesis of PVD and gives further
evidence of PVD being a general pain disorder similar to other chronic
pain disorders.
Activation of vestibule-associated lymphoid tissue in localized
provoked vulvodynia
Am J Obstet Gynecol. 2014 Oct 30. pii: S0002-9378(14)02153-X. doi:
10.1016/j.ajog.2014.10.1098. [Epub ahead of print]
.Tommola P1, Bützow R2, Unkila-Kallio L3, Paavonen J3, Meri S4.
OBJECTIVE: Localized provoked vulvodynia (LPV) may have
inflammatory etiology. We wanted to find out whether the cell-mediated
immune system becomes activated in the vestibular mucosa in LPV.
STUDY DESIGN: This was a controlled cross-sectional study. Vestibular
mucosal specimens were obtained from 27 patients with severe LPV and
15 controls. Detailed clinical history of the patients was obtained. For
immunohistochemistry, antibodies against CD3 (T cells), CD20 (B cells),
IgA (mucosal plasma cells), CD163 (dendritic cells [DCs]), CD68
(macrophages), and CD117 (mast cells) were employed. Mann-Whitney
U test and χ2 test were used for statistical analyses.
RESULTS: More B lymphocytes and mature mucosal IgA-plasma cells
were found in patients than in controls (P < .001 and P < .001,
respectively). In LPV samples, B and T cells were arranged into germinal
centers representing local immune activation. Germinal centers were not
seen in controls. Antigen-presenting DCs and macrophages were found
both in patients and controls with similar densities. DCs were found to
extend their dendrites into the luminal space through an intact epithelium.
Similar amounts of mast cells were found evenly scattered throughout the
stroma of vestibular mucosa of both patients and controls.
CONCLUSION: We demonstrate here local organized vestibuleassociated lymphoid tissue analogous to mucosa-associated lymphoid
tissue. Vestibule-associated lymphoid tissue may emerge as a response to
local infection or inflammation in LPV.
Genetic Differences May Reflect Differences in Susceptibility to
Vulvodynia in General or in Spontaneous Remission Propensity
J Sex Med. 2014 Nov 26. doi: 10.1111/jsm.12775. [Epub ahead of print]
Reed BD1, Harlow SD, Plegue MA, Sen A. No abstract available