|Vol. 7, No. 3 / August 2009
FIGHT DYSPAREUNIA: REPLACE PAIN WITH PLEASURE
A pitfall in the assessment of patients who report pain during sex is over-estimating the link with sexual abuse.
It is critical that one clinician take responsibility for patient referral to different specialists.
Recent reports suggest that the link between urogenital atrophy and pain is weaker than once thought.
Department of Psychology, McGill University, Sex and Couple Therapy Service, McGill University Health Center, Montreal, Quebec, CanadaIn the absence of physical pathology or marital strife, sexual pain has historically been seen as a “sex problem” caused by a variety of factors, ranging from a history of abuse to lowered sexual arousal secondary to inadequate technique. Patients saw sexologists for treatment, which usually involved efforts to increase arousal or to work through trauma. There is no published evidence to suggest that improving a patient’s sex life resolves dyspareunia for most women. Pain stems from physical and psychological factors, both of which must be addressed in a comprehensive assessment. In short, the pain is not sexual, the sex is painful. Viewing sexual pain as a chronic pain syndrome has practical implications for treatment approaches, many of which have proven successful. Additionally, more precise language is evolving to describe sexual pain, as mental health professionals and gynecologists take another look at this phenomenon that troubles many premenopausal and postmenopausal patients.For the past 2 decades, clinicians have learned to assess complaints of pain during intercourse by focusing on the sexual aspects, eg, asking questions about sexual conflict, sexual practices, and sexual history. In fact, there is no evidence to support the common assumption that increasing a patient’s arousal by changing her technique or her partner’s will improve her pain.In a controlled study, women with and without provoked vestibulodynia were asked to watch erotic and neutral videos.
Physiologic arousal was assessed by measuring surface labial skin temperature. Subjective arousal was assessed using questionnaires about mood, pain, and sexual functioning. Sensitivity to touch and pain was also measured in both groups while patients watched erotic and neutral films. There was no difference in physiologic arousal between the groups when watching erotic videos, but women with provoked vestibulodynia (vulvar pain that requires a physical stimulus) reported decreased subjective arousal. Furthermore, women with provoked vestibulodynia were more sensitive to pain during the erotic videos than the neutral videos, implying that increased sexual arousal does not diminish pain. A second study showed that women with provoked vestibulodynia express hypersensitivity to pain similar to that seen in patients with fibromyalgia.
2Another pitfall in the assessment of patients who report pain during sex is overestimating the link with sexual abuse. Unfortunately, case-control studies of women with and without pain during intercourse show that there are high rates of past sexual abuse in both groups.
Without denying that a traumatic instance can lead to pain during intercourse, it is important to recognize that it may not be the cause at all.Experience is beginning to show that pain during intercourse can—and should—be assessed as other pain syndromes would. Patients should be carefully questioned about location, quality, intensity, and duration of pain. They should also be asked about the situations that provoke pain and the activities with which pain interferes. Clinicians can ask patients to describe the pain, particularly asking if it is burning, cutting, or shooting pain. Many women report that they experienced pain the first time they tried to insert a tampon, before they were sexual.
There is reason to believe that pain may start at a young age but only comes to clinical attention when it begins to interfere with sex.Not only is it informative to ask patients to describe their symptoms, but such questions also acknowledge the reality of the patient’s experience of pain and improve patients’ satisfaction with their treatment. Recurrent pain cannot be reduced to simple pathology. Although initially there may be something physically wrong, by the pain time becomes chronic, this precipitating factor has disappeared and the pain has a life of its own.
To psychiatrists, psychologists, and sexologists, this type of pain is called dyspareunia. The Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text rev (DSM-IV-TR), published by the American Psychiatric Association defines dyspareunia as pain that interferes with intercourse. Most disorders are defined by their symptoms or mechanisms, not by the activities with which they interfere, making dyspareunia an oddity.
There may be nonsexual triggers of pain—annual gynecologic exams, sports—that women try to avoid, but most women do not want to avoid intercourse. Therefore, one of the reasons why sexual pain has this unusual definition is that the interference with intercourse is what motivates a woman to see a clinician.
Gynecologists have long used a variety of terms for sexual pain, such as “superficial pain” and “deep pain”; “superficial dyspareunia” and “deep dyspareunia”; or “chronic pelvic pain.”
They differentiate between these types of pain because they believe there must be different anatomical causes.
Slowly, new terminology is being developed for specific pain syndromes, with differentiation between vulvar aches and pelvic aches. Subtypes of vulvar or pelvic pain are being distinguished and further classified by the stimulus. In particular, there is a distinction between pain that is provoked and that which is unprovoked. The most commonly used term for pain that requires a physical stimulus is “provoked vestibulodynia,” formerly called vulvar vestibulitis syndrome. The International Society for the Study of Vulvovaginal Disease has stated that vulvar vestibulitis is not an appropriate term for this condition because it implies inflammation, which has not been documented among patients with this diagnosis.
The condition was renamed “provoked vestibulodynia,” meaning pain in the vulvar vestibule—the area just before the entrance to the vagina—in the presence of a mechanical stimulus, such as penetration. There are many terms for pain that occurs without stimulation. The most commonly used are chronic pelvic pain or vulvodynia, which is sometimes called generalized or unprovoked vulvodynia.
An individual woman may have both provoked and unprovoked pain. As researchers and clinicians try to understand the different syndromes, it is important to consider the location of the pain, the existence of a related pathology, as well as pain qualities and duration.
Psychology, pathology, and pain
The psychological and physical aspects of pain are intertwined. Often the original cause of the pain is unknown, having happened years before. However, after months of pain, it becomes part of a person, evoking unique memories and reactions.
For example, consider vaginismus, which is not generally regarded as a pain syndrome. DSM-IV-TR defines vaginismus as a spasm of the muscles in the vaginal area that prevents penetration altogether. Clinical experience shows that most women with vaginismus can tolerate a gynecologic exam if the physician prepares the woman properly and does not rush. Of those women who can tolerate an exam, many are likely to have provoked vestibulodynia on examination. This observation points to the possibility that provoked vestibulodynia and vaginismus are actually part of a continuum of muscle tension and fear. Indeed, some women suffering from vaginismus experience a phobic reaction to vaginal penetration.
Whether pain or fear came first is individual for each woman. If penetration hurts a woman every time, she may begin to fear the experience and become tense. Conversely, some women may fear intercourse without having had a negative experience, leading to the spasm tension and pain. Regardless of the sequence of events, physical and psychological factors produce a continuum with multiple dimensions of pain, muscle tension, and fear.
Multidisciplinary care for pain patients
For a woman with sexual pain, nothing is more frustrating than being sent from one specialist to the next, hearing from each that nothing is wrong with her. The best approach is to involve a gynecologist, a mental health professional with training in sexuality, a pelvic floor physical therapist, and often, a dermatologist in a comprehensive initial assessment.
It is reasonable that every woman who complains of pain during intercourse is evaluated by a gynecologist for an identifiable pathology. However, even when pathology exists, it does not always translate into pain. Similarly, “provoked vestibulodynia” is defined by the lack of pathology. Furthermore, many young women report sharp, cutting, or burning pain during entry with no known pathology.
Dermatological evaluation can identify a number of skin problems that may cause pain for some women. The caveat here, too, is that sometimes these findings have nothing to do with the pain.
Pelvic floor physical therapists deal primarily with incontinence but work with the same pelvic muscles that are involved in sexual pain. Pelvic floor physical therapists have had success evaluating and treating sexual pain by working on the muscles that are the source of the pain.
Finally, pain is ultimately in the brain and the mind, and psychology is a major tool for addressing it. Thus, the involvement of a mental health professional on the team is a key component of the comprehensive evaluation and treatment of a pain patient.
In the absence of a formal collaboration among health care providers for the treatment of sexual pain, it is critical that one clinician take responsibility for referring a patient to different specialists, coordinating the information they provide, and completing an adequate assessment. Honesty is the best approach with these patients. When the cause of the pain is not readily apparent, most patients appreciate a clinician’s efforts to work with specialists to integrate information and develop an individualized care plan.
Treating a chronic pain syndrome
A practical consequence of focusing on the pain rather than the sex is a change in the approach to treatment. Pain management is standard for chronic pain syndromes, and it is possible to apply strategies such as cognitive behavioral pain management,
to the treatment of sexual pain. In every other type of recurrent pain with muscle involvement, relieving muscle tension through stretching, massage, and relaxation provides some relief; sexual pain is no different. When conservative measures fail, vestibulectomy is an excellent surgical option that has been shown to reduce the pain 2-fold compared with biofeedback and cognitive-behavioral therapy.
Characteristics of pain patients
Epidemiological data reveal that 15% of women have experienced pain during intercourse in the last 6 months.
Four groups of women are particularly prominent among sexual pain patients. The first is women in their 20s and 30s. These women are particularly distressed about experiencing sexual pain because of the effect the pain has on establishing their sexual lives.
Perimenopausal and postmenopausal women comprise the second group of women among whom sexual pain is particularly prevalent. Traditionally, dyspareunia during the menopausal period has been attributed to declining estrogen levels. A decrease in estrogen can cause urogenital atrophy and vaginal dryness, leading to pain during penetration. The standard treatment has been to recommend use of lubricants or estrogen therapy. Unfortunately, lubricants often are inadequate and some women are reluctant to use estrogen. Furthermore, a significant number of women derive no benefit from lubricants or estrogen.
Recent reports suggest that the link between urogenital atrophy and pain is weaker than once thought.
Research is beginning to go beyond the physiologic changes to consider other factors of the menopausal transition, such as potential changes in sexual life, partner, work, and self-image. Ongoing investigations at the Sex and Couple Therapy Service of McGill University Health Center are examining hormonal status, physical status, psychological status, partner interactions, and medical history in 200 menopausal women. Preliminary data suggest several interesting trends. First, postmenopausal women, some of whom have urogenital atrophy, describe their pain the same way the young women do: superficial pain that meets the criteria for provoked vestibulodynia. About 15% of these women report having had pain prior to menopause, yet most say that their clinician never asked when the pain began, simply assuming that it started with menopause. Based on this, there is cause to believe that there is a variety of premenopausal and postmenopausal pain syndromes; there is no reason for variation to stop just because menopause begins.
A third group of interest in the study of dyspareunia is postpartum women, 9% of whom continue to experience pelvic or genital pain 1 year after giving birth.
They too describe their pain as burning, cutting, or radiating and report sexual and nonsexual triggers. Of the women surveyed, none were receiving treatment for their pain, indicating that postpartum dyspareunia is underrecognized among clinicians.
Finally, a fourth group might be premenopausal women, ages 35 to 50, who have deep or chronic pelvic pain.
Many patients become quite frustrated by practitioners who cannot provide an explanation for or are dismissive of their sexual pain. Experience has shown how easy it is to find young women to participate in sexual pain studies, which is an unfortunate testament to the prevalence of sexual pain, and an important reminder to be attentive to such complaints.
Reflecting shifts in understanding sexual pain, the DSM-IV planning committee is rewriting the criteria for all sexual dysfunctions and considering proposals for new definitions of dyspareunia and vaginismus. Much remains to be understood about sexual pain syndromes, and additional research is needed to differentiate among types of pain. However, it is already clear that shifting the focus from arousal and trauma to pain can improve treatment and increase patient satisfaction.
Dr Binik has received grant/research support from Pfizer Canada and has served as a consultant to Boehringer Ingelheim.
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Sexuality, Reproduction & Menopause
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