Recurrent pain during intercourse occurring for the first time within or sub- sequent to the menopausal transition is typically attributed to vulvovaginal and urogenital atrophy (also referred to as atrophic vaginitis) (83). These conditions are manifestations of tissue aging, cytological changes, and chemical trans- formations within the vagina, urethra, and bladder, which result from declining levels of endogenously produced estrogens at menopause (84,85). Both the DSM-IV-TR (3) and the ICD-10 (4) specifically mention this problem but do not classify it as dyspareunia. In the DSM-IV-TR, it would be termed a “sexual dysfunction due to a general medical condition,” whereas in the ICD-10, it is classified as “postmenopausal atrophic vaginitis.” These classi- fications and descriptions appear to be based on clinical experience since there is, in fact, very little systematic research evidence to support a strong link between declining estrogen levels, vulvovaginal atrophy, and recurrent pain during intercourse (86 – 88).
Regardless of etiology, many areas of these women’s lives must be addressed simultaneously in order to achieve therapeutic success. Once the pain is consis- tently present, a vicious cycle is put into motion (Fig. 10.2), involving physical, muscular, psychological, sexual, and relationship factors.
CURRENT TREATMENT STRATEGIES
As with classification and diagnostic approaches to dyspareunia, treatment approaches have historically adopted a similar dualistic approach by attempting to alleviate the pain via a variety of medical interventions, failing which, psychotherapy is recommended. Typical medical treatment is characterized by a focus on the vestibule to the exclusion of other systems that may be involved (e.g., pelvic floor musculature). In addition, current medical interventions have not incorporated empirically based treatments for dyspareunia, which have recently been published.
Figure 10.2 The vicious cycle of pain. Once the experience of pain is initiated (shown here as starting from a physical irritation) and continues without appropriate treatment, it begins to encompass many different factors, including physical, muscular, psychological, sexual, and sexual/relationship. The involvement of these different systems usually leads to increases in the amount of pain and distress experienced, and can explain pain mainten- ance in the absence of physical findings, as in most cases of dyspareunia and back pain. Although this figure indicates that the initiating symptom can evolve into a complex cycle, theoretically, the cycle can start at any point or at multiple points simultaneously.
Vulvar Vestibulitis Syndrome
Treatment for vestibulitis is typically guided by the medical model. This model follows a traditional strategy of starting with conservative, non-invasive treat- ments and progressing to more invasive ones (89). Palliative interventions (e.g., sitz baths) to reduce the pain are the first-line treatment choice for dyspa- reunia. If these are not effective, treatment progresses to topical interventions (e.g., lidocaine, corticosteriods), systemic medications (e.g., oral corticosteriods, antifungals), followed by injectable medical treatments (e.g., interferon), “neuro- physiological” treatments (e.g., biofeedback, pharmacotherapy), and ending with surgical intervention (e.g., vestibulectomy). However, there is little evidence to support the use of topical, systemic, or injectable treatments. Although one placebo-controlled study of the effectiveness of cromolyn cream (90) and one randomized trial of fluconazole (91) found these treatments to be ineffective for relieving the symptoms of vulvar vestibulitis, one study found that long-term lidocaine ointment application decreased pain scores and re-established sexual activity in a group of vestibulitis sufferers (92). Follow-up data and a randomized clinical trial are needed in order to fully assess the effects of this kind of treatment, as local and systemic medications, such as creams, antibiotics, and injectable medical treatments may cause more harm than benefit (5). In addition, there is no empirical evidence for the success of any medication, such as antidepressants, for the pain of vestibulitis.
Cognitive-behavioral interventions for vulvar vestibulitis syndrome include cognitive-behavioral pain management, sex therapy, and pelvic floor biofeedback to target both pain reduction and sexual functioning. Success rates ranging from
43% to 86% have been reported in two uncontrolled studies in which sex therapy and pain management were combined (93,94). In 1996, Weijmar Schultz et al. (95) published a prospective and partially randomized treatment outcome study investigating the effectiveness of behavioral intervention with or without surgery. Results from this study indicated that women in both groups benefited in terms of pain reduction, with no significant differences between women who had undergone the behavioral intervention alone vs. those who underwent the combined treatment of behavioral intervention and surgery. The authors suggest that the behavioral approach should be the first line of treatment for ves- tibulitis sufferers, with the surgery acting as an additional form of treatment for refractory cases.
Biofeedback training has been used in an effort to reduce hypertonicity of the pelvic floor muscles (61). With the aid of a vaginal sensor, the patient is provided with direct visual feedback regarding their level of muscle tension, facilitating muscle training with respect to contraction, relaxation, and the acquisition of voluntary control. After 4 months of training, subjective pain reports decreased an average of 83%, with 52% of the women reporting pain- free intercourse, and 79% of women who were abstaining from intercourse resuming activity posttreatment. However, this study contained a mixed group of women with vulvar pain and likely contained a high proportion of vaginismic women, considering that many participants were not engaging in intercourse at the beginning of the study. The effectiveness of physical therapy, which includes a pelvic floor biofeedback component in addition to soft tissue mobilization and other techniques specific to this treatment, has recently been evaluated in a retrospective study of vestibulitis sufferers (96). Results indicated that after an average of 16 months of treatment, physical therapy yielded a moderate to great improvement in over 70% of participants. Treatment resulted in significant pain reduction during intercourse and gynecological examinations, and increa- ses in intercourse frequency and levels of sexual desire and arousal. These findings indicate that physical therapy is indeed a promising treatment modality for women who suffer from vulvar vestibulitis syndrome, although prospective studies are needed.
Vestibulectomy has been the most investigated treatment for vulvar vestibulitis to date with over 20 published outcome studies, yielding success rates ranging from 43% to 100% (42). This minor surgical procedure, preformed as day surgery under general anesthesia, consists of the excision of the hymen and sensitive areas of the vestibule to a depth of 2 mm, with some procedures involving the mobilization of the vaginal mucosa to cover the excised area. Following this procedure, women are generally instructed to abstain from all forms of vaginal penetration for 6 – 8 weeks.
Our research group conducted a randomized treatment outcome study of vulvar vestibulitis comparing vestibulectomy, group cognitive-behavior therapy, and pelvic floor biofeedback (97). At posttreatment and 6-month follow-up, there was significant pain reduction for all three treatment groups. However, vestibulectomy resulted in approximately twice the pain reduction (47 – 70% depending on the pain measure) of the two other treatments (19 – 38%); it was characterized by a high success rate and by elevated percen- tages of pain reduction. In addition, there were significant improvements in overall sexual functioning and self-reported frequency of intercourse at the
6-month follow-up, with no treatment differences. However, means for inter- course frequency for all three groups remained below the mean frequency of intercourse for healthy women of similar age. In a 2.5-year follow-up of this study (98), members of all three treatment groups continued to improve over time. Vestibulectomy remained superior to the other two treatments with respect to pain ratings on the cotton-swab test, whereas women in the group therapy con- dition reported equal improvements in terms of self-report measures of painful intercourse. Changes in overall sexual functioning and intercourse frequency were maintained, with no group differences. These results suggest that although the benefits of group therapy may take longer to appear, it can be just as effective as surgery in reducing the pain experienced during intercourse.
Alternative treatments for vulvar vestibulitis syndrome include acupuncture and hypnotherapy. Although few studies currently exist, there are promising data regarding the effect of acupuncture on pain reduction and overall quality of life (99). In addition, a recently published case study indicated that hypnosis reduced pain and helped re-establish sexual pleasure (100). Randomized controlled trials are needed in order to truly establish the effectiveness of these treatments. Alternative treatments seem promising, yet to date, only cognitive- behavioral therapy, biofeedback, and vestibulectomy have been empirically validated. It is also likely that concurrent treatment with multiple non-invasive methods may be even superior to single treatments, though this has yet to be investigated.
Little information exists with respect to validated treatments for vulvodynia. McKay (13) recommends low-dose amitriptyline for symptom control in vulvodynia. This treatment is effective for neuropathic pain syndromes (101), which have a similar pain presentation to vulvodynia. Glazer (102) reported that pelvic floor muscle rehabilitation reduced pain and improved sexual functioning in vulvodynia sufferers. However, no randomized controlled trials have been conducted with respect to any treatment for vulvodynia. Despite the lack of knowledge concerning valid treatments for this condition, there is much agreement that it should be multidisciplinary (5,80,81).
Postmenopausal dyspareunia is considered a major indicator for hormonal treatment (103). If nonhormonal vaginal lubricants, such as Replens, are not ade- quate, then estrogen-based creams or estradiol inserts in ring or tablet format are often recommended. In principle, systemic estrogen-based hormone replacement therapy may also be prescribed. Significant reduction of urogenital atrophy can be obtained through estrogen supplementation, which may, in turn, provide the context for improvements in sexual functioning (104). Presently, evidence from randomized controlled trials is tenuous regarding the benefit of hormone replacement for dyspareunic pain (105). Beyond alleviating symptoms of urogenital atrophy that may subsequently lead to sexual impairment, hormonal supplementation has not been found to substantially contribute to postmeno- pausal sexual functioning (104 – 106).
Major confusion exists in the literature with respect to the nomenclature and classification of dyspareunia. The DSM-IV-TR classifies idiopathic dyspareunia as a sexual dysfunction (3), whereas the ICD-10 (4) distinguishes between organic and psychogenic dyspareunia, neither of which are explicitly defined. In addition, the current nomenclature with respect to dyspareunia subtypes is confusing and fails to clearly differentiate among the various conditions (16). We suggest that a careful characterization of the pain associated with these con- ditions will clarify this diagnostic labeling confusion and help to unify the field. Throughout this chapter, we have established the complexity of dyspareunia and how this class of disorders can affect a woman’s life on multiple physiological, emotional, cognitive, and interpersonal levels. Given the large prevalence of women suffering from dyspareunia, it is essential for primary health care provi- ders to become familiar with these conditions and to establish collaborations with other health professionals in order to provide their patients with multidisciplinary treatment options.
Given the physiological, cognitive, affective, and interpersonal complexity of dyspareunia, it is likely that no one “cure” for dyspareunia or for other chronic pain conditions will be found. Thus, we propose a multimodal treatment approach for all types of urogenital pain discussed in this chapter, tailored to each patient, and including careful assessment of the different aspects of the pain experience. Clinicians should also educate their patients as to the multi- dimensional nature of chronic pain so that the treatment of so-called psychologi- cal or relationship factors is not experienced as invalidating. Although pain reduction is an important goal, sexual functioning should also be worked on simultaneously through individual or couple therapy, as it has been shown that pain reduction does not necessarily restore sexual functioning (97).
Further research is needed to further examine the pain component of dyspareunia using standardized tools in an effort to more fully understand the mechanisms involved in the development and maintenance of this painful and disruptive condition. Currently, we are investigating the effects of sexual arousal on genital and nongenital sensation, baseline measures of vestibular blood flow through thermal and laser Doppler imaging techniques, and sensitivity to body-wide pressure in women with vulvar vestibulitis syndrome. We hope to extend these research avenues to include the examination of women suffering from vulvodynia and postmenopausal dyspareunia in the near future. In addition, our research group is presently conducting a randomized treatment outcome study of women with vestibulitis, examining the effects of pain relief therapy compared with typical medical treatment. Future treatment outcome studies will include the investigation of the effects of physical therapy, as well as combined treatments, in an effort to develop and implement effective treatment strategies for the numerous women suffering from dyspareunia.