Dyspareunia Dyspareunia, one of the most common types of sexual dysfunction seen by gynecologists, affects some two-thirds of women during their lifetime. Both psychological and physical factors are involved—the mind being able to powerfully modulate both immune and neurological systems, causing objective changes in the latter. The gynecologist’s assessment of dyspareunia needs to be holistic: biological, psychological, and sexual (Fig. 11.4).
There are three aspects to the management of dyspareunia: 1.
Assisting the couple to have rewarding sexual intimacy even if intercourse initially is precluded 2.
Identifying the psychological issues contributing to and arising from the chronic pain 3.
Treating, whenever possible, the underlying pathophysiology that triggered the chronic pain circuits
It is helpful to clarify that the popular depiction of sex as foreplay followed by “real sex” (i.e., intercourse) is not the reality for many sexually satisfied couples. The couple can be encouraged to consider the many varieties of human sexual interaction and ways of giving and receiving genital and nongenital sexual pleasure. It is important for the couple to see removal of intercourse from the menu of sexual activity as an opportunity for more exploration and creativity, and not as a loss. Inclusion of the partner in the assessment and evaluation of chronic dyspareunia allows his feelings to be addressed and his compliance with nonpenetrative sex encouraged. The couple rendered emotionally distant because of chronic dyspareunia may find it difficult to adapt to alternative forms of lovemaking.
Provoked Vestibulodynia PVD is defined as pain on vestibular touch (from tampon, examining finger, penis, tight seam on clothing, etc.) where physical findings are limited to variable (possibly absent) vestibular erythema and the presence of allodynia (feeling a burning pain from the touch
Descending excitation?
Descending inhibition?
Tricyclics, sensory nerves
WBC releaseIncreased afferent input cytokines tryptase,from hypertonic pelvic bradykinin, stimulatingmuscles sensory nerves
Cromolyn, lidocaine
Figure 11.4 Schematic of proposed pathophysiological mechanisms underlying the chronic pain of vulvar vestibulitis syndrome and therapeutic interventions. WBC, white blood cells.
stimulus) on localized areas around the outer edge of the hymen and inner edge of the labia minora where the two meet. The whole introital circumference may be affected: typically the lower part (lower horseshoe or 4 to 8 o’clock location) is involved along with the areas immediately around the openings of Skene’s ducts. Typically pelvic muscle tone is heightened. This is the most common cause of dyspareunia seen in clinics, with at least 50% of women reporting lifelong symptoms and others acquiring them after possibly multiple occasions of painless intercourse. PVD is considered a chronic pain syndrome, with features suggesting both central and peripheral sensitization within the nervous system. This means that there are physical changes within the nervous system that perpetuate the pain cycles, and these can be targeted both by medications (chronic pain drugs) and mind skills including CBT and mindfulness. The cause of the sensitization within the nervous system is not established with certainty, but internal stress appears to be a likely cause. Women with PVD report higher levels of perfectionism, reward dependency, fear of negative evaluation, and harm avoidance, higher levels of trait anxiety, and shyness (55). Higher rates of depression and anxiety disorders are found in women with PVD compared to controls. Women with PVD have more catastrophic thoughts about intercourse pain and the negative consequences on the partner and durability of the relationship than women with other types of dyspareunia (55). There is evidence of hyper-vigilance for pain. Many women with PVD have other pain syndromes such as irritable bowel syndrome, temporomandibular joint pain, interstitial cystitis, dysmenorrhea, and, especially for midaged women, fibromyalgia (55).