M.M. ter Kuile

Vaginismus and dyspareunia : is there a difference in clinical presentation ?

The purpose of this exploratory study was to identify clinical similarities and differences in patients with vaginismus and dyspareunia. Thirty patients who were referred to an outpatient clinic for psychosomatic gynecology and sexology, with either of these two diagnoses, were investigated by means of a standardized interview, physical examination and self-rating questionnaires. Based on the interview, no significant differences were demonstrated between patients with vaginismus and dyspareunia, in the ability to insert a finger into the vagina or to have a gynecological examination. No differences were found in the reported level of pain during coitus (or attempted coitus), inserting one finger into the vagina, or during gynecological examination. Patients with vaginismus, however, more often reported that coitus was impossible. The physical examination and self-rating questionnaires showed no differences at all between patients with vaginismus and dyspareunia in palpated vaginal muscular tension and reported anxiety or tension during the examination. Moreover, in both groups redness and painful areas on the vulva were equally common. Redness and pain on the same location were more frequently present in the dyspareunia group. Patients with dyspareunia reported higher levels of pain during the examination. In conclusion, neither the interview nor the physical examination produced useful criteria to distinguish vaginismus from dyspareunia. A multi-axial description of these syndromes is suggested, rather than viewing them as two separate disorders.

Objective assessment of sexual arousal in women with a history of hysterectomy

Objective  The potential contribution of psychological and anatomical changes to sexual dysfunction following hysterectomy is not clear. Radical hysterectomy for cervical cancer causes surgical damage to the autonomic nerves which are responsible for the increased vaginal blood flow during sexual arousal. Simple hysterectomy causes more limited nerve disruption. Photoplethysmographic assessment of vaginal pulse amplitude objectively measures vaginal blood flow during sexual arousal. We hypothesised that damage of the autonomic nerves results in a disrupted vaginal blood flow response during sexual stimulation.

Vaginal blood flow after radical hysterectomy with and without nerve sparing. A preliminary report

Radical hysterectomy with pelvic lymphadenectomy (RHL) for cervical cancer causes damage to the autonomic nerves, which are responsible for increased vaginal blood flow during sexual arousal. The aim of the study of which we now report preliminary data was to determine whether a nerve-sparing technique leads to an objectively less disturbed vaginal blood flow response during sexual stimulation. Photoplethysmographic assessment of vaginal pulse amplitude (VPA) during sexual stimulation by erotic films was performed. Subjective sexual arousal was assessed after each stimulus. Thirteen women after conventional RHL, 10 women after nerve-sparing RHL, and 14 healthy premenopausal women participated. Data were collected between January and August 2006. The main outcome measure was the logarithmically transformed mean VPA. To detect statistically significant differences in mean VPA levels between the three groups, a univariate analysis of variance was used. Mean VPA differed between the three groups (P= 0.014). The conventional group had a lower vaginal blood flow response than the control group (P= 0.016), which tended also to be lower than that of the nerve-sparing group (P= 0.097). These differences were critically dependent on baseline vaginal blood flow differences between the groups. The conventional group follows a vaginal blood flow pattern similar to postmenopausal women. Conventional RHL is associated with an overall disturbed vaginal blood flow response compared with healthy controls. Because it is not observed to the same extent after nerve-sparing RHL, it seems that the nerve-sparing technique leads to a better overall vaginal blood flow caused by less denervation of the vagina.

Difficulties in the Differential Diagnosis of Vaginismus, Dyspareunia and Mixed Sexual Pain Disorder

This retrospective study was undertaken to investigate predictors of vaginismus, dyspareunia and mixed sexual pain disorder in respect of symptom profile and treatment history variables of female patients and their partners. The study sample consisted of 147 female patients attending a university hospital outpatient clinic for Psychosomatic Gynecology and Sexology. All patients met the DSM-III-R criteria of the diagnoses of vaginismus (n = 50), dyspareunia (n = 46), or of both diagnoses (n = 51). No univariate differences were found between members of the three groups or between their partners. It was not possible to make a multivariate prediction of group membership.

The sexual and physical abuse questionnaire (SPAQ): a screening instrument for adults to assess past and current experiences of abuse

OBJECTIVE We reconstructed and validated a simple questionnaire to be completed by adult respondents for the assessment of sexual and physical abuse during childhood and later life, the Sexual and Physical Abuse Questionnaire (SPAQ). METHOD The criterion validity of the questionnaire was investigated in a population of psychiatric outpatients (n = 134) using the Structured Trauma Interview [Am. J. Psychiatr. 156 (1999) 379] as gold standard for the assessment of sexual and physical abuse. RESULTS All questionnaires were returned fully completed. The measures of agreement and the predictive measures of the questionnaire were satisfactory, in particular with respect to experiences of sexual abuse. Positive answering of the questionnaire increased the odds for sexual abuse by a factor of 12-17.5, and negative answering of the questionnaire reduced the odds by a third. The odds for physical abuse were increased by a factor of 8 with positive answering of the questionnaire, and reduced by a third with negative answering. CONCLUSION The questionnaire may be a useful screening instrument in research and in clinical practice to assess sexual abuse during childhood and later years. As a screening instrument for physical abuse it is less satisfactory.

Evidence for associations among somatoform dissociation, psychological dissociation, and reported trauma in patients with chronic pelvic pain

This study investigates somatoform as well as psychological dissociation, somatization and reported trauma among patients with chronic pelvic pain (CPP). Women with CPP (n = 52) who were newly referred to a gynecology department, or whose pain had resisted treatment, completed standardized self-report questionnaires and received a structured interview for DSM-IV dissociative disorders. The prevalence of dissociative disorders in the sample was very low. As hypothesized, self-reported somatoform dissociation was positively correlated with self-reported psychological dissociation and features of DSM-IV dissociative disorders; women who reported more serious psychic trauma, in particular sexual and physical abuse, experienced more somatoform and psychological dissociation than women reporting less trauma, or no trauma at all; and the association of somatoform dissociation and reported trauma was stronger than the association of psychological dissociation and trauma. Physical abuse/life threat posed by a person predicted somatoform dissociation best. The results are consistent with findings among psychiatric patients, and, therefore, strengthen the thesis that somatoform dissociation, (features of) dissociative disorder, and reported trauma are strongly intercorrelated phenomena.

Impaired sexual function in women with systemic sclerosis: A cross‐sectional study

OBJECTIVE To compare sexual functioning and distress in women with systemic sclerosis (SSc) with that in healthy controls and determine the association between disease characteristics and sexual function. METHODS We conducted a cross-sectional study of 69 women with SSc (ages 18-60 years) and 58 healthy, age-matched controls. Assessment included the Female Sexual Function Index (FSFI), Female Sexual Distress Scale (FSDS), Hospital Anxiety and Depression Scale, Short Form 36 health survey, sociodemographic characteristics, and in patients only, the Health Assessment Questionnaire. RESULTS Of 69 eligible patients with SSc, 37 (54%) responded, in addition to 37 (64%) of 58 controls. The FSFI total score and the subscale scores for lubrication, orgasm, arousal, and pain were significantly lower and the FSDS scores were significantly higher in patients with SSc. Longer disease duration and higher levels of marital dissatisfaction were significantly associated with low sexual function in patients with SSc. Longer disease duration, more depressive symptoms, and the use of antidepressants were significantly associated with sexual distress. Multivariate analyses indicated that marital distress was the only variable significantly associated with low sexual function in patients with SSc (beta = 0.40, P < 0.05), whereas depression was the only variable significantly associated with sexual distress (beta = 0.32, P < 0.05). The same pattern of associations was found in the healthy control group. CONCLUSION Women with SSc reported significantly impaired sexual functioning and more sexual distress then healthy controls. Impaired sexual functioning and sexual distress were associated with marital distress and depressive symptoms. These results indicate that in daily practice, inquiring about sexuality and screening for depressive symptoms is indicated in every patient with SSc, irrespective of their clinical characteristics.

Feasibility and effects of a decision aid about fertility preservation

Abstract This paper reports on the feasibility and preliminary effects of a decision aid (DA) about female fertility preservation (FP). We conducted a pilot multicentre randomized controlled trial of women with breast cancer aged 18–40 who were randomized to brochures or the DA. Over 18 months, 62 women were eligible, of which 42 were invited by their healthcare provider (74%) to participate in the study. A total of 36 women signed up for participation and 26 (72%) were randomized to brochures (n = 13) or the DA (n = 13). In both groups, many women (87%) read the brochures and eight women used all available brochures. In the intervention group, 7/13 women logged in to the DA. Women who received brochures had slightly less decisional conflict, whereas knowledge improved in both groups. Our results indicate that both brochures about FP and a detailed DA have beneficial effects with regard to knowledge, but the DA seemed to introduce slightly more decisional conflict (DC) than the brochures. Although we encountered challenges with recruitment, our design and measurements seem feasible and the effects of the information materials seem promising, hence justifying conducting a larger study.

Nociceptive and stress hormonal state during abdominal, laparoscopic, and vaginal hysterectomy as predictors of postoperative pain perception

The primary objective of this study is to compare pain perception during and after surgery between abdominal hysterectomy (AH), laparoscopic hysterectomy (LH), and vaginal hysterectomy (VH). The secondary objective of this study is to investigate whether pain indicators during surgery predict pain perception and demand for analgesics postoperatively. Prospective observational analysis of intraoperative nociceptive state (by means of pulse transit time; PTT), heart rate, and stress hormone levels (adrenalin and noradrenalin) were correlated with postoperative pain scores and stress hormone levels and demand for postoperative analgesics such as morphine. Intraoperative PTT levels and perioperative and postoperative stress hormone levels did not differ significantly between AH, LH, and VH. During the first hours postoperatively, LH patients showed insignificant lower pain scores, compared to AH and VH. One day postoperatively, LH patients reported significantly lower pain scores. High intraoperative stress hormone levels predicted a significant higher demand for morphine postoperatively, accompanied with significant higher pain scores. No differences were found with respect to intraoperative pain indicators well as pain perception during the first hours after surgery between AH, LH, and VH. If VH is not applicable, LH proves to be advantageous over AH with respect to a faster decline in pain scores.

Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain

Abstract Background and aims Chronic vulvovaginal pain is strikingly common and has a serious impact on women’s lives. Nevertheless, there are few longitudinal studies focusing on mechanisms involved in the pain development. One area of interest is how women cope with sexual activities and how this affects their pain. In this study, avoidance and endurance coping behaviors were explored as possible mediators of the relation between catastrophizing and pain, cross-sectionally and longitudinally. Methods 251 women (18-35 years old) with vulvovaginal pain were recruited in university settings and filled out questionnaires about their pain, catastrophizing and coping behaviors at two occasions, with five months in between. Multiple mediation models were tested, exploring avoidance and endurance as mediators of the relation between catastrophizing and pain. Results The results showed that avoidance was an influential mediator of the link between catastro¬phizing and pain. Using multiple mediation models we found that although the indirect effects of both avoidance and endurance were significant cross-sectionally, only avoidance was a significant mediator in the combined model exploring associations over time. Conclusions This study indicates that the strategies women with vulvovaginal pain use for coping with sexual activities are important for the course of pain. Avoidance and, to a lesser degree, endurance strate¬gies were identified as important mediators of the effects of catastrophizing on pain. When exploring the links over time, only avoidance emerged as a significant mediator. Implications In this longitudinal study, catastrophizing was linked to vulvovaginal pain, via avoidance and endurance of sexual activities. Hence, targeting catastrophizing early on in treatment, as well as addressing coping, may be important in clinical interventions.