Mary Jane Minkin

A randomized clinical trial for women with vulvodynia: Cognitive-behavioral therapy vs. supportive psychotherapy

Abstract Many treatments used for women with vulvodynia are based solely upon expert opinion. This randomized trial aimed to test the relative efficacy of cognitive‐behavioral therapy (CBT) and supportive psychotherapy (SPT) in women with vulvodynia. Of the 50 participants, 42 (84%) completed 10‐week treatments and 47 (94%) completed one‐year follow‐up assessments. Mixed effects modeling was used to make use of all available data. Participants had statistically significant decreases in pain severity (p’s < 0.001) with 42% of the overall sample achieving clinical improvement. CBT, relative to SPT, resulted in significantly greater improvement in pain severity during physician examination (p = 0.014), and greater improvement in sexual function (p = 0.034), from pre‐ to post‐treatment. Treatment effects were well maintained at one‐year follow‐up in both groups. Participants in the CBT condition reported significantly greater treatment improvement, satisfaction and credibility than participants in the SPT condition (p’s < 0.05). Findings from the present study suggest that psychosocial treatments for vulvodynia are effective. CBT, a directed treatment approach that involves learning and practice of specific pain‐relevant coping and self‐management skills, yielded better outcomes and greater patient satisfaction than a less directive approach.

Assessing Sexual Function and Dyspareunia with the Female Sexual Function Index (FSFI) in Women with Vulvodynia

Using the Female Sexual Function Index (FSFI; Rosen et al., 2000), we assessed forty-two women with vulvodynia. Internal consistency was high (Cronbachs alphas = 0.90–0.97) for all scales. We compared scale scores to published healthy and patient sample data and found very large effect sizes (1.15–2.83), which indicated that women with vulvodynia reported significantly worse overall sexual function than women without sexual dysfunction and greater pain with sexual intercourse than women with female sexual arousal disorder. Results highlight difficulties experienced across all domains of sexual function, particularly with regard to dyspareunia, for women with vulvodynia. Findings also support the internal consistency and discriminant validity of the FSFI.

Sexually transmitted infections and the aging female: Placing risks in perspective

Gynecological literature is replete with multiple papers on sexually transmitted infections (STIs) in young women. Although those past the reproductive prime may well be at lower risk for STIs than women in the peak reproductive years, STIs are regularly seen in the older cohort and are a cause for significant morbidity and distress. Care givers reluctantly approach or are outright amiss in assessing sexual health of their aging patients, nor is this population adequately counseled regarding practices of safe sex. Sexuality among the aging population, safe behaviors, and diagnostic challenges of STIs in an older cohort are herein discussed.

Improved compliance and patient satisfaction with estradiol vaginal tablets in postmenopausal women previously treated with another local estrogen therapy

Up to half of all postmenopausal women will experience changes in the genitourinary tract induced by the hypoestrogenic state, collectively known as vaginal atrophy. Vaginally administered local estrogen therapy (LET) is the standard of care for symptoms of vaginal atrophy that do not respond to nonhormonal interventions. Several LET formulations are available, and choice of therapy is based largely on patient needs and preferences. This online survey of postmenopausal LET users was conducted to investigate reasons for switching to vaginal estradiol tablets from other formulations and to evaluate factors associated with patient preference for and compliance with use of LET. Data was analyzed from 73 respondents currently using estradiol vaginal tablets who have previously used the estradiol vaginal ring, estradiol vaginal cream, and/or conjugated estrogen vaginal cream. Patients in this survey rated vaginal symptoms of vaginal atrophy as being more bothersome than urinary symptoms. Respondents preferred their current treatment with the vaginal tablet to their previous treatment with a cream or ring. The preference for tablets over creams was mainly related to formulation and application rather than to any perceived safety issues. Tablets were perceived as efficacious, convenient, and neat to apply. The study participants also reported a longer duration of tablet use compared with creams or rings, and greater compliance with vaginal tablets than with vaginal cream. This study provides new insights into reasons for patient noncompliance with estrogen cream or ring therapy that can be used to maximize patient adherence with LET.

Prevalence of postmenopausal symptoms in North America and Europe.

Objective:This study aims to evaluate differences and similarities in the prevalence of postmenopausal symptoms and their impact on postmenopausal women and male partners of postmenopausal women in North America and Europe. Methods:The Internet-based survey Clarifying Vaginal Atrophys Impact on Sex and Relationships (CLOSER) was conducted in North America and Europe. The questionnaire included questions on symptoms experienced by women after menopause and the impact of these symptoms overall and specifically on emotional and physical relationships. This study included 8,200 respondents: 4,100 were postmenopausal women who had experienced vaginal discomfort and 4,100 were male partners of postmenopausal women with this symptom. Differences were significant at the 95% level of confidence. Results:The survey identified vaginal dryness, hot flashes, night sweats, disrupted sleep, and weight gain as the top five symptoms experienced by postmenopausal women in North America and Europe. Overall, symptoms were found to be more prevalent in women from the United States, United Kingdom, and Canada (P < 0.05), and less prevalent in women from Sweden and Italy compared with other countries. In regards to the impact of symptoms overall and on emotional and physical relationships, the greatest number of women from the United States, United Kingdom, and Canada found the impact to be “worse than expected.” Conclusions:The impact of postmenopausal symptoms on relationships is greater in women from countries where symptoms are more prevalent. Postmenopausal women and male partners of postmenopausal women may benefit from greater education about menopause and open discussions with their healthcare provider.

Postmenopausal vaginal atrophy: evaluation of treatment with local estrogen therapy

Postmenopausal vaginal atrophy, resulting from decreased estrogen production, frequently requires treatment. Estrogen preparations provide the most effective treatment; local application is preferred to systemic drugs when treating only vaginal symptoms. As local estrogen therapies have comparable efficacy, this study aimed to understand treatment practices, assess experiences with different forms of local estrogen-delivering applicators, and evaluate satisfaction. Women who were US residents aged ≥18 years, menopausal (no spontaneous menstrual period for ≥1 year or with a double oophorectomy), and receiving local estrogen therapy for 1–6 months (vaginal cream [supplied with a reusable applicator] or vaginal tablets [supplied with a single-use/disposable applicator]), completed an online questionnaire. Data from 200 women (100 cream users and 100 tablet users; mean therapy duration 3.48 months) showed that most stored medication in the room in which it was applied (88%) and applied it at bedtime (71%), a procedure for which cream users required, on average, more than twice the time of tablet users (5.08 minutes versus 2.48 minutes). Many cream users applied larger-than-prescribed amounts of cream, attempting to achieve greater efficacy (42%), or lower-than-recommended doses (45%), most frequently to avoid messiness (33%) or leakage (30%). More tablet users (69%) than cream users (14%) were “extremely satisfied” with their applicator. Postmenopausal women using local estrogen therapy were generally more satisfied with the application of vaginal tablets than cream. Patient satisfaction may help to facilitate accurate dosing. Positive perceptions of medication will help to optimize treatment, which, although not assessed in this study, is likely, in turn, to improve vaginal health.

Sexuality, Sexual Dysfunction, and Menopause

A 55-year-old postmenopausal woman complains of complete sexual disinterest. We have taken care of her for many years. She had a fairly uneventful menopause, with some vasomotor symptoms (VMS); her last menstrual period was 4 years ago. The vasomotor symptoms are mostly resolved at this point. She has been married for 30 years; she has two children who have both graduated from college and are out of the house. She is a high school teacher in the neighboring town. Upon investigating her brother, she does note that once she starts participating in sexual activities (or as she states, “once she gets going”), she gets interested, but she could care less about “getting going in the first place.” She has recently heard about a new medication, which she has heard referred to as “the female Viagra,” and has also recently read an article on the promise of testosterone for sexual health in women. She is coming in to ask whether we thought that might help her situation. Her physical examination is unremarkable except for evidence of vulvovaginal atrophy (VVA), which is a significant change since her last exam a year prior. Her vagina now shows pallor and a loss of rugae. When we checked her vaginal pH, it is now 5.5.

A Randomized Clinical Trial for Women With Vulvodynia : Cognitive-Behavioral Therapy vs. Supportive Psychotherapy

Vulvodynia is a difficult-to-treat gynecological disorder that has received little mention in the medical literature. Major complaints by women with vulvodynia include chronic vulvar pain, sexual dysfunction, and emotional distress. Treatment of this disorder has been largely based on expert opinion. One psychological intervention, cognitive-behavioral therapy (CBT), emphasizes a self-management approach and has been associated with significant reductions in pain severity, disability, and affective distress in a few uncontrolled and randomized controlled clinical trials. In this randomized controlled trial, the investigators evaluated the efficacy of CBT for the treatment of vulvodynia in comparison to supportive psychotherapy (SPT), a less directive psychological intervention. Of the 50 participants randomized to a CBT group (n = 25) or a SPT group (n = 25), 42 (84%) completed the treatments, and 8 (16%) dropped out. Ninety-six percent of the remaining participants completed immediate posttreatment evaluation and 94% completed the 6- and 12-month follow-up evaluations. Women in the CBT group were taught self-management skills that alter thoughts, feelings, and behaviors, whereas those in the SPT group were treated by nondirective talk therapy lacking specific behavioral interventions. An equal number of treatments were administered in 10 weekly individual 60-minute sessions to each group. The pain outcome was assessed by physician ratings or self-reports of participants. Sexual and emotional function was assessed only by the participants. Mixed effects modeling was used to assess changes over time in outcomes. At the end of the treatment sessions, pain severity was significantly reduced on self-reports in both treatment groups and in physician ratings (P < 0.05 for all). Participants in the CBT group reported a greater improvement in overall sexual functioning than those in the SPT group (P < 0.017). Compared to baseline values, several parameters of emotional function were improved in both treatment groups (P < 0.05 for all). Among all participants, improvements in pain severity, sexual function, and emotional function were maintained or continued to improve to the 1-year follow up. Participants in the CBT group reported significantly greater satisfaction and more credibility for the treatment than those in SPT group (P < 0.05 for all). Although both CBT and SPT appear to be effective psychosocial treatments for vulvodynia, these findings indicate that CBT, a directed self-management behavioral approach, is associated with better pain and sexual function outcomes, and greater patient satisfaction than SPT, a less directed nonbehavioral approach.

Protect yourself from malpractice suits

There are many areas in the practice of gynecology that can lead to malpractice lawsuits for a practitioner who is not careful, even if he or she practices good medicine. Potential risks include failure to diagnose cancer, not following up with patients, failure to thoroughly check test results, and not keeping proper documentation. The cautious physician will attend to every problem that a patient presents, make sure that patients follow instructions, keep meticulous documentation, and always follow up to make sure his or her patient is progressing well.