Willibrord C. M. Weijmar Schultz

Women's sexual pain disorders

INTRODUCTION Womens sexual pain disorders include dyspareunia and vaginismus and there is need for state-of-the-art information in this area. AIM To update the scientific evidence published in 2004, from the 2nd International Consultation on Sexual Medicine pertaining to the diagnosis and treatment of womens sexual pain disorders. METHODS An expert committee, invited from six countries by the 3rd International Consultation, was comprised of eight researchers and clinicians from biological and social science disciplines, for the purpose of reviewing and grading the scientific evidence on nosology, etiology, diagnosis, and treatment of womens sexual pain disorders. MAIN OUTCOME MEASURE Expert opinion was based on grading of evidence-based medical literature, extensive internal committee discussion, public presentation, and debate. Results. A comprehensive assessment of medical, sexual, and psychosocial history is recommended for diagnosis and management. Indications for general and focused pelvic genital examination are identified. Evidence-based recommendations for assessment of womens sexual pain disorders are reviewed. An evidence-based approach to management of these disorders is provided. CONCLUSIONS Continued efforts are warranted to conduct research and scientific reporting on the optimal assessment and management of womens sexual pain disorders, including multidisciplinary approaches.

Vaginal plethysmography in women with dyspareunia

We investigated by means of vaginal plethysmography the extent to which the genital reactions of women with dyspareunia (N = 18) differed from those of women without dyspareunia (N = 16) during sexual arousal. In addition, we used questionnaires to investigate whether the genital reaction was correlated with the womens subjective experience of sexual arousal. In both groups, there was a clear increase in vaginal vasocongestion while they watched various erotic scenes compared with the situation at rest. While participants watched video fragments showing oral sex (cunnilingus and fellatio), the reactions were the same across the two groups. While participants watched video fragments showing coitus, there was a further increase in vaginal vasocongestion in the women without dyspareunia, but a decrease in vasocongestion in women with dyspareunia. The results of questionnaires assessing their perceived levels of sexual arousal while watching the video fragments showed that this reduction in genital response ...

Tibolone and transdermal E-2/NETA for the treatment of female sexual dysfunction in naturally menopausal women: Results of a randomized active-controlled trial

INTRODUCTION There are some data to suggest that tibolone improves sexual function in postmenopausal women. However, evidence about the effects of tibolone on female sexual dysfunction is lacking. AIM To compare the efficacy on sexual function of tibolone 2.5 mg to continuous combined transdermal estradiol (E2)/norethisterone acetate (NETA) (50 microg/140 microg) in naturally postmenopausal women with sexual dysfunction. MAIN OUTCOME MEASURE Differences between treatment groups in the change from baseline for the composite subscore of the arousal, desire, and satisfaction domains of the self-reported Female Sexual Function Index (FSFI). METHODS A multicenter, double-blind, randomized, clinical trial was performed. Sexual function was assessed with the FSFI at baseline, week 12, and week 24. The outcomes of the Female Sexual Distress Scale (FSDS) and the frequency of satisfying sexual events (daily diaries) were secondary end points. RESULTS Four hundred three women, mean age 56, were included. Both therapies improved sexual function assessed by the FSFI. In the per protocol analysis, but not in the intent-to-treat analysis, the increase in FSFI scores was significantly larger in the tibolone group when compared with the E2/NETA patch group at week 24 (P = 0.036 and P = 0.025 for the composite subscore and total FSFI score, respectively). The satisfying sexual event rate increased from three to four times per 28 days at week 24 (P < 0.001 from baseline for both groups), with no difference between groups. The FSDS showed a significant decrease from baseline (P < 0.001), which was comparable for both treatment groups. CONCLUSIONS Both treatments resulted to improved overall sexual function, as determined by scores on the FSFI, an increase in the frequency of sexual events, and a reduction in sexuality-related personal distress. The statistically significant higher FSFI scores in the tibolone group, when compared to the E2/NETA group, may be because of tibolones combined estrogenic and androgenic properties.

Sexual functioning of people with rheumatoid arthritis: a multicenter study

The objective of this study is to compare men and women with rheumatoid arthritis (RA) to controls regarding sexual motivation, activity, satisfaction, and specific sexual problems, and to determine the correlation of physical aspects of the disease with sexual functioning. Questionnaire for screening sexual dysfunctions (QSD), self-constructed questionnaire on experienced distress with joints during sexual activities, arthritis impact measurements scales 2 (AIMS2), and the modified disease activity score 28 (DAS 28) were the methods used. RA patients were recruited from a registration base in three Dutch hospitals. Controls were age and sex matched healthy volunteers. A completed questionnaire was sent back by 271 patients (response 23%). Forty-seven men and 93 women were clinically examined to obtain the DAS 28. Male patients felt less sexual desire, and female patients masturbated and fantasized less than controls. Differences in satisfaction were not found. Male and female patients did not experience more sexual problems than controls. Among the women, correlations were predominantly found between age and sexual motivation and activities, among the men between physical health and sexual problems. Up to 41% of the men (4–41 depending on the joints), and up to 51% of the women (10–51 depending on the joints) have troubles with several joints during sexual activities. Medications influencing ejaculation in men correlated with distress with orgasm. Conclusions are that patients are less sexually active than controls and a considerable number of both male and female patients have trouble with their joints during sexual activities. However, patients do not differ from controls regarding sexual satisfaction. Physiological changes due to RA are apparently independent from those on psychological level. It is argued that sexual satisfaction also depends on personal and social factors. In men, physical health and disease activity are more related with sexual problems than in women.

Psychosexual functioning after the treatment of cancer of the vulva - a longitudinal-study

Ten couples, the women beginning treatment for carcinoma of the vulva, participated in a 2‐year longitudinal study on sexual functioning before and after treatment. Sexual functioning was measured on admission and at 6, 12, and 24 months posttreatment. Sexual functioning was made operational in terms of current sexual behavior, sexual motivation, sexual (dis)satisfaction, and the perception of genital sensations of sexual arousal. An age‐matched nonpatient control group was added to the study and the impact of physical variables was also evaluated. Within 1 year, all women who were sexually active before the treatment had resumed their sexual activities. At the 6‐month assessment an increase in relational sexual dissatisfaction could be detected. Over the remaining observation period the womens satisfaction with sexual interaction with the partner was not found to be different from their pretreatment satisfaction and not different from the satisfaction in the control group, in spite of the physical damage and persisting poor perception of genital symptoms of sexual arousal during lovemaking. Satisfaction with sexual interaction with the partner under these circumstances appears to be more an expression of satisfaction with the intimate aspects of the sexual relationship than of satisfaction with the physiologic arousal aspects of the sexual relationship. It is argued that psychological and social variables are more crucial for sexual rehabilitation than physical variables. Therefore, psychosocial issues constitute the most promising focus for intervention.

Long-term results of an individualized, multifaceted, and multidisciplinary therapeutic approach to provoked vestibulodynia.

INTRODUCTION Although it is highly recommended to use a multifaceted approach to treat provoked vestibulodynia (PVD), the large majority of treatment studies on PVD used a one-dimensional approach. AIM To evaluate the long-term treatment outcome of a multifaceted approach to vulvar pain, sexual functioning, sexually related personal distress, and relational sexual satisfaction in women with PVD. METHODS Retrospective questionnaire survey 3-7 years after treatment. MAIN OUTCOME MEASURES Sexual functioning, sexually related personal distress, and relational sexual satisfaction were measured using the Female Sexual Function Index (FSFI), the Female Sexual Distress Scale (FSDS), and the Dutch Relationship Questionnaire (NRV), respectively. An additional questionnaire assessed socio-demographic variables, intercourse resumption, and the level to which the women would recommend the treatment to other women with PVD. Post-treatment vulvar pain scores were obtained using a visual analog scale (VAS). Pretreatment scores were reported in retrospect on a separate VAS. RESULTS The questionnaires were completed by 64 out of 70 women (91%). Mean follow-up was 5 years (range 3-7). Comparison of the mean pretreatment and post-treatment VAS scores showed a significant reduction in vulvar pain. Pain reduction was reported by 52 women (81%), whereas no change and pain increase were reported by 7 women (11%) and 5 women (8%), respectively. Post-treatment, 80% of the women had resumed intercourse. Only 5 women (8%) reported completely pain-free intercourse. Comparisons with age-related FSFI and FSDS Dutch norm data showed that scores for sexual functioning in the study group were significantly lower, while scores for sexually related personal distress were significantly higher. There were no significant differences in relational sexual satisfaction ratings between the study group and the NRV Dutch norm data. CONCLUSION These retrospective data on long-term treatment outcome support the hypothesis that a multifaceted approach to PVD can lead to substantial improvements in vulvar pain and the resumption of intercourse.

FSD PHARMACOTHERAPY: Tibolone and Transdermal E2/NETA for the Treatment of Female Sexual Dysfunction in Naturally Menopausal Women: Results of a Randomized Active-Controlled Trial

INTRODUCTION There are some data to suggest that tibolone improves sexual function in postmenopausal women. However, evidence about the effects of tibolone on female sexual dysfunction is lacking. AIM To compare the efficacy on sexual function of tibolone 2.5 mg to continuous combined transdermal estradiol (E2)/norethisterone acetate (NETA) (50 microg/140 microg) in naturally postmenopausal women with sexual dysfunction. MAIN OUTCOME MEASURE Differences between treatment groups in the change from baseline for the composite subscore of the arousal, desire, and satisfaction domains of the self-reported Female Sexual Function Index (FSFI). METHODS A multicenter, double-blind, randomized, clinical trial was performed. Sexual function was assessed with the FSFI at baseline, week 12, and week 24. The outcomes of the Female Sexual Distress Scale (FSDS) and the frequency of satisfying sexual events (daily diaries) were secondary end points. RESULTS Four hundred three women, mean age 56, were included. Both therapies improved sexual function assessed by the FSFI. In the per protocol analysis, but not in the intent-to-treat analysis, the increase in FSFI scores was significantly larger in the tibolone group when compared with the E2/NETA patch group at week 24 (P = 0.036 and P = 0.025 for the composite subscore and total FSFI score, respectively). The satisfying sexual event rate increased from three to four times per 28 days at week 24 (P < 0.001 from baseline for both groups), with no difference between groups. The FSDS showed a significant decrease from baseline (P < 0.001), which was comparable for both treatment groups. CONCLUSIONS Both treatments resulted to improved overall sexual function, as determined by scores on the FSFI, an increase in the frequency of sexual events, and a reduction in sexuality-related personal distress. The statistically significant higher FSFI scores in the tibolone group, when compared to the E2/NETA group, may be because of tibolones combined estrogenic and androgenic properties.

Vaginismus: Heightened Harm Avoidance and Pain Catastrophizing Cognitions

INTRODUCTION Catastrophic appraisal of experienced pain may promote hypervigilance and intense pain, while the personality trait of harm avoidance (HA) might prevent the occurrence of correcting such experiences. Women inflicted with vaginismus may enter a self-perpetuating downward spiral of increasing avoidance of (anticipated) pain. In vaginismus the anticipation of pain may give rise to catastrophic pain ideation. This may establish hypervigilance toward painful sexual stimuli, which consequently results in negative appraisal of sexual cues. This process could impair genital and sexual responding, intensify pain and trigger avoidance, which in turn may contribute to the onset and persistence of symptoms in vaginismus and to certain extent also in dyspareunia. AIMS To investigate whether women suffering from vaginismus are characterized by heightened levels of habitual pain catastrophic cognitions, together with higher levels of HA. METHODS This study consisted of three groups: a lifelong vaginismus group (N = 35, mean age = 28.4; standard deviation [SD] = 5.8), a dyspareunia group (N = 33, mean age = 26.7; SD = 6.8), and women without sexual complaints (N = 54, mean age = 26.5; SD = 6.7). MAIN OUTCOME MEASURES HA scale of Cloningers tridimensional personality questionnaire, and the pain catastrophizing scale. RESULTS Specifically women inflicted with vaginismus showed significantly heightened levels of catastrophic pain cognitions compared with the other two groups, as well as significant enhanced HA vs. the control group, and a trend vs. the dyspareunia group. Both traits were shown to have cumulative predictive validity for the presence of vaginismus. CONCLUSION This study focused on the personality traits of catastrophizing pain cognitions and HA in women with lifelong vaginismus. Our findings showed that indeed, women suffering from vaginismus are characterized by trait of HA interwoven with habitual pain catastrophizing cognitions. This study could help in the refinement of the current conceptualization and might shed light on the already available treatment options for women with vaginismus.

Anticonvulsant pharmacotherapy for generalized and localized vulvodynia: a critical review of the literature

Abstract Anticonvulsant therapy has occasionally been recommended to treat vulvodynia. However, convincing evidence to support this therapeutic option is lacking. The goal of this study was to critically review studies published on the effectiveness of anticonvulsants for the treatment of vulvodynia. Evaluation of the methodological quality of relevant publications was the main outcome measure. MEDLINE, PubMED and Cochrane were used to identify studies published in English between January 1999 and February 2013. Searches were performed between December 2012 and February 2013. Articles were appraised with the Oxford Centre for Evidence-Based Medicine – Levels of Evidence. Eight relevant studies were identified: two case reports, three retrospective studies, two non-randomized prospective studies and one open-label pilot trial study. Gabapentin formed the main focus (87.5%) to reduce vulvar pain; success rates ranged from 50 to 82%. Lamotrigine was used in one study (12.5%) to relieve symptoms; satisfaction was reported in 82%. These results seem promising, but the majority of studies have several methodological weaknesses regarding sample size and design. Insufficient evidence was available to recommend anticonvulsants for the treatment of vulvodynia. Further studies are necessary with double-blind, randomized-controlled designs to investigate the effectiveness of anticonvulsant therapy for vulvodynia.

Measuring posttraumatic stress following childbirth: a critical evaluation of instruments

Objectives. To evaluate instruments used to assess posttraumatic stress disorder (PTSD) following childbirth with both quantitative (reliability analysis and factor analysis) and qualitative (comparison of operationalization) techniques. Methods. An unselected population of 428 women completed the Traumatic Event Scale-B (TES-B) and the PTSD Symptom Scale-Self Report (PSS-SR) 2–6 months after delivery. Results. Assessment of internal consistency yielded similar results for the TES-B and PSS-SR (Cronbachs α = 0.87 and 0.82, respectively). Factor analysis revealed two rather than three DSM-IV symptom categories for both instruments: childbirth-related factors (re-experiencing/ avoidance) and symptoms of depression and anxiety (numbing/ hyperarousal). Although the TES-B and the PSS-SR sum-scores show a strong relationship (Spearmans ρ = 0.78), agreement between the instruments on the identification of PTSD cases is low (κ = 0.24); discrepancy between TES-B and PSS-SR is largely due to differences in instruction to respondents, formulation of items, answer categories, and cut-off values. Conclusions. Large operationalization differences between TES-B and PSS-SR have been identified, i.e., in the formulation of questions, answer categories, cut-off values and instructions to respondents. Comparison between studies using different instruments for measuring PTSD following childbirth should be done with utmost caution.