Vaginismus and Dyspareunia: differences and treatment
Cognitive interpretations such as attributions or beliefs about pain contribute to the increase in its intensity (Jodoin et al., 2011) and therefore play an important role in disorders such as vaginismus and dyspareunia.
Chronic pain problems involving the female reproductive system represent an important topic that affects women of all ages. Although there has been significant progress in the field, these pathologies are still poorly understood: only 60% of women actively seek treatment, and 52% of these do not receive a formal diagnosis (Harlow et al., 2014). Sexual pain, vaginismus, and dyspareunia disorders, which are now classified within DSM-5 as a single entity called genito-pelvic pain and penetration disorder (American Psychiatric Association, 2013), afflict according to estimates from 14 to 34% of young women and 6.5 to 45% of older women. (van Lankveld et al., 2010)
Although vaginismus and dyspareunia were both classified as sexual pain disorders within DSM-IV, they were differentiated by their main clinical characteristics. Dyspareunia was mainly characterized by genital pain during intercourse / penetration, which could be introital (located at the entrance of the vagina), deep (concerning the deep part of the vagina or the pelvis), or both (Graziottin, Gambini, 2017). In contrast, vaginismus was characterized by involuntary spasms of the vaginal muscle, strong enough to interfere with or prevent penetration. (Graziottin, Gambini, 2017; Perez et al., 2016)
Within clinical practice, however, the disorders often appeared in comorbidity, or were difficult to differentiate: negative expectations or fear of experiencing genital pain in dyspareunia, for example, could cause an involuntary contraction of the pelvic muscle making sexual intercourse difficult , and likewise the involuntary contraction of the pelvic muscle in vaginismus could cause genital pain during an attempted penetration. In addition, it was found that spasm of the vaginal muscle, the main feature of vaginismus, was not a valid and reliable criterion when it was tested empirically (Reissing et al., 2014; Perez et al., 2016) .
The current DSM-5 diagnostic criteria for genito-pelvic pain and penetration disorder (GPPPD) include persistent and recurring difficulties in one of the following areas, for at least 6 months and resulting in clinically significant distress: (1) vaginal penetration during the relationship; (2) marked vulvo-vaginal or pelvic pain during intercourse or vaginal penetration attempts; (3) marked fear or anxiety about pelvic or vulvo-vaginal pain before, during or as a result of vaginal penetration. (4) marked tension or contraction of the pelvic floor muscles during the attempted vaginal penetration.
The conceptual models of sexual pain present a multifactorial view, as empirical evidence suggests the existence of multiple etiological pathways, which lead to the development and maintenance of pain and the associated relational and psychosexual difficulties.
Recent studies show at least four possible pathways that can influence the risk of developing this disorder: (1) hormonal changes, (2) neurological changes, (3) chronic inflammation and (4) hypertonia of the pelvic floor muscles (Bouchard et al., 2002; Harlow et al., 2008). The onset could be triggered by physical / mechanical trauma in the genital area, resulting in inflammation, dysfunction of the pelvic muscles and other local changes that would lead to sensitization of nociceptors and other peripheral and central alterations of the pain processing process (Bergeron et al., 2011). Cognitive, behavioral, affective and interpersonal factors can modulate the experience of pain and the associated negative consequences,
Similarly to biological factors, the psychological factors involved in the etiology of the disorder are also multifactorial and varied. In a large-scale cross-sectional study, adolescent girls who experienced pain during intercourse most frequently reported a personal history of sexual abuse, fear of being sexually abused and trait anxiety (Bouchard et al., 2002). In the same study, teenagers who reported sexual abuse were more prone to report sexual pain than those who did not experience abuse (Landry, Bergeron, 2011). Using a case-control study, researchers sought to examine the role of psychosocial stressors in the etiology of sexual pain. Compared to women without the disorder, women with sexual pain experienced three times more serious physical or sexual abuse during childhood, or experienced a strong fear of being abused as girls (Khandker et al., 2014). In one study it was shown that vulvo-vaginal pain was four times more likely in women who had previously experienced a depressive or anxiety disorder, and that these disorders were also more present as a consequence of vulvar pain than healthy controls (Khandker et al., 2011).
Consistent with the biopsychosocial model, empirical evidence exists that indicates that cognitive interpretations such as attributions or beliefs about pain contribute to the increase in its intensity (Jodoin et al., 2011) and therefore have a great role in its management and modulation. Women with the disorder report higher levels of catastrophisation towards pain (i.e. an exaggerated and pessimistic perspective), compared to the healthy control sample (Payne et al., 2007; Pukall et al., 2002) and also show high levels of hypervigilance towards pain compared to a neutral stimulus. Higher levels of catastrophing, fear of pain, hypervigilance and low self-efficacy are correlated with greater pain, while higher levels of anxiety and avoidance are correlated with a higher level of sexual dysfunction. (Desrochers, et al. 2009).
As the disorder is experienced in sexual contexts, research has gradually focused on the role of relational factors. The partner’s response, the most studied of the relational factors, can be negative (hostility), worried or facilitating (affection and encouragement to the use of adaptive coping strategies). In cross-sectional studies, more facilitating partner responses were associated with less female sexual pain (Rosen et al., 2012) and better sexual functioning (Rosen, 2014), as well as greater couple, relationship and sexual satisfaction ( Rosen, 2015).
By contrast, greater negative and worried partner responses have been associated with greater pain (Desrosiers, 2008; Rosen, 2015) and greater depressive symptoms in women (Rosen, 2014), as well as lower sexual functioning and lower satisfaction relational and sexual. While facilitating responses promote the use within the couple of adaptive coping strategies and shared emotional regulation in the face of pain, the partner’s hostile or worried responses reinforce the avoidance of pain and sex and compromise coping and the regulation of emotions related to painful sensations. Greater ambivalence in emotional expression within the couple (one of the indicators of poor emotional regulation) has been associated with a reduction in functioning and sexual satisfaction (Awada, 2014). Additionally, studies that looked at partners’ pain cognitions showed that less pain catastrophing was related to a lower level of pain in women. In contrast, greater negative attributions to pain predicted greater distress within the couple, less sexual and relationship satisfaction, and higher levels of pain in women (Jodoin et al., 2008). studies that looked at partners’ pain cognitions showed that less pain catastrophing was related to a lower level of pain in women. In contrast, greater negative attributions to pain predicted greater distress within the couple, less sexual and relationship satisfaction, and higher levels of pain in women (Jodoin et al., 2008). studies that looked at partners’ pain cognitions showed that less pain catastrophing was related to a lower level of pain in women. In contrast, greater negative attributions to pain predicted greater distress within the couple, less sexual and relationship satisfaction, and higher levels of pain in women (Jodoin et al., 2008).
These studies highlight the different ways in which the beliefs and experiences related to pain in the partner can directly or indirectly influence the woman’s sexual pain, as well as conditioning the psychological, relational and sexual serenity within the couple.
Couples in whom the disorder is present are more prone to experience relational obstacles than other couples in the general population. For example, women with these symptoms have an insecure attachment style more frequently (Granot et al., 2011), and couples with symptoms report less sexual communication than healthy couples (Smith, Pukall, 2011; Pazmany, 2014). In contrast, less sexual communication and the presence of insecure attachment are associated with greater sexual suffering in women (Pazmany, 2015), less sexual functioning within the couple (Leclerc et al., 2014), and less relationship satisfaction. These studies underline the importance to be attributed to the dyadic context in which the symptom occurs.
The development and persistence of genito-pelvic pain disorder and penetration have been conceptualized in the form of a vicious circle, using the fear-avoidance model to explain the maintenance of pain (Basson, 2012).
An initial experience of pain produces anxious and catastrophic thoughts about pain and its meaning. These lead to somatic hyper-vigilance which amplifies all potentially negative sensations, increases the negative emotions associated with pain and the avoidance of sexual activity. Following this, there is a hypertonic response of the pelvic floor muscles, which increases the negativity of the experience. Pain prevents genital arousal, leading to less lubrication and painful penetration. Repeated experiences of sexual pain confirm the fear and necessity of hyper vigilance, contributing to the avoidance of vaginal penetration. Finally, avoidance of sexual activity prevents the disconfirmation of negative automatic thoughts (van Lankveld, 2006).
Cognitive behavioral therapy has been one of the most studied interventions for the treatment of genito-pelvic pain disorder and penetration (Goldfinger, 2016), and several studies have shown its effectiveness (ter Kulle, 2007; van Lankveld, 2006; Breton, 2008; Bergeron, 2016; Brotto, 2015; Goldfinger, 2016; Bergeron, 2001; Engman et al., 2010; Lofrisco, 2011; Ter Kuile, 2015). The main objectives of the therapy are cognitive distortions, emotional dysregulation and maladaptive behaviors that underlie the symptoms and disturb the couple’s relationship. (Bergeron, 2014). One of the key points of therapy is establishing realistic therapeutic goals: some examples are the reduction of pain from severe to moderate or mild; the reduction of muscle tension in the perineum / pelvis; the reduction of negative cognitions related to pain (less frequent catastrophic thoughts and the ability to consider situations that generate pain in a more positive way); positive coping (the ability to focus on the positive components of sexual experience); improvement of sexual functioning (exploration of sexual expressions that do not include penetration, and the ability to communicate one’s desires to the partner) (Engman, 2010).
The initial therapeutic approach consists in the couple’s psychoeducation (Dunkley, Brotto, 2016;). Neither the patient nor the partner should face the problem by taking a passive role: it is an opportunity to understand the problem, increase knowledge on female anatomy and dispel myths about sexuality. The couple should also be informed about the biopsychosocial nature of the disorder and the role of psychological and couple issues as trigger and maintenance factors (Weijenborg et al., 2009). The couple should also be made aware of behavioral strategies that can help reduce pain.
Another important goal in the initial approach to the disorder is anxiety reduction. It is not uncommon for the couple to be stuck in a circle of avoidance when they introduce themselves to the therapist: intimacy, discussion of the problem, search for solutions, and finally sexual activity. By the time they finally begin treatment, they are likely to feel anxious because it will be necessary to discuss the problem and then resume what they were actively avoiding: sex. It is important that the therapist is aware of this situation and positively reinforces the fact that the couple sought help. It is of fundamental importance to inform them that the therapy will focus on increasing desire, excitement and intimacy, and not on increasing the frequency of penetrations. Complete sexual intercourse is not a primary goal, but a consequence of successful treatment (Meana et al., 2017).
In a second stage of therapy, it is important that the therapist questions certain thoughts about sex that are common between couples. Two common cognitive distortions in women affected by the disorder, as previously mentioned, are hyper vigilance and pain catastrophization. Addressing these distortions is essential to reducing dysfunctional emotional reactions. Furthermore, the use of sexual fantasies should be encouraged, as positive sexual cognitions increase desire and arousal, which can increase lubrication and pleasure, and reduce pain.
The couple should also be encouraged to actively express their emotions and physically show affectivity. The goal is to disconnect physical affection from the anticipation of genital pain, reducing anticipatory anxiety. This can be achieved through the sensory focusing technique developed by Masters and Johnson and published in 1970 in their book Human Sexual Inadequacy. The aim is to gradually switch from non-genital caresses to genital caresses, and finally to penetration. At first, penetration is prohibited, which usually reduces the patient’s anxiety, allowing her to focus on pleasant bodily sensations. This gradual exposure to physical contact usually results in an increase in desire and arousal, and a reduction in pain.
Since contraction of the pelvic muscles is considered a response conditioned by fear, the use of exposure techniques is recommended (ter Kuile et al., 2007). It is also advisable to use progressively larger vaginal dilators (systematic desensitization), associated with a specific physiotherapy program (Dunkley, Brotto, 2016). The effectiveness of this intervention is mediated by the reduction of avoidance behavior and cognitive distortions, as well as by the increase in pain control (ter Kuile, 2015). At the end of the cognitive-behavioral treatment the anxiety levels in the woman are lowered, and in addition an increase of the couple’s harmony and an improvement of the general sexual satisfaction are obtained (Kabakci, Batur, 2003)