Best Practice & Research Clinical Obstetrics and Gynaecology 28 (2014) 991e999

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

Psychosexual aspects of vulvovaginal pain

Sophie Bergeron, PhD, Associate Professor a, *,
Wendy M. Likes, PhD, Associate Professor b,
Marc Steben, MD, Associate Professor, Associate Physician c
a
Department of Psychology, Universit
e de Montr
eal, Montr

eal, Qu

ebec, Canada
b
College of Nursing, College of Medicine, Department of Ob-gyn, University of Tennessee Health Science
Center, Memphis, TN, USA
c
Department of Social and Preventive Medicine, Faculty of Medicine, Universit
e de Montr

eal, STI unit,
Institut national de sant

e publique, Montr
eal, Qu

ebec, Canada

Keywords:
Vulvovaginal pain problems are major health concerns in women
vulvovaginal pain of childbearing age. Controlled studies have shown that vulvova-
vulvodynia ginal pain can adversely affect women and their partners' general
provoked vestibulodynia psychological well-being, relationship adjustment, and overall
psychological adjustment quality of life. These women have significantly lower levels of
sexual function sexual desire, arousal, and satisfaction, as well as a lower inter-
cognitiveebehavioral therapy course frequency than normal controls. They also report more
anxiety and depression, in addition to more distress about their
body image and genital self-image. Empirical studies indicate that
specific psychological and relationship factors may increase vul-
vovaginal pain intensity and its psychosexual sequelae. Random-
ized clinical trials have shown that psychosexual interventions,
namely cognitiveebehavioral therapy (CBT), are efficacious in
reducing vulvovaginal pain and improving associated psychosex-
ual outcomes. Women reporting significant psychological, sexual,
and/or relationship distress should be referred for psychosexual
treatment. A multimodal approach to care integrating psychosex-
ual and medical management is thought to be optimal.
© 2014 Elsevier Ltd. All rights reserved.

* Corresponding author. Sophie Bergeron, Department of Psychology, Universite
de Montre
al, C.P. 6128, Succursale Centre-
Ville, Montre
al, Que

bec H3C 3J7, Canada. Tel.: þ1 514 343 6111 5353; Fax: þ1 514 343 2285.
E-mail address: [email protected] (S. Bergeron).

http://dx.doi.org/10.1016/j.bpobgyn.2014.07.007
1521-6934/© 2014 Elsevier Ltd. All rights reserved.
992 S. Bergeron et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 28 (2014) 991e999

Vulvovaginal pain problems are major health concerns in women of all ages. As conditions that are
often misdiagnosed, mismanaged, trivialized, or ignored, they entail a great personal cost to patients
and a significant financial cost to society [1]. A case in point is vulvodynia: a population-based study
suggests that the lifetime cumulative incidence of vulvodynia is 16% [2,3] and its incidence is thought
to be increasing in young women [4,5]. In fact, many women suffering from vulvovaginal pain are
under the age of 30, with community estimates showing that one in five women aged 18e29 report
chronic dyspareunia [6]. In addition to disrupting all aspects of sexual function, controlled studies have
shown that vulvovaginal pain can adversely affect women and their partners' general psychological
well-being, relationship adjustment, and overall quality of life [7,8]. Because of their deleterious impact
on sexuality and romantic relationships, vulvovaginal pain problems may indeed carry a heavier
psychosocial burden in comparison to other pain problems common in women, with many patients
reporting feelings of shame, inadequacy, and low self-esteem [9]. Further, up to 45% of women with
vulvodynia report a comorbid-pain condition, and having a comorbidity is associated with increased
feelings of isolation and invalidation [10]. In terms of help-seeking behaviors, epidemiological results
indicate that only 60% of women who report chronic vulvovaginal pain seek treatment, and 40% of
these never receive a formal diagnosis [5]. A recent study involving a community sample showed that
women saw an average of five physicians before diagnosis [10]. The quality of health care received by
this patient population is thus less than optimal. It has been suggested that a multimodal approach
taking into account not only the biomedical components of vulvovaginal pain but also its psychosexual
aspects may constitute a promising avenue for managing this complex and multifaceted pain problem,
as exemplified by the recent recommendations of the Third International Consultation on Sexual
Medicine relating to women's sexual pain disorders [11].

Psychological, sexual, and relationship consequences

Women with vulvovaginal pain show important impairments in many life domains, primarily their
sexuality, intimate relationships, and mental health. Specifically, controlled studies have shown that
they report significantly less sexual desire, arousal, and satisfaction, more difficulty reaching orgasm, as
well as lower frequencies of intercourse and more negative attitudes toward sexuality than pain-free
controls [12]. Research conducted in laboratory settings indicates that there are no significant differ-
ences between women with vulvovaginal pain and non-afflicted women relative to their physiological
level of sexual arousal when exposed to an erotic stimulus, although women with pain tend to report
more negative feelings toward the stimulus [13e15]. Both quantitative and qualitative studies show
that many women with vulvovaginal pain also report negative changes in their sexual self-esteem and
in their body image, such as feeling less sexually desirable, feeling less confident about their sexuality,
and feeling less feminine than before [16e19]. Specifically, a study conducted among a community
sample of 330 women showed that, in comparison to pain-free controls, women with vulvovaginal
pain reported significantly more distress about their body image and a more negative genital self-
image. Moreover, a more negative genital self-image was strongly and independently associated
with an increased likelihood of reporting vulvovaginal pain, above and beyond anxiety [20]. In the
same community sample of women with vulvovaginal pain, worse self-image cognitions about vaginal
penetration contributed uniquely to increased pain intensity, whereas worse self-image cognitions
about vaginal penetration and genital self-image contributed to poorer sexual functioning. Finally,
worse self-image cognitions about vaginal penetration, body image, and genital self-image each
contributed independently to increased sexual distress [21]. These findings suggest that body image
and genital self-image are significantly poorer in women with vulvovaginal pain and may influence key
pain and sexuality outcomes.
Although there appear to be no differences in relationship satisfaction between women with
vulvovaginal pain and asymptomatic controls, and no association between relationship satisfaction
and pain in women with vulvovaginal complaints [22], this intimate pain nonetheless puts a sig-
nificant strain on romantic relationships. Indeed, the fear of losing one's partner is noted across
samples of women with vulvovaginal pain [23,24]. It thus may come as no surprise that most afflicted
women choose to continue engaging in vaginal penetration despite the pain and the limited satis-
faction they derive from this sexual activity [25]. The question of why women continue to have sex
 S. Bergeron et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 28 (2014) 991e999 993

despite vulvovaginal pain was asked to a group of sexually active young women and adolescents.
Four reasons emerged: resignation, sacrifice, guilt, and the motivation to behave in a manner
consistent with the notion of the ideal woman [26]. This situation may also become quite distressing
for the partner, who may feel as though he is an incompetent lover and who may at times wonder
whether he might be partly responsible for the pain. This may further complicate the dynamics of the
relationship. In a study involving 38 vulvodynia couples, men's higher levels of both internal and
global attributions for the pain e that is, thinking that the pain is their fault and that it affects all life
domains e were associated with their poorer relationship satisfaction, whereas global and stable
attributions e thinking that the pain will never go away e were related to their lower sexual
satisfaction [8].
As for mental health, several controlled studies involving clinical samples and using a wide variety
of measures of depressive symptomatology have shown that women with vulvovaginal pain have
higher depression scores than pain-free controls [16,25,27,28], although three other controlled studies
were unable to detect such a difference [12,13,29]. These contradictory findings could be attributed to
the use of community samples in the latter studies, which typically report less distress. Many
controlled studies have also found that these women display more state and trait anxiety than pain-
free controls [30e32]. Further, there is evidence suggesting that anxiety may decrease the level of
physiological sexual arousal in this population [15]. In summary, vulvovaginal pain results in several
psychosexual sequelae, many of which require targeted interventions. Empirical work to date also
suggests that specific psychosexual factors may maintain and exacerbate the different dimensions of
vulvovaginal pain.

Psychosocial precursors/maintenance factors

To date, controlled research has shown that compared to asymptomatic controls, women with
vulvovaginal pain report more anxiety [28,30,31,33], depression [16], and pain catastrophizing.
Higher levels of hypervigilance to pain, fear of pain, and catastrophizing have been found to be
significant predictors of increased pain in this population, whereas greater anxiety and avoidance are
associated with poorer sexual function. In addition, lower levels of pain self-efficacy, or the belief in
one's capacity to meet the challenges of managing pain, are related to both worse pain and sexual
function [34].
Three studies provide some evidence suggesting that psychosocial factors may contribute to the
development of persistent vulvovaginal pain. A population-based survey of adult women found that
sexual, physical, and psychological abuse was linked to a four- to sixfold increased risk of reporting
vulvodynia in adulthood [32,35]. Another large-scale cross-sectional study focusing on adolescent
girls with pain during intercourse showed that they reported significantly more sexual abuse and
fear of physical abuse than controls [32]. Further, a community-based study showed that the odds of
vulvodynia were four times more likely among women with antecedent depression or anxiety
compared to women without [36]. However, because this area of research is still in its infancy, most
works to date have been cross-sectional. Nonetheless, taken together, findings highlight the
importance of environmental variables in the development of idiopathic vulvovaginal pain and
indicate that psychosocial factors may contribute to the persistence of the pain and its associated
negative sequelae.
Pain during intercourse is not limited to the woman's experience, but occurs in a relational
context. In a first study on the dyadic aspects of provoked vestibulodynia conducted with 43
couples, greater partner solicitousness, that is, demonstrations of sympathy, but also greater
partner hostility, that is demonstrations of anger, were significantly associated with higher levels of
pain during intercourse, suggesting that partner responses, both positive and negative, may play a
role in the experience of vulvovaginal pain [37]. Results from a larger cross-sectional study of 191
couples indicated that higher solicitous partner responses e assessed from the perspective of both
the woman and partner e were associated with higher levels of women's pain intensity. Further-
more, the associations were mediated by greater patient and partner pain catastrophizing and self-
efficacy [38,39]. In fact, partner pain catastrophizing and self-efficacy directly predicted patient
pain, suggesting that the partner's view of the pain may modulate patient symptomatology [40].
994 S. Bergeron et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 28 (2014) 991e999

Lower negative partner responses were also associated with more sexual satisfaction in women,
and this association was mediated by greater dyadic adjustment [38,39]. Another study with a
sample of 121 couples showed that facilitative partner responses e defined as partner responses
that encourage a patient's efforts at adaptive coping with the pain (e.g., decreased avoidance) e
were associated with lower vulvovaginal pain and higher sexual satisfaction [41]. Facilitative re-
sponses may be fostered in a targeted couple intervention by helping couples to focus on less
painful activities, on the emotional benefits of sexual activity, and on expressing affection and
pleasure during or after sexual activity.
Rosen et al. (in press) recently completed a 2-month daily diary study involving 69 heterosexual
couples coping with vulvodynia [42]. They found that a woman's pain during intercourse increased on
days when she perceived greater solicitous and negative partner responses, and when her male partner
reported greater solicitous and lower facilitative partner responses. A woman's sexual functioning and
satisfaction increased on days when she perceived greater facilitative and lower solicitous and negative
partner responses, and when her male partner reported lower solicitous responses. Further, a man's
sexual functioning and satisfaction decreased on days when he reported greater solicitous and negative
responses. These findings highlight the influence of partner-perceived variables on women's pain and
sexual experience, as well as the impact of PVD on male partners' sexuality. To summarize, research
findings have consistently shown that facilitative responses yield positive couple outcomes and should
be fostered in an intervention, whereas solicitous and negative partner responses lead to negative
outcomes and should be reduced.
Other recent research on relationship variables and vulvovaginal pain has focused on attachment,
emotion regulation, and intimacy. Attachment theory can provide a useful framework for under-
standing how couple dynamics may influence the experience of vulvovaginal pain and associated
psychosexual difficulties. Attachment patterns are constructed within early interactions with primary
caregivers [43]. Recent studies indicate that romantic attachment patterns are closely linked to sexual
thoughts, emotions, and behaviours [44,45]. In a study involving 116 couples in which the women
presented with provoked vestibulodynia, both anxious (anxiety about rejection) and avoidant
(avoidance of intimacy) attachment styles were associated with women's lower sexual satisfaction.
Attachment avoidance was associated with women's lower sexual function. Interestingly, women's
sexual assertiveness was found to be a significant mediator of the relationship between their attach-
ment styles, sexual function, and satisfaction. This suggests that anxious and avoidant attachment may
limit women's ability to be assertive in their sexuality, and that this lack of assertiveness may in turn
lead to less satisfying sexual activities for these couples [46].
Indeed, how couples communicate about the vulvovaginal pain problem and its resulting negative
consequences on their sex life could have an impact on their degree of adaptation to this challenge. A
study conducted among 254 couples in which the woman suffered from vulvovaginal pain showed
that those who had low ambivalence concerning the expression of their emotions, that is, couples
who were the most comfortable with their level of expressiveness, had higher sexual satisfaction and
sexual function, less depressive symptoms, and better dyadic adjustment [46]. This suggests that an
emotional regulation that is low in ambivalence for both members of the couple may promote better
psychological, sexual, and relational outcomes for women and their partners, possibly by facilitating
their sharing about intimate aspects of the vulvovaginal pain problem and its impact on their
sexuality.
Intimacy is another relationship variable that could help couples navigate the challenge of vul-
vovaginal pain. In a sample of 91 women diagnosed with provoked vestibulodynia and their partners,
women's reported greater sexual intimacy was associated with women's increased sexual satisfac-
tion and higher pain self-efficacy, beyond the effects of partners' sexual intimacy. In addition,
women's reported greater sexual intimacy and women's greater relationship intimacy were asso-
ciated with their increased sexual function, beyond the effects of partners' sexual and relationship
intimacy [47].
Taken together, findings concerning the psychosocial correlates of vulvovaginal pain suggest that
the context within which this pain is experienced does matter. How women and their partners think,
feel, and communicate about this pain influences the extent to which they can adapt to it, reduce its
intensity, and maintain a healthy sex life and relationship despite it.
 S. Bergeron et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 28 (2014) 991e999 995

Psychosexual interventions

The goals of most psychosexual interventions are to help patients view their vulvovaginal pain
as a multidimensional problem influenced by a variety of factors including thoughts, emotions,
behaviors, and couple interactions; modify those factors associated with vulvovaginal pain with a
view to increasing adaptive coping and decreasing pain intensity; improve the quality of their
sexual functioning, including sexual desire which is often significantly low in this population,
steering the focus away from intercourse while developing a more positive attitude toward other
pleasurable sexual activities; and reduce avoidance of physical intimacy by working with their
fear of pain. Mental health professionals working with these women also aim to facilitate
adherence to other treatment regimens or procedures, such as gynecological examinations or
physical therapy.
Sex therapy and behavioral pain management combined together have been reported as successful
in two studies focusing on dyspareunia, although these did not include control groups [48,49]. In the
first randomized trial focusing on a psychological intervention for vulvovaginal pain, Bergeron et al.
(2001) randomly assigned women with provoked vestibulodynia to a group cognitiveebehavioral
therapy (CBT) intervention, biofeedback, or vestibulectomy. While findings indicated that vestibulec-
tomy resulted in significant decreased pain outcomes among participants compared to the other two
treatments, all three interventions showed equally enhanced sexual function and psychological
adjustment outcomes. Treatment gains associated with CBT for PVD were maintained at 6-month and
2.5-year follow-ups for improvements in both pain and sexual functioning [50]. More importantly,
women assigned to CBT did not differ from those assigned to vestibulectomy at the 2.5-year follow-up
on the main outcome measure e pain during intercourse e prompting us to further investigate CBT.
Posttreatment results from a second randomized trial show that women in the group CBT were
significantly more satisfied with their treatment, displayed significantly less pain and pain cata-
strophizing, and reported significantly better global improvements in pain and sexual functioning than
women assigned to a topical corticosteroid condition. These findings suggest that CBT may yield a
positive impact on more dimensions of PVD than do some first-line medical treatments. Nevertheless,
one limitation of these trials is that women's sexuality, although improved, remained within the
clinical range of sexual dysfunction. This may be due to the fact that the partners were not involved.
Another randomized trial examining the efficacy of individual CBT for vulvar pain compared to a
supportive psychotherapy demonstrated that CBT yielded significantly greater improvements in pain
and sexual function from pre- to posttreatment, with gains maintained at 1-year follow-up [51]. The
results of this study suggest a potential benefit for greater treatment outcome and patient satisfaction
with a more directed approach such as CBT [51].
A systematic review of PVD treatment studies concluded that because behavioral treatments
yield comparable success to several medical interventions but with no negative side effects, CBT
represents an encouraging noninvasive option that can target pain as well as psychosexual con-
sequences experienced by the woman and her partner [52]. However, CBT has been investigated
successfully in a group and in an individual format, but never in a couple format for PVD, which is
the most common and recommended way that CBT for sexual dysfunction is delivered in clinical
settings.

How to identify women who need psychosexual counseling

Women who report significant sexual impairment, sometimes to the point of abstaining from all
partnered sexual activities, may need more than a medical intervention to surmount the vicious cycle
of pain and avoidance that they are caught in. Significant depressive and anxiety symptoms, which
would be verbalized as discouragement, not seeing the light at the end of the tunnel, and feeling like a
hopeless case, also warrant a psychological assessment and possibly psychotherapy combined with
medical treatment. Anger at health-care professionals, although expected and understandable to some
degree, may constitute another red flag when displayed at more intense and sustained levels despite
the repeatedly empathic stance of the caregiver. Significant relationship difficulties also need to be
addressed in couple therapy, especially since they may interfere with ongoing treatment, for example,
996 S. Bergeron et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 28 (2014) 991e999

in the case of a partner who sabotages the woman's efforts at improving her condition, or simply does
not support her in any way. In addition, women with preexisting relationship or sexual difficulties
could be in need of couple therapy to cope with the added burden of pain. Finally, women who have
tried multiple treatments and have not benefited from any single intervention, or women who have
experienced many negative side effects from a medical treatment or complications from surgery, may
have underlying psychological predispositions that prevent them from deriving all the positive effects
typically associated with a given modality. Indeed, higher levels of pretreatment pain catastrophizing
and lower pretreatment levels of pain self-efficacy have been shown to predict, at 6 months post
treatment, worse outcomes following both CBT and a topical application [53]. Certain personality traits
or attachment difficulties could also make it more difficult for some patients to develop a trusting
relationship with their health-care provider, which is thought to be a key ingredient of any successful
treatment, particularly in the context of a multimodal approach [54].

A multidisciplinary approach to care

There are only two published studies evaluating a multimodal approach to the treatment of vul-
vovaginal pain, both of which involved psychosexual counseling and pelvic floor rehabilitation in
addition to the usual medical care provided by a physician or nurse. In their uncontrolled, prospective
investigation, Backman, Widenbrant, Bohm-Starke, and Dahlof [55] found that 67% of 24 participants
reported occasional or mild pain at the 6-month follow-up, while 63% reported a major improvement
in their sexual function. Using a retrospective questionnaire survey 3e7 years post treatment, Spoel-
stra, Dijkstra, van Driel, and Weijmar Schultz [56] showed that 80% of women had resumed intercourse
and 81% reported pain reduction, although only 8% reported completely pain-free intercourse. These
findings are encouraging and suggest the need for more empirical work aimed at assessing the efficacy
of an integrated approach to care.
From a clinical standpoint, the advantages of this model are numerous and often include an
accelerated, more focused treatment process, less patient resistance to any one single biomedical or
psychosocial intervention, more motivated and persistent patients and health-care providers,
increased coherence among the various health disciplines involved, and multiple facets of vulvovaginal
pain being targeted simultaneously [57].
Nonetheless, despite its high prevalence, health professionals trained in the treatment of vulvo-
vaginal pain are a rarity in some large cities of developed countries, let alone in rural areas and in other
parts of the world, making patient access to a multimodal approach to care often difficult, if not
altogether impossible. Telemedicine and e-interventions show promise in reaching remote pop-
ulations of women. Self-help groups may also provide patients with the much-needed support and
serve to disseminate knowledge among themselves. In summary, there is a strong need for more in-
tegrated health-care services addressing the psychosexual dimensions of vulvovaginal pain, in order
for a larger proportion of afflicted women and couples to break out of their isolation and to receive the
care and pain relief they deserve.

Summary

Vulvovaginal pain has a significant negative impact on the sexual function and psychological
adjustment of afflicted women and their partners. Cross-sectional and daily diary studies show that
specific psychological factors can modulate pain and psychosexual sequelae. Individual variables
include higher pain catastrophizing, hypervigilance to pain, fear of pain, anxiety and avoidance, and
lower pain self-efficacy. Interpersonal factors include spouse solicitous and negative responses,
poorer sexual and relationship intimacy, anxious and avoidant attachment styles, and higher
ambivalence over emotional expression. There is growing evidence that CBT e a treatment targeting
these different psychological factors e can effectively reduce vulvovaginal pain and associated
psychosexual difficulties. Combining this type of care with concurrent medical management is
thought to represent the most optimal model for treating vulvovaginal pain and the significant
distress that it generates in patients and their partners, although this model has not been validated
empirically.
 S. Bergeron et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 28 (2014) 991e999 997

Practice points

 Women with vulvovaginal pain show significantly more psychological distress and sexual
dysfunction than normal controls.
 Women with antecedent anxiety, depression, and/or sexual abuse may be more at the risk of
developing vulvovaginal pain.
 Psychological and relationship factors modulate pain and associated psychosexual
difficulties.
 Cognitiveebehavioral therapy is an effective treatment for vulvovaginal pain.
 Including the partner in any type of treatment for vulvovaginal pain can make a difference in
key patient outcomes.

Research agenda

 Randomized clinical trials to test the efficacy of couple cognitiveebehavioral therapy and of a
multimodal approach to care.
 Predictors and mediators of psychosexual treatment outcomes.
 Daily diary and prospective designs to identify temporal patterns of relations between psy-
chosocial factors, pain, and psychosexual difficulties.
 Longitudinal research in community samples of prepubescent girls followed up through
adulthood to test hypothesized causal relations between childhood trauma, hypothalamo-
pituitary-adrenal axis dysregulation, and vulvovaginal pain.

Conflict of interest statement

None declared.

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