Provoked vestibulodynia (PVD) needs holistic management and a chronic pain approach

Dr. Rosemary Basson (biography and disclosures)

Frequently asked questions I’ve noticed

How to manage provoked vestibulodynia (PVD) is an extremely common question. PVD affects 12 -15 % women most of whom are relatively young.^[1] Medical treatments including anti-seizure drugs, tri-cyclic anti-depressants, topical anaesthetics, calcium channel inhibitors and bo-tox are similar or less effective than placebo^{[2, 3, 4]} and pelvic muscle physiotherapy although beneficial is usually insufficient. Vestibulectomy, rarely performed in BC, is offered in some centres but with strict exclusion criteria^[5].

Symptoms include burning dyspareunia or pain with other penetrative sex, post-coital burning and post-coital dysuria. A cotton swab test of the vestibule identifies the allodynia (pain from a non-painful touch stimulus), diagnostic of PVD. Intercourse may have been painless in the past or pain may begin with first intercourse (or tampon) attempt. Some women give histories of “vaginismus” with major fear of penetration, but subsequently develop the allodynia of PVD. Thus some women with PVD have never been able to have intercourse. Estrogen deficiency related atrophy and PVD may co-occur.^[6]

Data that answer these questions

The common co-morbidity of PVD^[7] with irritable bowel syndrome (IBS), temporo-mandibular joint syndrome, interstitial cystitis and severe dysmenorrhea in adolescence plus the finding of decreased pain thresholds elsewhere in the body^[8] strongly supports a chronic pain approach. The demonstrated central sensitization of the CNS,^[9]  possible genetic vulnerability^[10], along with high stress (i.e., allostatic load),^[11] underlie current conceptualizations of PVD.^[12] Past anxiety disorders and major depression are eleven and four times more common in women with acquired PVD as compared to controls.^[13] Stress and/or mood may not only maintain but trigger the changes of central sensitization.^[14]

As medications have minimal benefit for PVD, non-pharmacological approaches are needed. There is ongoing benefit from cognitive behavioral therapy (CBT)^[12]: controlled study of 50 women showed CBT to be superior to supportive psychotherapy.^[15] Of 78 women randomized to vestibulectomy, EMG biofeedback or group CBT, 51 were able to be followed for 36 months. Long-term improvements in dyspareunia in this subsample were similar for the CBT and surgical groups (both superior to EMG biofeedback).^[16]  Our experience, in line with that of support groups confirms only a small minority of women in clinical settings consider surgery to be an option.^[17] CBT incorporates cognitive interventions that encourage change (e.g., identification and challenging of catastrophizing thoughts women have about their pain, sexuality and often their relationships, as well as behavioural changes to reduce avoidance behaviour and muscle tension). Reduced pain catastrophizing, anxiety about pain, expectations of reduced pain severity and increased sense of control over pain have all been shown to reduce pain intensity and are amenable to cognitive therapy. Behavioral changes can be made to again enjoy the sexual experience: anticipation of pleasure can lessen residual pain.

Research has shown the practiced skill of mindfulness to be associated with reductions in pain and pain related brain activity^[12] whereas low mindfulness has been linked to pain catastrophizing, the latter significantly correlating with dyspareunia in PVD^{[18, 19].} Mindfulness, a meditative practice defined as “non-judgmental, present-moment awareness” is now incorporated into a number of aspects of western medicine and controlled study of pain relief from mindfulness is beginning e.g. mindfulness was found to be superior to supportive group therapy for IBS symptoms including pain^[20]. Our preliminary data show mindfulness to benefit pain and sexual dysfunction from PVD ^[21]. Detailed analysis for publication is in progress: compared to waitlist, 4 2-hour small group sessions focusing primarily on mindfulness significantly improved dyspareunia, allodynia, sexual response, catastrophizing and self-efficacy. We now have CIHR funding to compare CBT with mindfulness. In contrast to the change-oriented nature of CBT, mindfulness meditation is an acceptance-based approach that emphasizes awareness of the present moment but without judgment. There is an “uncoupling” of the physical sensations from the emotional and cognitive experience of pain. Functional brain imaging shows altered pain processing in mindfulness practitioners. Both mindfulness and CBT are effective in lessening perceived stress. Reducing stress is expected to influence the top-down regulation of pain responsivity inherent to central sensitization as well as the neuroendocrine skin pathophysiology of PVD¹².  Mindfulness practice encourages self-acceptance. Reduction of self-criticism to decrease allostatic load may be a key mechanism by which mindfulness could address the changes of central sensitization that maintain this genital pain. Both CBT and mindfulness also benefit the frequently comorbid depression and anxiety disorders^[13].

Practice tip: Current approach to therapy in Vancouver

UBC Sexual Medicine /BC Centre for Sexual Medicine: Purdy Pavilion UBC: 604 822 3690 F: 604 822 3148.

After detailed assessment of (usually) both partners, referred patients are invited to join our 8 weekly 2.25 hour small-group therapy program. The two small group multi-modal therapy arms include: mindfulness based cognitive therapy (MBCT) or CBT, plus education about chronic pain, management of the sexual sequelae of PVD including fear of starting a new relationship (or of leaving an unhealthy one) as well as pregnancy and fertility concerns. Patients are followed for the next 12 months. Usual wait times are 3 to 4 months or less if cancellations come up.

VGH Multidisciplinary Program for PVD: Leslie Diamond Centre: 604 875 4111:63445 F 604 875 4869.

After similar detailed assessment, this small-group program focuses more on education and physiotherapy with less detail and time learning CBT and mindfulness.

Community mindfulness programs: a number of therapists offer MBSR (Mindfulness-Based Stress Reduction) programs in the community, to be found via Google search. Some private psychologists teach CBT and/ or mindfulness: the College of Psychologists of BC at 1-800-665-0979 can advise. Online support: The National Vulvodynia Association www.nva.org.

References

1. Danielsson I, Sjoberg I, Stelund H. Prevalence and incidence of prolonged and severe dyspareunia in women: Results from a population study. Scand J Public Health 2003;31:113-8. (View with CPSBC or UBC)
2. Foster D C, Kotok MB, Huang LS et al. Oral desipramine and topical lidocaine for vulvodynia. Obstet Gynecol 2010;116:583-93. (View with CPSBC or UBC)
   
3. Bornstein J, Tuma R. Topical nifedipine for the treatment of localized vestibulodynia. J Pain 2010;11(12):1403-9. (View with CPSBC or UBC)
   
4. Petersen CD, Giraldi A, Lundvall L. Botulinum toxin type A –a novel treatment for provoked vestibulodynia? J Sex Med 2009;6:2523-2537 (View with CPSBC or UBC)
5. Tommala Tommola P, Unkila-Kallio L, Paavonen J. Surgical treatment of vulvar vestibulitis: A review. Acta Obstet Gynecol Scand 2010;89:1385-1395. (View with CPSBC or UBC)
   
6. Kao A, Binik YM, Amsel R et al. Challenging atrophied perspectives on postmenopausal dyspareunia: a systematic description and synthesis of clinical pain characteristics. J Sex Marital Ther 2012;38:128-50 (View with CPSBC or UBC)
   
7. Arnold LD, Bachmann GA, Rosen R et al. Vulvodynia: Characteristics and associations with comorbidities and quality of life. Obstet Gynecol 2006;107:617-24. (View with CPSBC or UBC)
   
8. Sutton KS, Pukall CF, Chamberlain S. Pain ratings, sensory thresholds, and psychosocial functioning in women with provoked vestibulodynia. J Sex Marital Ther 2009;35:262-81. (View with CPSBC or UBC)
   
9. Foster DC, Dworkin RH, Wood RW. Effects of intradermal foot and forearm capsaicin injections in normal and vulvodynia-afflicted women. Pain 2005;117:128-36 (View with CPSBC or UBC)
   
10. van Lankveld JJ, Granot M, Weijmar Schultz WC et al.Women’s sexual pain disorders. J Sex Med 2010;7:615-31. (View with CPSBC or UBC)
    
11. Ehrström S, Kornfeld D, Rylander E, Bohm-Starke N. Chronic stress in women with localized provoked vulvodynia. J Psychosom Obstet Gynecol 2009;30:73-9. (View with CPSBC or UBC)
    
12. Basson R. The Recurrent Pain and Sexual Sequelae of Provoked Vestibulodynia: A Perpetuating Cycle. J Sex Med 2012;9:2077-92. (View with CPSBC or UBC)
    
13. Khandker M, Brady SS, Vitonis AF et al. The influence of depression and anxiety on risk of adult onset vulvodynia. J Women’s Health 2011;20:1445-51. (View with CPSBC or UBC)
    
14. Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain. Pain 2011;152:S2-S15. (View with CPSBC or UBC)
    
15. Masheb RM, Kerns RD, Lozano C et al. A randomized clinical trial for women with vulvodynia: cognitive behavioral therapy vs. supportive psychotherapy. Pain2009;141:31-40. (View with CPSBC or UBC)
    
16. Bergeron S, Khalifé S, Glazer HI, Binik YM. Surgical and behavioral treatments for vestibulodynia: two-and-one-half year follow-up and predictors of outcome. Obstet Gynecol 2008;111:159-66. (View with CPSBC or UBC)
    
17. National Vulvodynia Association www.nva.org and learnpatient.nva.org
18. Desrochers G, Bergeron S, Landry T, Jodoin M. Do psychosexual factors play a role in the etiology of Provoked Vestibulodynia? A critical review. J Sex Marital Ther 2008;34:198-226. (View with CPSBC or UBC)
    
19. Sutton KS, Pukall CF, Chamberlain S. Pain ratings, sensory thresholds, and psychosocial functioning in women with provoked vestibulodynia. J Sex Marital Ther 2009;35:262-81. (View with CPSBC or UBC)
    
20. Gaylord SA, Palsson OS, Garland EL, Faurot KR, Coble RS, Mann JD, Frey W, Leniek K, Whitehead WE. Mindfulness training reduces the severity of irritable bowel syndrome in women: results of a randomized controlled trial. Am J Gastroenterol 2011;106:1678-88. (View with CPSBC or UBC)
    
21. Brotto L. Mindfulness applications to women’s sexual dysfunction: applications for low desire, sexual distress, and provoked vestibulodynia. J Sex Med 2011;8(Suppl 3):94. (View with CPSBC or UBC)
    

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