Original Research
Pain
Psychobiological Correlates of Vaginismus: An Exploratory Analysis

https://doi.org/10.1016/j.jsxm.2017.09.015Get rights and content

Abstract

Background

Evidence concerning the determinants of vaginismus (V), in particular medical conditions, is inconclusive.

Aim

To investigate, in a cohort of subjects consulting for female sexual dysfunction, whether there is a difference in medical and psychosocial parameters between women with V and women with other sexual complaints.

Methods

A series of 255 women attending our clinic for female sexual dysfunction was consecutively recruited. V was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. Lifelong and acquired V cases were included.

Outcomes

Patients underwent a structured interview and physical, gynecologic, laboratory, and clitoral ultrasound examinations; they completed the Female Sexual Function Index (FSFI), the Middlesex Hospital Questionnaire, the Female Sexual Distress Scale–Revised (FSDS), and the Body Uneasiness Test.

Results

V was diagnosed in 20 patients (7.8%). Women with V were significantly younger than the rest of the sample (P < .05). No differences were found for traditional risk factors such as a history of sexual abuse, relational parameters, or gynecologic diseases or for newly investigated parameters (ie, neurologic, hormonal, and metabolic alterations). Women with V showed significantly higher histrionic-hysterical symptoms and traits (as detected by MHQ-H score; P < .05) compared with subjects with other sexual complaints. When the scores of all MHQ subscales were simultaneously introduced in a logistic model, the association between V and MHQ-H score was confirmed (P = .013). Women with V also showed higher FSFI pain and FSDS total scores, even after adjusting for age (P < .05). In an age-adjusted model, FSDS total score increased as a function of the years of duration of V (P = .032) but not as a function of its severity. All observations were confirmed in a case-control study (ratio = 1:3).

Clinical Implications

Our data demonstrate that some novel contributors of V should be investigated, namely histrionic-hysterical traits. This psychological comorbidity could offer valuable insights for intervention and managing complications.

Strengths and Limitations

This is the first study to assess the role of many metabolic and hormonal parameters as potential determinants of V. The main limitation is its exploratory and cross-sectional nature; our data need to be confirmed in larger, more systematic analyses.

Conclusion

V was associated with histrionic-hysterical traits, FSFI pain domain, and sex-related distress. A history of abuse, relational parameters, gynecologic diseases, and hormonal and metabolic alterations do not seem to play a role in the development of V.

Maseroli E, Scavello I, Cipriani S, et al. Psychobiological Correlates of Vaginismus: An Exploratory Analysis. J Sex Med 2017;14:1392–1402.

Introduction

Vaginismus (V) is a condition that greatly impairs the quality of life of women and their partners,1 and its prevalence in sexual clinical settings ranges from 5% to 17%.2 In the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), V was defined as “a recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration, causing personal distress.”3 The 5th edition of the DSM (DSM-5) recently introduced a substantial revision of the definition, classifying V with dyspareunia under the broader label of “genito-pelvic pain/penetration disorder,”4 and it indicates that if a medical condition is the cause of the sexual problem, then the diagnosis of sexual dysfunction would not be assigned. However, this new classification has raised several concerns. Indeed, in the proposed diagnostic guidelines for the International Classification of Diseases, Eleventh Revision (ICD-11), expected to be approved by the World Health Organization in 2018, V (referred to as “sexual pain-penetration disorder”) is a separate diagnosis from dyspareunia and vulvodynia, which remain in the genito-urinary chapter.5 The most innovative feature of the ICD-11 classification compared with the DSM-5 is its attempt to integrate “organic” and “non-organic” dysfunctions, thus recognizing the important role of medical conditions as potential etiologic or contributory factors in sexual disorders, including V.5

It has been traditionally suggested that, in women with V, adverse physical and/or psychological conditions act through a vicious cycle of fear and avoidance, in which attempted penetration causes distress and muscle tension (as part of a protective reaction), producing further avoidance and thus leading to an unrelenting fear of penile penetration.6, 7 Among psychological comorbidities, patients with V show increased anxiety and self-focused attention8 and alexithymia, defined as a poor capacity for emotional processing.9 A persistent negative attitude toward sexuality, passive aggressiveness, and a history of childhood sexual abuse also have been traditionally associated with V.10, 11, 12 For organic risk factors, little information is currently available and it is supported by inconclusive evidence.1, 13 Only a few dated case series have identified some potential physical determinants for V, namely congenital (ie, hymeneal) abnormalities, infections and/or irritations, genitourinary syndrome of menopause, trauma associated with genital surgery or radiotherapy, endometriosis, and vaginal lesions and tumors.14, 15, 16, 17, 18, 19 Given these facts, it is clear that studies are needed to explore and further understand the medical problems that could be associated with V.

The aim of this exploratory study was to investigate, in a cohort of subjects consulting for female sexual dysfunction (FSD), whether there is a difference in organic and psychosocial parameters between women with V and women with other sexual complaints. Therefore, we explored the following medical conditions as potential determinants of V:

  • Neurologic diseases associated with neuropathic pain and dysesthesia20

  • Diabetes mellitus complicated by neuropathic pain, dysesthesia, and inadequate arousal or lubrication21

  • Metabolic syndrome, obesity, hypertension, and dyslipidemia, which have been associated with inadequate arousal or lubrication21, 22

  • Menopause related not only to hormonal changes (hypoestrogenic states)23 but also to metabolic alterations

  • Dysthyroidism (hyper- and hypothyroidism), in light of the role thyroid hormones play in regulating the contraction-relaxation cycle in the skeletal muscle24; in particular, experimental hypothyroidism has been demonstrated to modify the morphometry of pelvic (pubococcygeus) and perineal (bulbospongiosus) muscles25

  • Dysregulation of morning cortisol, a hormonal reflection of chronic stress, linked to chronic pelvic pain26, 27

  • Resistance of the clitoral arteries, which has been positively associated with metabolic syndrome and obesity and negatively associated with the arousal response22

  • Androgen levels, for their role in FSD and their anabolic effect on pelvic floor musculature28, 29, 30; promising data are available on the efficacy of local androgen treatment in conditions related to sexual pain31

Section snippets

Methods

The present study is a retrospective analysis of a consecutive series of 255 women attending the Sexual Medicine Outpatient Clinic for FSD at the University of Florence, (Florence, Italy). For all these women, clinical, biological, psychological, sexual, and clitoral Doppler ultrasound parameters had been previously collected according to a standardized protocol. All procedures were in accordance with ethical standards and approved by the institutional research committee (protocol

Demographic, Clinical, and Biochemical Parameters

Of 255 women consulting for FSD, V was diagnosed in 20 patients (7.8%); 80% of them (n = 16) reported lifelong V and 20% (n = 4) reported acquired V. At gynecologic examination, 10% of subjects (n = 2) presented with grade 1 severity V, 30% (n = 6) presented with grade 2, 30% (n = 6) presented with grade 3, 25% (n = 5) presented with grade 4, and 5% (n = 1) presented with grade 5 (Table 1). In the control group, composed of women presenting with other sexual symptoms (n = 235), the main

Discussion

This is the first study to assess the role of several clinical, biochemical, pharmacologic, and psychological parameters as potential determinants of V in a population of women consulting for FSD. The present analysis demonstrated that V was not associated with most clinical, metabolic, and hormonal parameters investigated, and that some traditional risk factors, such as relational factors and sexual abuse, were not significantly related to the condition. As expected, subjects with V showed a

Statement of authorship

Category 1

  1. (a)

    Conception and Design

    • Elisa Maseroli; Linda Vignozzi

  2. (b)

    Acquisition of Data

    • Irene Scavello; Sarah Cipriani; Manuela Palma; Linda Vignozzi

  3. (c)

    Analysis and Interpretation of Data

    • Elisa Maseroli; Irene Scavello; Mario Maggi; Linda Vignozzi

Category 2
  1. (a)

    Drafting the Article

    • Elisa Maseroli; Irene Scavello; Mario Maggi; Linda Vignozzi

  2. (b)

    Revising It for Intellectual Content

    • Elisa Maseroli; Massimiliano Fambrini; Giovanni Corona; Edoardo Mannucci; Mario Maggi; Linda Vignozzi

Category 3
  1. (a)

    Final Approval of the Completed Article

    • Elisa Maseroli;

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    Conflicts of Interest: The authors report no conflicts of interest.

    Funding: None.

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