Original ResearchPainPsychobiological Correlates of Vaginismus: An Exploratory Analysis
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:
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Neurologic diseases associated with neuropathic pain and dysesthesia20
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Diabetes mellitus complicated by neuropathic pain, dysesthesia, and inadequate arousal or lubrication21
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Metabolic syndrome, obesity, hypertension, and dyslipidemia, which have been associated with inadequate arousal or lubrication21, 22
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Menopause related not only to hormonal changes (hypoestrogenic states)23 but also to metabolic alterations
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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
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Dysregulation of morning cortisol, a hormonal reflection of chronic stress, linked to chronic pelvic pain26, 27
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Resistance of the clitoral arteries, which has been positively associated with metabolic syndrome and obesity and negatively associated with the arousal response22
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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 Conception and Design Elisa Maseroli; Linda Vignozzi
Acquisition of Data
Irene Scavello; Sarah Cipriani; Manuela Palma; Linda Vignozzi
Analysis and Interpretation of Data
Elisa Maseroli; Irene Scavello; Mario Maggi; Linda Vignozzi
- (a)
Drafting the Article
Elisa Maseroli; Irene Scavello; Mario Maggi; Linda Vignozzi
- (b)
Revising It for Intellectual Content
Elisa Maseroli; Massimiliano Fambrini; Giovanni Corona; Edoardo Mannucci; Mario Maggi; Linda Vignozzi
- (a)
Final Approval of the Completed Article
Elisa Maseroli;
References (62)
- et al.
Psychological treatment for vaginal pain: does etiology matter? A systematic review and meta-analysis
J Sex Med
(2015) - et al.
Women's sexual pain and its management
J Sex Med
(2005) Wives who refuse their husbands
Psychosomatics
(1973)Vaginismus
Am J Obstet Gynecol
(1978)Lifelong vaginismus: a clinical study of 60 consecutive cases
J Soc Gynecol Obstet Can
(1996)- et al.
Genital and sexual pain in women
Handb Clin Neurol
(2015) - et al.
Cardiometabolic risk and female sexual health: the Princeton III summary
J Sex Med
(2012) - et al.
Cardiometabolic risk and female sexuality: focus on clitoral vascular resistance
J Sex Med
(2016) - et al.
Inflammation and symptom change in interstitial cystitis or bladder pain syndrome: a multidisciplinary approach to the study of Chronic Pelvic Pain Research Network Study
Urology
(2016) - et al.
Androgens and female sexual function and dysfunction—findings from the Fourth International Consultation of Sexual Medicine
J Sex Med
(2016)
The Female Sexual Function Index (FSFI): linguistic validation of the Italian version
J Sex Med
Validation of the female sexual distress scale-revised for assessing distress in women with hypoactive sexual desire disorder
J Sex Med
SIEDY Scale 3, a new instrument to detect psychological component in subjects with erectile dysfunction
J Sex Med
The role of somatic symptoms in sexual medicine: somatization as important contextual factor in male sexual dysfunction
J Sex Med
Hysterical traits are not from the uterus but from the testis: a study in men with sexual dysfunction
J Sex Med
Sexual behavior and oral contraception: a pilot study
J Sex Med
Clitoral vascularization and sexual behavior in young patients treated with drospirenone-ethinyl estradiol or contraceptive vaginal ring: a prospective, randomized, pilot study
J Sex Med
Associations between physical and mental health problems and sexual dysfunctions in sexually active Danes
J Sex Med
A psychophysiological investigation of sexual arousal in women with lifelong vaginismus
J Sex Med
Vaginismus and accompanying sexual dysfunctions in a Turkish clinical sample
J Sex Med
The pathophysiology and etiology of vaginismus
Taiwanese J Obstet Gynecol
Vaginismus: a review of the literature on the classification/diagnosis, etiology and treatment
Womens Health (Lond)
Incidence and prevalence of the sexual dysfunctions: a critical review of the empirical literature
Arch Sex Behav
Diagnostic and statistical manual of mental disorders
Diagnostic and statistical manual of mental disorders
Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations
World Psychiatry
Recommendations for the management of vaginismus: BASHH Special Interest Group for Sexual Dysfunction
Int J STD AIDS
Alexithymia and vaginismus: a preliminary correlation perspective
Int J Impot Res
Committee on Health Care for Underserved Women. Committee opinion no 498: adult manifestations of childhood sexual abuse
Obstet Gynecol
Experiencing vaginismus–sufferers beliefs about causes and effects
Sex Marital Ther
Origins of psychogenic vaginismus
Psychother Psychosom
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Vaginismus, Dyspareunia and Abuse History: A Systematic Review and Meta-analysis
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2021, Sexual Medicine ReviewsCitation Excerpt :GPPPD has been shown to be very common: prevalence studies of vulvodynia, a common cause for dyspareunia, have indicated lifetime estimates ranging from 10% to 28% in reproductive-aged women.86 The prevalence of vaginismus in sexual clinical settings ranges from 5% to 17%.87 Home confinement and quarantine may have a significant impact on women with GPPPD, both on a psychological and on a practical level.
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2021, Sexual Medicine ReviewsCitation Excerpt :Some authors have raised concerns over this approach, pointing out that GPPPD fails to capture the complexity of sexual difficulties in women who have never been able to experience intercourse. Indeed, women with “lifelong vaginismus” may be distinguished from women with dyspareunia by factors such as histrionic personality traits,83 catastrophic penetration cognitions, avoidance behavior, and disgust of sexual intercourse and related stimuli.84 In the past, sexual function in women with GPPPD was assumed to remain unaffected except for the vaginal penetration difficulties.85
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2020, European Journal of Obstetrics and Gynecology and Reproductive BiologyCitation Excerpt :There was no relation with ‘prolapse’ (pooled RR 1.10; 95%CI, 0.53–2.30). In this review, we evaluated 38 studies [27–64] on women and girls both with and without a past history of sexual assault, and found strong and consistent associations between sexual assault history and the presence of gynaecological disorders. Our findings are consistent with reports that women and girls experiencing sexual assault have adverse sexual and reproductive health outcomes [18].
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2018, Journal of Sexual MedicineCitation Excerpt :Accordingly, the meta-analysis of the RCTs did not show a clearly greater effect of psychological therapies over controls. Moreover, women with vaginismus, who have been reported to show higher histrionic personality traits—characterized by attention seeking—than women with other sexual symptoms,22 could be easily influenced by the simple fact of being evaluated or included in a study. The ideal design for addressing this point is the placebo-controlled RCT; so far, such studies are not present and apparently, not even ongoing.
Conflicts of Interest: The authors report no conflicts of interest.
Funding: None.