Vulvar vestibulitis: medical, psychosexual and psychosocial aspects, a case-control study

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1 Acta Obstet Gynecol Scand 2000; 79: Copyright C Acta Obstet Gynecol Scand 2000 Printed in Denmark All rights reserved Acta Obstetricia et Gynecologica Scandinavica ISSN ORIGINAL ARTICLE Vulvar vestibulitis: medical, psychosexual and psychosocial aspects, a case-control study INGELA DANIELSSON 1, INGA SJÖBERG 2 AND MARIANNE WIKMAN 3 From the Departments of Obstetrics and Gynecology, 1 Sundsvall Hospital, Sundsvall, 2 Umeå University Hospital, Umeå, and the 3 Psychosomatic Section, Umeå University Hospital, Umeå, Sweden Acta Obstet Gynecol Scand 2000; 79: C Acta Obstet Gynecol Scand 2000 Background. Vulvar vestibulitis is suspected to be increasingly prevalent among young women, but the etiology is still unclear. The aim of this study was to explore the differences in medical, psychosexual and psychosocial factors between women with vulvar vestibulitis and a control group. Methods. A case-control study was made with 38 women with vulvar vestibulitis and 71 healthy age-matched controls. All the women answered a structured questionnaire about their medical and gynecological history which included psychosexual and psychosocial background factors and current aspects as well. Results. Women with vulvar vestibulitis have very much the same psychosocial and sexual background factors as their controls, whereas there are many differences in their medical background factors, both gynecological and others. It is very clear that they suffer from many other somatic symptoms more often than their controls. Conclusions. There are no indications of a primary sexual disturbance in women with vulvar vestibulitis. However, the finding that women with vulvar vestibulitis have many different somatic symptoms indicates a psychosomatic strain in the illness. Regardless of whether this is primary or secondary, it should be taken into consideration when treating the patients. Key words: case-control study; medical factors; psychosexual factors; somatic symptoms; vulvar vestibulitis Submitted 10 March, 2000 Accepted 18 May, 2000 Vulvar vestibulitis is a continuing challenge to all gynecologists, dermatologists, and family practitioners who see women suffering from the condition. It was described by Scene as early as 1889, and by Kelly in a textbook in 1928, but after that it took many years before Friedrich published his often-cited work in 1987 (1 3). Vulvar vestibulitis is regarded as the most common subtype of vulvodynia (4, 5). The condition is suspected to be increasingly prevalent, with reported rates of 15 percent of cases at a general gynecological practice (3, 6). The etiology is still unknown, but a wide range of factors have been suggested as causative, even if Abbreviations: VAS: visual analog scale; HPV: human papillomavirus infection; OC: oral contraceptives; NS: not significant. most of the evidence was derived from clinical reports rather than from controlled studies. Recurrent vaginal candidosis (7, 8), HPV -infection (9 11), hormonal influence (12, 13), a connection between interstitial cystitis and urethral conditions (14, 15), and sympathetically maintained pain (16, 17), are some of the factors that have been discussed. Two reports have recently shown that women with vulvar vestibulitis have an increased number of intraepithelial nerve endings in the vulvar vestibulum, indicating an alteration in the nerve supply most probably caused by a long-standing inflammatory reaction (18, 19). Some authors have proposed that vulvar vestibulitis should be regarded as a chronic pain syndrome (16, 20 23). Psychological or psychosexual factors have been dis-

2 Vulvar vestibulitis: a case-control study 873 cussed in some papers, but most studies lack a control group (24 27) and the results have been partially conflicting. In the two published studies with control groups (28, 29), Nunns et al. found considerable psychological dysfunction and that all aspects of sexual activity and practice were adverse in patients with vulvar vestibulitis, whereas Meana et al. reported no significant overall psychopathological differences but significant sexual impairment as well as negative attitudes towards sexuality. In yet another paper, Meana et al. (22) concluded that a shift in the conceptualization of dyspareunia from sexual dysfunction involving pain to a pain syndrome resulting in sexual dysfunction had taken place. In a recently published study by White and Jantos (30) on sexual behavior changes in vulvar vestibulitis, the study cohort was compared to normals. The authors found significant differences mainly in negative feelings towards sex and interest in participating in sexual activities, but also several parameters with no significant differences, for example the level of sexual desire. Their conclusion was that the most significant influencing factor in sexual behavior changes appeared to be the actual experience of chronic pain. The purpose of the present study was to explore the differences in medical, psychosexual and psychological aspects of women with vulvar vestibulitis and an aged-matched control group. Material and methods Patients were recruited in 1998 from two clinics in two cities in the northern part of Sweden. Twelve women were consecutively recruited from the Vulva Clinic at the University Hospital in Umeå to which most of the women from the area with vulva symptoms are referred. Twenty-six women were recruited, also consecutively, from the Adolescent Health Center in Sundsvall. Most of these women were not referred but attended the clinic as their primary clinic. In Sweden there are adolescent health centers in most cities, devised for young people from the age of 13 to about 25 to come for counseling on reproductive health issues and some medical and mental health services. All of the 38 women were years old, with a mean age of 21. They were all diagnosed as having vulvar vestibulitis according to Friedrich s criteria, i.e. severe pain on vulvar penetration, vestibular erythema, tenderness on pressure in vestibulum with a cotton-tipped applicator, and a symptom duration of at least six months (3). Only those women who had not received any other treatment but local ointments were accepted, and all eligible women agreed to participate in the study. One of the authors of this report diagnosed all the patients at the Vulva Clinic while another diagnosed all the patients at the Adolescent Health Center. Before starting the study, these two researchers examined and diagnosed ten patients jointly to get full consensus in diagnosis of the patients. The control group consisted of 71 women, years with a mean age of 21, recruited from the same clinics, as well as from another adolescent health center in the area. The initial plan was for each patient to have two healthy controls, matched for age and current use of oral contraceptives (OC), because OC are suspected to influence mood and libido (31, 32). The control group, who were attending the clinics mainly to receive contraceptive counseling, prescriptions of contraceptives or a medical check-up, were asked before joining the study whether they had ever previously sought medical advice for dyspareunia. Only those who had not, were admitted as controls. However, it turned out later in the study that many women had experienced symptoms of dyspareunia, but without seeing a physician. Eight women, who had had at least moderate problems for six months or more, were dropped from the study, since it could not be excluded that they suffered from vulvar vestibulitis, and some new controls were enrolled. Eighteen other women in the control group, who reported that they had, or had had, slight problems with painful coitus but mostly for a short time and never for more than five months, were not excluded. The women were requested to answer a structured questionnaire about their medical and gynecological history (26 questions), current and previous social and sexual life (22 questions), current signs of depression and their satisfaction with their bodies and their looks (6 questions). There were some detailed questions about vulvar pain and its impact on their sexual life (12 questions). In an attempt to judge if the women had experienced any sexual trauma or abuse, the women were asked if Table I. Characteristics of the patient group Mean duration of symptoms 29 (6 96) months Mean age for onset of symptoms 18.5 (14 24) years Pain since first coitus 18% Duration of pain after intercourse O 1h 42% O 1h 6h 42% O 6h 16% Pain at other times than at coitus 68% O When using tampons 50% O When urinating 39% O Other occasions 32%

3 874 I. Danielsson et al. they had ever been forced to engage in sexual activity, with or without intercourse. In addition, since it has been shown that pelvic examinations can be experienced as very unpleasant and humiliating by some women, the women were also asked how they reacted to their first and subsequent pelvic examination (33). Some of the questions on the questionnaire had multiple choice answers, while others could only be answered with yes or no. A Visual Analog Scale (VAS) was used for some of the questions, where 0 was very dissatisfied and 10 very satisfied. The questionnaires were completed in a separate room, with a midwife nearby to ask if the women had any difficulties in completing the questionnaire. Before the study started the questionnaire was tested on young healthy women and patients and subsequently partly revised. For analysis the answers were often dichotomized as deemed most appropriate for each question. See also the results section. The Ethics Committee at the University of Umeå approved the study, and all the participating women submitted written informed consent. The data was analyzed using the Statistical Package for Social Sciences (34). For statistical analyses Mann-Whitney s and chi-square tests were used. Results Demographic variables There were no significant differences in main occupation between the cases and controls; 76% of both groups were students, 16% of the cases and 20% of the controls were gainfully employed (NS). The unemployment rate was low: 5% for the cases and 4% for the controls. Also in their living arrangements, whether the women lived with one or two parents, alone, or with a friend or a partner, there were no significant differences. The proportion of non-smokers was 74% among the patients, with 59% in the control group (non-significant). Medical and gynecological history The main medical characteristics of the patients are shown in Table I. Thirty two percent had pain exclusively when having intercourse, others at other times as well. Forty-five percent of the women in both groups had been in hospital care at least once in their lives. The patients used a minimum of one type of medicine on a regular basis in 29% of the cases, while the figure for the control group was 18% (non-significant). One of the patients and one of the controls were on antidepressant medication. On the other hand, significant differences were found on the reported occurrence of somatic symptoms in most items of the questionnaire (Table II). In Table III, different gynecological factors and reproductive history are presented, and some significant differences are noted. The majority of the patients had a history of candida infection. They also more often had dysmenorrhea and other gynecological problems, whereas there were no differences between the groups in the age for menarche and starting to use oral contraceptives, or the age of first coitus. Premenstrual syndrome was defined as feeling mentally distressed the two weeks preceding the onset of the menstrual period. In the space provided for other gynecological problems, the most frequently noted problems were abnormal discharge and herpes simplex. Sexual history and sexual behavior Table IV presents the data from the section of the questionnaire that dealt with sexual history and behavior. The women suffering from vulvar vestibulitis had not experienced sexual abuse more often than the controls, nor was their first pelvic examination more often awkward than that of the controls. However, the subsequent pelvic examinations were deemed as more difficult among the pa- Table II. Reported occurrence of various somatic symptoms % Cases % Controls Symptom (nω38) (nω71) p-value Pain in the back, neck, or shoulders (quite often, often)* Gastrointestinal symptoms (quite often, often)* Headache (sometimes, quite often, often)** Urinary tract infection*** Asthma*** 10 4 NS Allergic conjunctivitis*** NS Skin problems or other eczema*** * Dichotomized as low: never, seldom; as high: quite often, often. ** Dichotomized as low: never; as high: sometimes, quite often, often. *** Yes or no.

4 Vulvar vestibulitis: a case-control study 875 Table III. Gynecological factors and reproductive history Factor Cases (nω38) Controls (nω71) p-value Menarche (mean, years) NS Dysmenorrhea (quite often, often) 79% 58% 0.05 History of candida infection 87% 28% History of HPV 16% 4% 0.05 History of other gynecological problems 31% 9% 0.01 History of premenstrual syndrome 8% 9% NS Mean age for starting to use OC (years) NS Mean age at first coitus and range (years) 16.3 (14 19) 16.7 (13 22) NS Number of sexual partners and range 3.0 (1 11) 4.1 (0 15) 0.05 Permanent partner at the time of the study 95% 76% 0.05 Mean number of pregnanciesy/parity 6/3 5/0 NS HPVΩhuman papillomavirus infection, OCΩoral contraceptives. Table IV. Sexual history and sexual behavior Cases Controls Factor (nω38) (nω71) p-value Ever been forced into sexual activity or intercourse* 11% 9% NS Awkward first pelvic examination* 32% 21% NS Awkward subsequent pelvic examinations* 40% 16% 0.05 Participated in sexual activity or intercourse without really wanting to, during past year* 60% 22% Participated in sexual activity or intercourse without really wanting to, previous years* 50% 44% NS Sexual desire (rather often, often)** 22% 74% Make sexual advances (rather often, often)** 22% 43% 0.05 Feeling sexual arousal during sex (rather often, often)** 47% 74% 0.05 Wanting to have sex, but not feeling sexual arousal (rather often, often) ** 27% 9% 0.05 Overall satisfaction with current sexual relationship (Mean VAS) Overall satisfaction with one s sexual relationship, before onset of vulvar vestibulitis (Mean VAS) 8.5 The woman s perception of her current partner s satisfaction with their sexual relationship (Mean VAS) * Yes or no. ** Dichotomized as low: no never, yes seldom; as high: yes rather often, yes often. tients. Women with vulvar vestibulitis had more often participated in sexual activity without really wanting to. It should be observed, however, that when asked how it had been in previous years, no differences were demonstrated. The women s overall satisfaction regarding their sexual relationship was lower for the women with vulvar vestibulitis than for the controls, as measured by a VAS. When these scores were compared to the scores from the Fig. 1. Frequency of participation in intercourse. time before the women acquired vulvar vestibulitis, no significant differences were seen. The same was true for the women s perception of their partner s satisfaction of their sexual relationship before the onset of vulvar vestibulitis (mean VAS 8.9). Figs. 1 and fig 2 show how often women participated in various sexual activities. The women with vulvar vestibulitis had intercourse less often but sex without intercourse more often than the controls. Social network and psychological factors Most of the results from the questions about social network and psychological factors are shown in Table V. The women s relationship to their mothers and fathers was measured using a VAS. When the women were asked about their ability to speak intimately with their mother, father, siblings or a close friend, no differences were seen between the groups, with the exception toward friends. However, it was more common among the patients that someone close to them had abandoned them. The

5 876 I. Danielsson et al. Fig. 2. Frequency of participation in sex without intercourse. patients got on well, or very well, at their jobs or schools in 84% of the cases, while the same figure for the controls was 94% (non-significant). As a whole, only minor differences in this category were seen between the groups, and not even when they were asked about depressive signs were any differences demonstrated. Discussion This study shows that women with vulvar vestibulitis have bodily symptoms and complaints more often than their matched controls. A number of investigators have discussed this aspect before, but without having comparisons from an age-matched control group (24 27, 35). However, in a study by Meana et al., no significant differences were noted when the women were asked about nongenital aches and pains (28). The many different somatic symptoms and complaints in our study support the concept of a psychosomatic element in vulvar vestibulitis, which has been suggested previously by others (24, 36). Even if there is no consensus on the definition of a psychosomatic symptom or complaint, it is generally considered that a variety of somatic symptoms, often with unclear etiology, implies a psychosomatic strain (37). A few of the gynecological factors deserve comment. The reported high frequency of one or several candida infections in this study corresponds to the findings in other studies (27, 38). Whether the reported high frequencies of candida infection can be affirmed, or whether they, at least partly, represent misdiagnosis, cannot be determined. If they do represent actual infections, it is very possible that the infection, or its treatment, causes permanent damage to the mucous membranes of the vestibulum. A reported history of HPV infection was more frequent among the patients than the controls, but since most of the women had received their diagnoses without being tested for HPV DNA, misdiagnosis cannot be excluded. Urinary tract infection was more common among the patients. This has been shown before, but the cause is unclear (26, 27). The figures for premenstrual syndrome (PMS) were low in our study and did not differ between the groups, in stark contrast to Jantos and White s study from 1997, in which 85% of the patients experienced PMS (27). The reasons for these differences could probably be explained, at least partly, by different ways of defining PMS, as well as differences in the two studies regarding age and the rate of using OC (39, 40). No differences were seen regarding the age for starting to use oral contraceptives, which has been shown in other studies (12, 13). Our controls were matched for current use of oral contraceptives, which might have interfered with the resulting figures. As mentioned earlier, vulvar vestibulitis is thought to be increasing in prevalence (3, 6, 17). The reason for this is unknown. It has been suggested in Sweden, mainly by the general public and in the mass media, that young women today are Table V. Social network and different various psychological factors Patients% (nω38) Controls% (nω71) p-value Relationship to mother (mean VAS) NS Relationship to father (mean VAS) NS Able to speak intimately with a close friend* Ever abandoned by someone close * Ever had someone close die* NS Ever been bullied in school* NS Felt unhappy or distressed during past year (several times often) ** NS Felt so unhappy or deeply distressed during past year that life did not seem worth living (several times often)** 5 3 NS Satisfied with one s looks (rather very satisfied)*** Satisfied with one s body (rather very satisfied)*** NS * Yes or no. ** Dichotomized as low: no never, yes sometimes; as high: yes several times, yes often. *** Dichotomized as low: very dissatisfied, rather dissatisfied; as high: rather satisfied, very satisfied.

6 Vulvar vestibulitis: a case-control study 877 exposed to numerous instances of early and bad sex, and that this could be the cause of the rising numbers of women with dyspareunia. Bazin et al. have demonstrated a connection between early menarche and early sexual debut and the occurrence of vulvar vestibulitis (12). Several studies have suggested linkage between sexual abuse and a variety of different symptoms, but the connection has been particularly strong between sexual abuse and chronic pelvic pain and sexual dysfunction (41 43). Meana et al. found no differences in their study of women with dyspareunia (28). As far as we know there have to date been no controlled studies concerning vulvar vestibulitis and sexual abuse. This study does not support the view that young women are exposed to bad sex in general, since all the women rated their overall satisfaction with their sexual relationship as high for the times when they did not have any symptoms of vulvar vestibulitis. Also there were no significant differences between the groups as to age at the menarche or first coitus or in the frequency of sexual abuse. The patients had not had a higher number of sexual partners. There were many differences in the women s experience of their current sexual life, but there was nothing in the study to confirm a primary sexual disturbance. This is in accordance with other studies (28, 30). What women with vulvar vestibulitis do have in common is that they have sexual activity without intercourse more often than the controls. It should also be observed that the patients took part in sexual activity without really wanting to more often than the controls. This calls for sexual counseling. We found very little difference between the two groups regarding psychosocial background factors. Surprisingly few women admitted to feeling unhappy or distressed during the past year, and very few said that life did not seem worth living. Others have reported much higher figures for depression (24, 27, 35). The patients satisfaction with their bodies and their looks was good, even if the controls were somewhat more satisfied with their looks. A thought-provoking finding is that the patients expressed a feeling that they had been abandoned more often than the controls. Whether this is a fact or just a feeling of abandonment cannot be determined. Also, fewer patients than controls felt it was easy to speak intimately with a close friend. This could point to a difficulty or fear on the part of the patients to come into close contact with other people, which corresponds with one of the author s clinical impression that some patients with vulvar vestibulitis have difficulties in establishing a deep therapeutical relationship. The high frequency of symptoms of dyspareunia among the controls was unexpected. Control women who had had problems that were deemed serious and which had lasted for at least six months (nω8) were excluded, since it could not be excluded that they suffered from vulvar vestibulitis. However, women who had had minor problems for a shorter duration were included (nω18), since otherwise all women who had experienced any vulvar problems for a short duration, such as a candida infection, would have had to be excluded. As regards the instrument, the reliability of a questionnaire may be questioned, as compared to a detailed interview, but it has been shown earlier that screening for sexual problems by use of a questionnaire is as good as a detailed interview (44). Our conclusion is that young women suffering from vulvar vestibulitis have, as a group and with very few exceptions, the same psychosocial and sexual background factors as their healthy controls. When it comes to the medical aspects, it is very evident from the study that women with vulvar vestibulitis suffer from many other somatic symptoms, both gynecological and others, than their vulvar vestibulitis. This indicates a psychosomatic element in the illness. Whether this is primary or secondary to their vestibulitis is not clear but should be taken into consideration when treating the patients. We suggest that different psychosomatic methods of treatment, as well as sexual counseling, should be tried out and added to more traditional treatments. We have tested acupuncture treatment in a pilot study and eye movement and desensitization therapy (EMDR), that has mainly been in use in post-traumatic stress earlier (45), in some patients, both with encouraging results. Acknowledgments This study was supported by grants from Mid-Sweden Research and Development Center and from The Research Unit of Primary Health Care in Sundsvall. References 1. Scene AJC. 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