Treatment of Provoked Vulvodynia in a Swedish cohort using desensitization exercises and cognitive behavioral therapy

This is a descriptive study of a cohort of women who attended a clinic for sexual
problems between 2012 and 2014 and were offered a combination treatment for their
PVD which continued for 10 weeks and focused on behavioural, emotional and physical
aspects. The treatment used physical and psycho-sexological methods since research
has shown the benefits of combinations of this kind 1], 8], 13], 15], 16], 19]. Effects of the treatment regime were measured using the McCoy Female Sexuality Questionnaire
(MFSQ) 20]. In an unpublished quality control study, the authors discovered that a substantial
number of women who sought help for PVD reported a history of depression and therefore
the Hospital Anxiety and Depression Scale (HADS) was also used in the present study
21]–23].

Study participants

A sample size calculation was carried out, based on previous results from a quality
control study (unpublished) at the same clinic. Based on the results, we anticipated
a 5 % increase in scores on MFSQ after treatment (??=?0.05, ??=?0.80) showing a necessary
sample size of 58 for a double-sided, pairwise analysis.

Inclusion and exclusion criteria

Women who were referred to the authorized sexual advisor and trained CBT therapist
in this study had first been diagnosed by a doctor. The diagnosis of PVD is typically
based on the patient’s self-report of pain at the entrance to the vagina during any
attempt at penetration and is confirmed by the cotton- swab test 24]. The women invited to participate had suffered their symptoms for at least 6 months
and had (a) severe pain upon vestibular touch or attempted vaginal entry, (b) tenderness
to pressure localized within the vulvar- vestibule and (c) vestibular erythema of
various degrees. The pain is often located between 4 and 8 o’clock on the introitus,
just exterior to the hyminal ring 17]. Women were excluded when they had current infection or diagnosed dermatological
disease of the genital area, a diagnosis of acute psychiatric illness or any other
major medical problems requiring medical treatment.

Ethical aspects

This study was approved by the Regional Ethics Committee in Lund, Sweden, (Dnr: 2012/116).
PVD is a condition which affects women’s self-esteem 1], 7] and for this reason treatment demands special prudence. The woman’s autonomy must
be respected allowing her to be involved in her treatment. Her personal experiences
should be carefully listened to, confirmed and never questioned for their accuracy.
The cultural, social and psycho-sexual lives of each individual must also be respected.
The women were aware that the answers they gave to the questionnaires would be the
basis for discussions and decisions regarding their individual treatment. The participants
in this study were informed about the therapist’s obligation to professional secrecy.
Case notes are protected against access by anyone other than the treatment team. In
this study, the referring doctor, the medical secretary and the therapist were the
only people with access to the case notes. Information was also given regarding the
participant’s right to terminate inclusion in the study at any time, without any effect
on the on-going treatment.

Recruitment and collection of data

When the women came for their first consultation with the therapist they were invited
to join the study before the consultation began and were given verbal and written
information. Those who were willing were asked to fill in questionnaires on which
individual dialogue and treatments would be based. A history questionnaire was based
on a questionnaire drawn up by the Swedish Society for Obstetrics and Gynaecology
25] and included questions regarding social situation, when PVD problems began, sexual
experiences and preferences, which treatments they had earlier received, previous
illnesses relative to the present problem, life style questions and health status.
The questionnaire is very extensive and only a small number of variables are reported
in this paper. A 12-question version of the MFSQ was used to measure sexual interest,
response and activity of participants at three points in time: before commencement
of treatment, directly after completion of treatment and at 6 months after treatment.
The participants were also asked to fill in the HADS questionnaire to measure psychological
distress.

The treatment

During a 10-week period the women recruited to the study attended ten treatment sessions.
These sessions focused on discussions about the woman’s intimate relationship, on
improving the individual’s knowledge of her bodily functions, helping her to train
her sexual responses and learning to feel sexual pleasure on the same terms as her
partner so that both could experience pleasure and no one’s needs dominated. Each
session took approximately 60 min. Discussions about the individual woman’s life situation,
about couple relationships and about how sexual pain may reflect relationship problems
were an integral part of the CBT. During the 10-week period the woman had contact
with the same therapist. The therapist herself received regular supervision sessions
with a cognitive psychotherapist/psychiatrist. All treatments were carried out by
the same therapist and were individualised which meant that some women made quicker
progress than others but all were offered the full ten sessions.

The sessions included information and education about dyspareunia, PVD and vaginismus
and how pain impacts desire, sexual response and arousal. A presentation was given
of the female genital anatomy, using a detailed plastic model and photographs of the
vulva and vagina. A gynaecological examination was carried out sensitively and carefully
and the woman’s individual pain problems were confirmed. With the aid of a hand mirror
the woman showed where her pain was located and explained her sensations of pain.
The woman was asked to avoid soap for intimate hygiene and instead to use neutral
oil. If the woman lived in a relationship with a partner she was instructed that penile
penetration should be avoided until there was improvement in her experience of pain.
Goals for treatment were negotiated between the patient and therapist and it was important
also to formulate interim goals, such as being able to carry out a vaginal examination
or penile penetration without pain or with reduced pain.

The woman was given information about CBT which required some homework in the form
of training to re-direct negative thought-pathways. Many women have repressed their
thoughts about sexual activity and part of their homework was also to allow these
thoughts freedom and to give thought to what they wanted and needed sexually. An important
example of this kind of re-direction is in how the woman might express her pain and
problems for her partner.

Exercises aimed to desensitize the pain memory response were gradually initiated and
included training to feel tension and relaxation in the muscles of the pelvic floor
and vagina by insertion into the vagina of one or two of the woman’s own fingers and
progressively the partner’s fingers. Rather than avoidance of touch to the painful
area the woman was instructed in regular, daily self-examination using a hand mirror,
to touch and massage the area with oil and to use acupressure. Use of tampons during
menstruation was encouraged. When the woman felt that she had mastered the exercises
and if she was living together with a partner she was asked to gradually introduce
the partner to partake in the exercises. Results of the homework were discussed each
time the woman and therapist met.

At each new session an agenda was formulated by the woman and therapist together and
was always initiated with the question “How have things been since our last meeting”? The woman was also encouraged to give a synopsis and critique of the previous session.
At each session a vaginal examination was carried out with the woman partaking actively
by means of a hand mirror. A dialogue was upheld about how the woman’s sex life and
relationship was developing. Sex resources such as vibrators, dildos and lubricating
gels were introduced progressively if these were acceptable. A discussion ensued about
how the homework had progressed and new homework was negotiated. Finally the woman
was asked to make a summary of the day’s session and feed-back was given by the therapist.

Instruments and outcome measurements

Outcome measurements were recorded at three points in time; at the first consultation,
after 10 weeks completed treatment and again at 6 months after treatment completion.
The MFSQ questionnaire was originally developed in USA and contained 19 items 20]. In international studies the questionnaire has been adjusted from the original 19
to seven, nine or ten items. A version with 12 items was used in the present study.
The 12 items concern sexual motivation (contentment with the extent of sexual activity,
fantasies, desire and excitement), sexual response (lubrication, frequency of sexual
intercourse, orgasm and masturbation), occurrence of dyspareunia and relationship
to the partner as a lover and as a friend. Nine of the items were answered on a seven
step Likert-type scale where 1?=?“never” or “very dissatisfied” and 7 = “very satisfied”,
“very pleasurable” or “every time”. Two items about intercourse and masturbation during
the preceding month were answered on a six step scale where 1?=?“never” and 6 = “more
than eight times”. The final item which pertained to avoidance of sexual intercourse
because of pain was answered on a five point scale where 1?=?“always” and 5?=?“never”.
For those who had not partaken in sexual activity or did not have a partner, it was
possible to answer “not relevant”. The highest total score on the MFSQ used in this
study was 80 points.

A global question answered on a visual analogue scale (VAS) was posed each time the
MFSQ was used: “How do you feel about the extent of your sexuality and your sexual life today?(Whether
you currently have a partner or not)”. The end points of the VAS were: 0 = “Very dissatisfied” and 10 = “Very satisfied”.
This question was asked in order to measure correlations between the question and
scores on the MFSQ in order to provide a measure of validity.

The women were also asked to fill in HADS at the same time points as the MFSQ scale.
HADS questionnaire is widely used to measure psychological distress such as anxiety
disorders and depression among patients in non-psychiatric hospital clinics 21]–23], 26]. HADS is divided into two sub-scales, anxiety and depression. Items are scored on
a 4-point Likert scale ranging from 0 to 3. Maximum possible total scores for anxiety
are 21 and 21 for depression.

Statistical analyses

The material generated by the questionnaires was analyzed using Predictive Analytics
Software (PASW version 17.0). Descriptive statistics were used to present some answers
from the history questionnaire. In order to evaluate changes in the woman’s sexual
motivation, response, occurrence of PVD and relationship with her partner before,
directly after completion of treatment and at a 6 months follow-up, statistical comparisons
of mean scores on the MFSQ (paired samples t-test) and comparisons of answers to the
individual items on MFSQ (Wilcoxon signed-rank test) were carried out. Total mean
scores for the HADS sub-scales anxiety and depression, were compared between measurements
using paired samples t-test since the range of scores was 0–21 for HADS sub-scales.
Correlation tests between the global question and the three total MFSQ scores were
carried out using Spearman’s correlation test. A p-value of ?0.05 was considered to be significant.