Rosemary Basson, MD, FRCP UK
ONLINE: June 6, 2012 – The Journal of Sexual Medicine, Volume 9, Issue 8, pages 2077-2092, August 2012
Provoked vestibulodynia (PVD) is characterized by pain, tenderness, and redness in the vestibule of the vaginal area. It affects around 12% of women and can be triggered by contact with various stimuli, such as a penis, dildo, speculum, feminine hygiene product, or tight clothing. It is not uncommon for women with PVD to develop sexual dysfunction and to lose interest in even nonpenetrative sex.
This study aims to discuss chronic pain in the context of PVD, analyze PVD’s chronicity and negative sexual sequelae, and examine the roles that cognitive behavioral therapy (CBT) and mindfulness practice can play in PVD’s treatment.
PVD has a number of possible causes, including genital infections, “micro trauma” to the vulva, and irritants that may change a woman’s sensitivity to pain. Many women with PVD also have other pain syndromes such as fibromyalgia or irritable bowel syndrome.
Pain Processing in the Brain
Pain processing involves physical sensations, thoughts, and emotions. Research has shown that acute pain stimuli activate similar brain regions in healthy and in chronic pain patients, but exacerbations of chronic pain activate areas involved in motivation and emotion. PVD has not yet been studied specifically in this way, however.
The authors also point out the association between depression and chronic pain. Patients with depression are often excluded from brain imaging studies; yet depression and chronic pain are often comorbidities. Depression affects the way pain is processed. Other studies on PVD suggest that chronic pain processing may involve parts of the brain associated with affect.
Pain from PVD is difficult to assess: “Women with PVD experience pain in the context of variable sexual arousal, variable negative emotions of anxiety, resentment, and frustration during and after sexual engagement,” the authors write.
Central sensitization is defined as “changes within the central nervous system that allow increased excitability of central nociceptive circuits.” Women with PVD may experience this, as shown in a study in which women with PVD were given intradermal capsaicin in the forearm and foot. This group had “greater spontaneous pain, greater punctate hyperalgesia, and greater dynamic allodynia than controls.”
It is possible that changes in the central nervous system pain circuitry could result in a different experience of pain: “In other words, a noxious stimulus is not mandatory to experience pain – if neurons in the pain pathways are sufficiently sensitive, they will be activated by low-threshold innocuous input.” Such changes may contribute to chronicity of pain and “could even be the main etiological factor.”
Chronic stressors could be responsible for switching pain processing from sensory areas of the brain to those that involve motivation, reward, and emotion. Stress and pain modulation are connected and accumulated stress may “dysregulate the brain’s neuromodulation of pain sensitivity.” Stress may also contribute to changes of spinal cord dorsal horn cell plasticity.
Women with PVD often show more symptoms of stress, feeling listless and burnt out. They may also have more Type D personality traits, such as depression, feelings of hopelessness and helplessness, and negative feelings about themselves. (The authors note that these symptoms could be a result of PVD and not contributing factors.) One study has shown that women with PVD were more likely to have anxiety disorders and depression before PVD diagnosis.
Mental stressors, including emotional ones, contribute to the overall allostatic load. Women with PVD may feel additional stress because they feel “sexually substandard” (due to the pain). They may criticize themselves. These factors may add to the chronicity – and a possible circular model – of PVD.
Skin and Peripheral Nerves
Stress can worsen certain skin conditions, as the skin reacts in similar ways as the systemic system. Mast cells and plasma cells are close to sensory nerve endings. When these cells are activated, inflammation, nerve hypersensitivity, and pain are all possible.
The authors note that “there is evidence of nociceptor proliferation in PVD as well as variably increased numbers of mast cells and plasma cells.”
Model of PVD
PVD is often attributed to an “unknown peripheral event” that triggers peripheral and central sensitization. However, about half of women with PVD report having pain from the time of their first intercourse, tampon insertion, or speculum exam and do not recall any prior trauma.
Most women with PVD are under stress and it is possible that this stress dysregulates the central nervous system, leading to pain.
A circular model of PVD is suggested, in which emotional distress leads to central desensitization in the brain and spinal cord and neuroendocrine changes in the skin that increase sensitivity to pain. This, in turn, leads to PVD and changes to brain pain circuits. Pain is not just sensory at this point, but includes emotional and motivational factors. Cognitive processing is now altered. From here, a woman may feel less motivation and desire to have sex. The stress of this pain and of being “sexually substandard” leads to more emotional distress and the cycle begins again.
PVD-Associated Sexual Dysfunction
Many women with PVD experience decreased sexual interest and satisfaction. They may consciously avoid painful sex and feelings of shame, guilt, and inadequacy. At a subconscious level, their ability to respond sexually may be impaired. The fear of pain may distract them from sexual stimuli, leading to problems with physical aspects of arousal, such as lubrication and pelvic floor tone.
Managing the Pain from PVD
Treating PVD has been challenging, as thoughts and emotions may be just as important as the pain. Two therapies – cognitive behavioral therapy (CBT) and mindfulness may benefit women by addressing both pain and sexual dysfunction. Combining these therapies can also help women with comorbid pain syndromes, depression, and anxiety.
Managing the Pain from PVD: Focus on CBT
Cognitive behavioral therapy may benefit women with PVD by changing cognitions and emotions connected to pain:
• Many women with PVD are prone to catastrophic thinking, needing to excel, and fearing others’ negative opinions. CBT can help in these areas, reducing the associated stress that exacerbates pain.
• CBT can help women perceive control over their pain, which may lessen its intensity. For example, women can choose (and have control over) when to try intercourse.
• Through CBT, women can learn to see sex as pleasurable, a reward in spite of some residual pain.
• Anxiety can worsen pain. CBT may alleviate some of the anxiety felt by women with PVD.
• Women can learn about the analgesic effect of sexual arousal, which may make them anticipate pain less.
Managing the Pain from PVD: Focus on Mindfulness Practice
Mindfulness is a meditative technique that separates the physical sensation of pain from the emotional or cognitive experiences of it. The authors explain, “Gradually, awareness develops that all thoughts and feelings are only temporary brain phenomena.”
Some main points about mindfulness practice and pain include:
• Mindfulness practice has been shown to lessen stress and restore altered cortisol and other immune responses.
• Mindfulness practice can involve noting the characteristics and locations of pain, but not their unpleasantness.
• As people anticipate pain, mindfulness practice may reduce negative assessment of it.
• Patients can learn to react to pain without judgment.
In terms of PVD, the authors made these points about mindfulness practice:
• Many women with PVD catastrophize their pain. Mindfulness practice may reduce this tendency, as women focus on what is happening moment to moment.
• Through mindfulness practice, women can learn to accept themselves. Being free from constant self-criticism can release stress and, in turn, decrease pain.
• Women practicing mindfulness may be able to accept some residual pain.
• Women can learn to separate the physical sensations of pain and the corresponding emotions about it.
Mindfulness-Based Cognitive Therapy (MBCT) for PVD
Combining CBT with mindfulness practice is fairly new and has not been widely researched. However, the authors suggest that this combination may be more effective than either modality on its own. CBT teaches women to “notice and critique automatic/catastrophic thoughts.” The addition of mindfulness practice allows women to “experience thoughts as simply mental events, not necessarily truths.”
Gradually, MBCT can help women start enjoying sex. As they learn to accept themselves, they can start seeing themselves as equal sexual partners who can negotiate what is or isn’t on the “sexual menu.” At first, painful/penetrative activities are discouraged, as women discover the analgesic effects of arousal and the rewards associated with sexual pleasure. Eventually, “expectation or reward, expectation of less pain, and nonreaction to any painful physical sensations all serve to limit pain intensity.”
Women may still postpone penetration, but two-thirds to three-quarters of women with PVD decide to go ahead with intercourse in spite of pain, according to surveys.
Psychological therapies can be beneficial for women with PVD. MBCT is designed to address both pain and sexual dysfunction and further study on this combination is encouraged.