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Painful Sex: How Far We've Come, How Far We've Yet To Go
By Frank W. Ling, MD, Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, TN, , is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationship to this field of study.
Source: Bergeron S, et al. Genital pain in women: Beyond interference with intercourse. Pain 2011;152:1223-1225.
Understanding sexual pain remains limited. with multiple etiologies and lack of evidence-based outcomes research, future investigations should focus on evaluating the intimacy of the couple, the partner relationship, and biomedical sources of pain such as the pelvic floor muscles.
The article by Bergeron et al is not new science, but, instead, is a "Topical Review." In addition, it doesn't appear in a journal that most women's health providers read. Both are reasons it makes a compelling focus for this Special Feature. This is not an article that is likely to get full attention in other publications since it doesn't adhere to the traditional scientific methods that so populate our classic journals. Nonetheless, I think that a summary of this review and its clinical implications for us as patient advocates is warranted.
For those not familiar with the Diagnostic and Statistical Manual of Mental Disorders-V, the authors inform us that the upcoming 5th edition of this categorization of psychiatric diagnoses will group vaginismus and dyspareunia into a single entity called "genito-pelvic pain/penetration disorder." Although this appears to be a better descriptor, it is still categorized as a sexual dysfunction with strong emphasis on a specific sexual act, intercourse. The authors suggest that a broader view of the problem would make even more sense, focusing not just on the coital act, but also emphasizing such critical components as the cognitive, affective, behavioral, and interpersonal aspects of pain associated with sex. The new disorder will include specific elements: proportion of successful vaginal penetration, pain with vaginal penetration, fear of vaginal penetration, pelvic floor dysfunction, and medical comorbidities.
The review summarizes what is currently known about biomedical factors; pelvic floor dysfunctions; cognitive, behavioral, and affective factors; and interpersonal factors. Suffice it to say that each of these areas of exploration has been shown to be a potential contributor to the end result of painful sexual experiences. Because of the complexity of any given patient's case, the authors recommend a more holistic approach to research in the future, to allow for understanding more than just the biomedical aspects of this condition.
So what's a well-intentioned clinician to do? Even the best data dealing with dyspareunia are flawed. Randomized, controlled trials are few and far between. Evidence-based medicine offers precious little insight into how best to treat that woman sitting in your office complaining of dyspareunia. The office schedule is full, and time pressures limit what can be offered. Even though this article tended to ask more questions than it answered, it does provide us with food for thought that leads us to some general guidelines which can be extrapolated to help our patients.
So it takes less than 15 seconds to inquire, to open the door, to let the patient see that you consider this aspect of her health to be of significance. After all, if you didn't think it was important, why would you ask? There are three logical outcomes: 1) no issues; 2) issues that are expressed and that can be addressed now and/or at a separate visit; 3) no issues expressed, but she brings up something at a subsequent visit because she sees that you are open to this type of concern. If an issue is raised that can be addressed in an efficient fashion, doing so at the same visit makes sense. If, on the other hand, it sounds more complex requiring more time, then the patient should have her concern acknowledged, but addressed when there is more time to focus on it. This keeps the office from backing up unexpectedly. Message: It takes no time at all to take a brief sexual history.
Message: When examining, always ask the patient, "is this the pain?"
I hope that this expansive application of a brief review article gives at least one person a little more motivation to try to help one more patient a little more than he/she would have before reading this column. Don't worry about saving the world...just try to help save the next patient you see. I think you'll be surprised at how rewarding and fulfilling it can be.