OB/GYN Quarterly Update

Painful sex: Look at how far we've come, and yet how far we have left to go

By Frank W. Ling, MD
Clinical Professor, Department of Obstetrics and Gynecology
Vanderbilt University School of Medicine
Nashville, TN

Source: Bergeron S, Rosen NO, Morin M. 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 supplement. 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 fifth edition of this categorization of psychiatric diagnoses will group vaginismus and dyspareunia into a single entity called "genito-pelvic pain/penetration disorder." Although this wording appears to be a better descriptor, it still is 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 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:

"Dyspareunia is better than no pareunia at all." Surely you've heard that one, haven't you? This old boys' network adage blatantly ignores the importance of the interpersonal and intimacy aspects of sexual activity. In reality, the devastation between partners caused by sexual pain can be tremendous, even to the point of undermining the entire relationship as well as the woman's mental health. We've probably all seen it in one way or another. Message: Don't ignore or trivialize a woman's complaint of pain with sex.

HATAH. Coined by Dr. Ray Good, a psychiatrist and obstetrician/gynecologist (although many of us think of ourselves as part-time psychiatrists also), this palindrome reminds us to ask the patient "How are things at home?" This is a shortcut into seeing what kind of environment the patient is in. The stressors, the obstacles, the support systems, etc. can be ferreted out using this fairly non-threatening question. Message: Identify where the woman is with regard to significant people and circumstances.

"Doesn't it take too long to obtain a sexual history?" Not really. Here is an easy approach:

Question 1: Are you sexually active? (Three seconds including question and answer.)

Question 2: Do you have any questions or problems? (10 seconds including question and answer and allowing time for the patient to think about her answer.)

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:

— issues;

— issues that are expressed and that can be addressed now and/or at a separate visit;

— or 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 approach keeps the office from backing up unexpectedly. Message: It takes no time at all to take a brief sexual history.

"I don't have the time or interest to be trained as a sex therapist." That's fine, because, in fact, becoming a certified sex therapist is a significant undertaking. The clinician can, however, with little effort, become a practitioner who identifies a problem and refers the woman/couple to an appropriate resource. Knowing what is available in your community is even something that can be delegated to office staff, but the key is to ask around to find individuals or clinics who can effectively address patients' sexual pain problems. Message: There is no shame in referring a patient for "genito-pelvic pain/penetration disorder."

"If I try to take a history, I really don't know how to approach it." Actually, you already know how to, because you can take a thorough history for pain in your sleep. It's just what we learned in our medical school class on history-taking: describe the pain, where is it, how long has it been there, when does it hurt, does it happen every time, what makes it better or worse, what treatments have helped/not helped it?

In this case, it's just a question of focusing on the sexual activity that brings about the pain. For example, does it hurt at the beginning (entrance or insertional dyspareunia) or upon deep thrusting? Such a question might differentiate vestibulodynia (vulvar vestibulitis syndrome) from pelvic endometriosis. Message: Taking a history for painful sex is not significantly different from taking a history for any other pain.

What role can the physical exam play? In fact, it can tell you why she hurts with sex. As long as the examination is thorough and systematic, the cause of the pain is likely apparent by the end of the examination. Thinking anatomically, the exam is straightforward including the vulva, vagina, pelvic organs, and pelvic floor muscles.

Ask the patient to point to where the pain is, using one finger only (that gives you a better chance to identify the specific location of the pain).

Gently palpate the area of pain to see if you can elicit the pain that is bothering her.

If the area of pain is over the lower abdomen, ask the patient to tense the abdominal wall by lifting her head off the table/trying to touch her chin to her chest (like doing an abdominal crunch) and/or lift her legs off the table without bending her knees (like doing a leg lift).

Ask the patient specifically, "Is this the pain?" (Don't assume that all pain is the same pain that she is complaining of).

Palpate the vestibule (specifically the Skene's and Bartholin duct openings) with a moist cotton-tipped swab to identify potential tenderness.

Gently insert an index finger into the vagina to press posteriorly and laterally to identify potential pelvic floor muscular pain.

Rotate the index finger 180 degrees and palpate urethra and bladder.

Palpate the vaginal cuff (if the patient has had her uterus removed) or cervix to see if that recreates her pain.

Palpate the adnexa cautiously because the abdominal wall might well be the source of pain.

Perform a recto-vaginal exam if her symptoms and other signs warrant. Message: When examining, always ask the patient, "is this the pain?"

You see what you look for. You look for what you know. This bit of wisdom sums up how far our diagnostic acumen will take us. Chances are that you will identify the conditions that are in your intellectual and clinical database. The more entities in that database, the more likely you'll be able to find the ultimate diagnosis. Even if your database is small, just trying is more than the patient might have gotten from others; plus, since you looked for a cause of the pain, you're far more likely to refer her to someone else who can continue the search. Message: The more conditions you know about, the more likely you'll find the right one.