Ask the Experts Obstetrics & Gynecology
1 “Evaluation and Treatment of Dyspareunia” John F. Steege, MD, and Denniz A. Zolnoun, MD, MPH May 2009 – Volume 113–‐ Issue 5 – 1124–36 Click Here to Read the Full Article Questions written by: Janice Bird, MD Women ObGyn Annapolis, Maryland Responses written by: John F. Steege, MD Dept. of Obstetrics and Gynecology University of North Carolina at Chapel Hill Chapel Hill, North Carolina 1. A large number of my patients with dyspareunia acquire it after a change in their anatomy (acute or chronic inflammation such as lichen sclerosus) or physiology (menopause). Even after identifying and treating the underlying problem, many women need relaxation and or desensitization exercises. Are there any recommended relaxation exercises that can be done at home without the aid of a physical therapist? Do you have any recommendations for an at‐
home desensitization protocol? Response from Dr. John F. Steege: Treatment of pelvic muscle control problems that are commonly associated with such anatomic changes will be successful only when the primary condition is under good control: the lichen sclerosus has been treated with steroids to the point of absence of symptoms; the vaginal atrophy has been ameliorated by estrogen in some fashion. Supplemental vaginal lubrication (commercial lubricants, vegetable oil) have been recommended and tried. The practicing gynecologist will then usually detect a vaginal introitus and/or pelvic floor tightening problem during the course of a pelvic examination, when (s)he notices that despite the tissue being comfortable to cotton‐tipped applicator palpation, there is a contracted introitus that is uncomfortable during insertion of the speculum or an examining finger. At that point, it is useful to ask the patient to first tighten, then relax the introital muscles, and then ask © 2009 The American College of Obstetricians and Gynecologists www.greenjournal.org Ask the Experts Obstetrics & Gynecology
2 the same for the pelvic floor. Usually, 2‐3 repetitions are necessary. Then mesh these findings with the history of vaginal tightening that may occur during attempted intercourse. If the patient has any degree of conscious, voluntary control of these muscles, then she can often build on this skill by practicing on her own. She can place an index finger in the introitus and sense her own degree of contraction. She then contracts and relaxes the muscles, just as she did during the pelvic examination in the office. She thereby re‐learns conscious control over these muscles. This process may take only a few weeks of regular practice, or longer, depending on the duration of the problem, her motivation, and her personal sense of comfort with her sexuality. Bridging over from this step to having intercourse can be a simple process, or can be much more complicated, depending on the emotional climate in the patient’s relationship, and again, her own personal history of comfort (or lack thereof) with sexual expression. The help of a trained and sensitive physical therapist is generally needed when 1) the patient has no control over contraction‐relaxation during office examination, 2) she cannot make any progress in her self‐directed home exercises, or 3) she cannot incorporate these skills in the intercourse situation. In this last case, the couple may well require the skills of a trained sex counselor or therapist. © 2009 The American College of Obstetricians and Gynecologists www.greenjournal.org Ask the Experts Obstetrics & Gynecology
3 2. Are vaginal dilators useful for relaxation exercises or desensitization? If so, what type of dilators do you recommend? Response from Dr. John F. Steege: This is an excellent question. Dilators can sometimes be quite helpful and reassuring to the patient as she works with gaining better control over the introital and pelvic floor muscles. Their best utility is in calibrating her progress, as it is sometimes difficult for her to tell how large the vaginal introitus is when relaxed. She should be given a series of dilators, gradually increasing in size, with the largest size carefully chosen to match the anatomic requirement (you need to ask very directly!). The instruction set for dilator use is very important. The patient will often view her own anatomy as abnormal, and she may even have been told that she is “built small,” an assessment not usually based on structural anatomic fact, but on observed functional muscular contraction. She may thus feel that if she is only strong enough to withstand the discomfort of “stretching,” she will succeed in changing the anatomy. In some instances, the surgically oriented gynecologist may covertly or overtly collude in this impression. Rather, dilators should be introduced as serving to learn relaxation and measure progress. Used properly in this way, they can facilitate progress. I find the commercial dilators generally available to be quite expensive and not very useful as they seem to be penis‐shaped and therefore oblige the patient to make a substantial jump from one size to the next, rather than a gradual transition. For many years, we have used self‐designed acrylic dilators that are very gently tapered, such that the largest diameter of the first dilator is the smallest diameter of the next size. We have these made in a local machine shop, and simply give them to the patient. Over the years, we have gradually accumulated a wide range of sizes. © 2009 The American College of Obstetricians and Gynecologists www.greenjournal.org Ask the Experts Obstetrics & Gynecology
4 3. In a number of postmenopausal hypoestrogenic women, I see spasm of the transverse perineal muscles without involvement of the levator ani muscles. The introitus becomes taut and involuntarily tight, but beyond there is plenty of room, without spasm of the levator ani muscles. They are unwilling to use any topical estrogen out of fear of the dangers outlined in the package insert. How would you approach this problem? Response from Dr. John F. Steege: This question raises an important point about something that is often misunderstood. Technically, vaginismus is defined as uncontrolled contraction of the introital muscles (usually, bulbocavernosus and transverse perinei). It does not include levator spasm, which can and does occur independently. Certainly, many women with vaginismus will also have levator spasm, but this is not part of the definition. The situation described in this question is not uncommon, especially when the post‐
menopausal woman has experienced a hiatus in her coital life, due to illness, temporary lack of a partner, etc. I think this is best approached as a task of rehabilitation. That means the temporary (weeks to months) applications of small amounts of estradiol cream to just the introitus, using a fingertip rather than an applicator. This keeps the dose to the very minimum, and largely avoids systemic absorption. Once some level of comfort is achieved, then estrogen cream can be replaced with other lubricants, and massage, contraction‐relaxation, and/or vaginal dilation used as described in the prior questions. Once comfortable intercourse is re‐
established, maintaining comfort may require no or very small amounts of topical estrogen. © 2009 The American College of Obstetricians and Gynecologists www.greenjournal.org Ask the Experts Obstetrics & Gynecology
5 4. Two studies (references 6 and 7) did not find an association between a history of physical and sexual abuse and sexual pain. I, however, have found such women to present with some of the most challenging pelvic examinations. Is there a disparity between the difficulty of a pelvic examination and dyspareunia in victims of abuse? Is there something to learn from this that could be applied to other aspects of pain management? Response from Dr. John F. Steege: Most every clinician has dealt with all too many patients who have been the victims of extraordinary trauma and carry with them the resulting emotional scars. I believe a correlation does exist between sexual pain and the more long‐standing and severe degrees of abuse. However, victims of this level of abuse have most often been simultaneously emotionally abused and deprived of essential nurturance in multiple other ways as well, making difficult the attribution of the damage done to particular life events. The main point of this discussion is that as clinicians, we need to be careful about attributing sexual problems to particular life events before we know much more about the person involved. Many victims of less intense abuse in fact deal with it with great courage and resourcefulness, and emerge with a satisfactory adjustment. We don’t help the patient if we convey a sense that such unhappy events uniformly and indelibly mark her. In terms of how the abused patient experiences a pelvic examination, the classic teaching is that the examiner should note if the patient drifts off into her own separate and non‐
communicating world during the examination, a process labeled “depersonalization.” This is a defense mechanism used to isolate her from something perceived as traumatic or reminiscent of previous trauma. In such a state, the person in fact may not report pain during the examination at all, and indeed may experience intercourse in the same way. Even without depersonalization going on, one must always be careful when comparing the sexual history with observations during pelvic examination. Lamont, in 1978, reported that about 25% of patients reporting vaginismus during intercourse demonstrate no spasm or discomfort during pelvic examination. I’m sure there are victims of substantial abuse who may © 2009 The American College of Obstetricians and Gynecologists www.greenjournal.org Ask the Experts Obstetrics & Gynecology
6 fare very poorly during intercourse, but tolerate a pelvic exam without noticeable problems. 5. I was surprised to see that a lack of desire "…is now regarded by mental health professionals as often normal." Do you agree with this opinion? Is desire synonymous with libido? I can understand how dyspareunia may result in a lack of desire, but are there cases where a lack of desire results in dyspareunia? Response from Dr. John F. Steege: Whole books could be written about the nuances of sexual desire. It seems to me that the discussion hinges on definitions. If the operational definition of “desire” is limited to: a) the presence of a conscious wish for sexual contact, and b) the clear outward expression of this wish, then a large percentage of women would be categorized as “lacking” this desire. If one only needs to be receptive to a partner’s initiation to qualify for having “desire,” then far more women would fit that definition. The therapy world seems to be more accepting of this definition of normal. However, life is never that simple, and one soon gets into the discussion of who’s in control in an emotional and sexual sense, how comfortable men really are with a woman who shows need and initiation, etc., etc. To avoid walking even further out on the thin ice of sexual politics, I would simply conclude that the most successful couples do not apply stereotypes, but put energy into clear communication and sharing of needs with each other, both emotional and sexual. The final question is a bit easier. Lack of desire can certainly prevent any sexual response, and the resulting lack of vaginal lubrication can be uncomfortable. Over time, vaginismus may develop, with or without levator spasm, etc., and the problems become part of a vicious circle. © 2009 The American College of Obstetricians and Gynecologists www.greenjournal.org