I have always been amazed at the lack of an interdisciplinary approach in the treatment of vulvovaginal pain disorders. These conditions overlap a number of specialties including pain management, gynecology, dermatology, urology, gastroenterology, rheumatology, pathology, neurophysiology and not least of all, sex therapy. Each of these fields has its own perspective in treating these disorders. Gynecologists look for infections, dermatologists look for dermatoses, pain physicians look for neuropathic pain; urologists, gastroenterologists and rheumatologists look for related conditions such as interstitial cystitis, irritable bowel and fibromyalgia, pathologists look for vulvar tissue pathology, and neurophysiologists look for pelvic floor muscle dysfunction. With all these specialists focusing on the parts they specialize in, the patient may well ask, "Does anybody care if I am having sex?" While pain relief is a major goal for vulvovaginal sufferers, the major functional consequences of these conditions is to limit and often preclude sexual intercourse. This is particularly so with vulvar vestibulitis syndrome in which there is only pain on pressure, such as that associated with attempted penile-vaginal intercourse. Otherwise these sufferers have no pain. For many essential vulvodynia sufferers, sexual intercourse raises the level of their chronic pain substantially and also leads to sexual abstinence, as with vestibulitis sufferers. It is my experience that patients do not want to simply reduce or eliminate their pain; they want to do so in order to get back to having sexual intercourse with their partners.

I don't think too many patients would ingest medicines, put creams on their vulvas and in their vaginas, do hours and months of muscle exercises, or undergo surgery so that when their vulvas are poked with a q-tip it does not hurt. No, my patients want to be able to have good, loving, intimate, physically and emotionally fulfilling sex with their partner!

I confess that when I first started working with vulvovaginal pain patients using pelvic floor muscle rehabilitation techniques, I specifically stayed away from dealing with the sexual aspects of these problems, because I too had been clincally trained to assume there must be some psychological underpinnings to these vulvovaginal pain conditions. Since then I have changed my practice dramatically for two reasons. First, a considerable database has now been published demonstrating that vulvovaginal pain patients do not show any psychopathology or abuse history that differentiates them from non-pain control groups. Second I saw more and more patients who were "cured" or substantially relieved of their pain and were considered successful outcomes because their vulvar tissue, flora or nerve endings were normalized. But when I asked many of these patients about sex, I discovered that many, perhaps even the majority, had not resumed sexual activity.

So a number of years ago I started to integrate my knowledge of sex therapy techniques into my work with vulvovaginal pain patients. I began to see all my patients with their sexual partners when possible. I began to spend considerable time reviewing sexual history information, discussing with my patients issues such as clitoral stimulation, masturbation, orgasms, oral sex, intercourse and nonintercourse sexual positions, thrusting duration, physiology of female arousal, anticipatory anxiety related to sexual pain, libido, vulvovaginal self examination, and a host of related topics. I had all my patients start re-experiencing orgasms (or for some, learning how to have them for the first time), conducting non-penetrative sexual activities with their partners; I encouraged them to become friendly with their genitals, their appearance, sensations, anatomy, etc. I continue to be amazed at how otherwise very well-educated people have such little knowledge about matters of sexuality. Many of my patients at first resisted this approach saying "just fix my tissue and I will get back to having sex; I used to have great sex." As it turns out this is simply not the way it works for most vulvovaginal pain sufferers; they do not get back to sex spontaneously after their pain is gone because they have developed powerful habits of sexual avoidance and fear and often have little remaining libido. I have found that "resexualizing" my patients immediately upon initiating treatment makes a marked difference in the final outcome of treatment. Getting my patients to be comfortable with their genitals, to understand how they work, and to maximize pleasurable sensations, is now an integrated part of my work.

I explain to my patients that it is normal to cut off awareness from areas of pain in their body. When this area is the genitals, patients not only lose sensory awareness of pain, but also of pleasure. Reconnecting to their genitals, exploring them as a source of pleasure, and the extended psychological benefit of self-acceptance are critical aspects in the rehabilitation of all vulvovaginal pain patients. I believe strongly that pain relief alone does not constitute adequate outcome in the treatment of vulvovaginal pain syndromes. We must restore these patients to their full potential as partners, as lovers, as intimates, in short, as complete women and as complete people.

It is my hope that vulvar pain patients, and the health care professionals who treat them, will read this and gain a little more awareness that, for many patients, our goal must include more than restoring tissue health to the vulva or eliminating vulvar pain. To have a truly successful therapeutic outcome, our goal must be to restore to our patients full sexual functioning, full gender identity, and full capacity to express love.

11/03/00

References:

Marin, M.G., King, R., Sfameni, S., Dennerstein, G.J., Adverse behavioral and sexual factors in chronic vulvar disease, Am J Obstet Gyencol, 2000 Jul;183(1):34-8

Bornstein, J., Zarfati, D., Goldik, Z., Abromovici, H., Vulvar vestibulitis: physical or psychosexual problem? Obstet Gynecol, 1999 May;93(5 Pt 2):876-80 Review.

Binik, Y.M., Meana, M., Berkley, K., Khalife, S., The sexual pain disorders: is the pain sexual or is the sex painful? Annu Rev Sex REs. 1999;10:210-35. Review

Article reprinted from the Fall 1999 edition of NVA News (Volume V, Issue III), published by the National Vulvodynia Association , PO Box 4491, Silver Spring, MD 20914; 301-299-0775

Dr. Glazer is a clinical associate professor of psychology in the Obstetrics and Gynecology Department at Cornell University Medical College, and an associate attending psychologist at New York Presbyterian Hospital. Contact information: 340 East 63rd St. #1A, New York, New York 10021, 212-832-0477.