Physical after-effects of colposcopy and related procedures, and their inter-relationship with psychological distress: a longitudinal survey

OBJECTIVE

To estimate prevalence of post-colposcopy physical after-effects and investigate associations between these and subsequent psychological distress.

DESIGN

Longitudinal survey.

SETTING

Two hospital-based colposcopy clinics.

POPULATION

Women with abnormal cytology who underwent colposcopy (±related procedures).

METHODS

Questionnaires were mailed to women 4, 8 and 12 months post-colposcopy. Details of physical after-effects (pain, bleeding and discharge) experienced post-colposcopy were collected at 4 months. Colposcopy-specific distress was measured using the Process Outcome-Specific Measure at all time-points. Linear mixed-effects regression was used to identify associations between physical after-effects and distress over 12 months, adjusting for socio-demographic and clinical variables.

MAIN OUTCOME MEASURES

Prevalence of post-colposcopy physical after-effects. Associations between the presence of any physical after-effects, awareness of after-effects, and number of after-effects and distress.

RESULTS

Five-hundred and eighty-four women were recruited (response rate = 73, 59 and 52% at 4, 8 and 12 months, respectively). Eighty-two percent of women reported one or more physical after-effect(s). Multiple physical after-effects were common (two after-effects = 25%; three after-effects = 25%). Psychological distress scores declined significantly over time. In adjusted analyses, women who experienced all three physical after-effects had on average a 4.58 (95% CI: 1.10-8.05) higher distress scored than those who experienced no after-effects. Women who were unaware of the possibility of experiencing after-effects scored significantly higher for distress during follow-up.

CONCLUSIONS

The prevalence of physical after-effects of colposcopy and related procedures is high. The novel findings of inter-relationships between awareness of the possibility of after-effects and experiencing multiple after-effects, and post-colposcopy distress may be relevant to the development of interventions to alleviate post-colposcopy distress.

TWEETABLE ABSTRACT

Experiencing multiple physical after-effects of colposcopy is associated with psychological distress.

Macro-regional variation in attitudes toward and experiences of vulvar and vaginal atrophy among Italian post-menopausal women: a post hoc analysis of REVIVE survey data

Italian participants in the European REVIVE survey reported that vaginal and vulvar atrophy (VVA) impaired various aspects of their lives, notably the ability to enjoy sex. The aim of the present study was to explore regional differences in knowledge, experiences, and treatment of VVA in the Italian REVIVE sample (n = 1000), which was analyzed according to region of residence. While many respondents were unfamiliar with the VVA condition, most could relate their VVA symptoms to the menopause. The rate of diagnosis of VVA was twice as high in Central Italy as in the North-East. For individual VVA symptoms, 25.4-41.6% of respondents judged that the symptom had worsened over time. There were no significant regional differences for symptoms in terms of reported rate, change in severity, impact on sexual activity, or health-care visits. Testosterone cream and OTC medication based on hyaluronic acid showed significant regional differences in lifetime rates of use. In Italy, there are modest regional differences in knowledge, diagnosis, and treatment of VVA, some of which may be explained by inter-regional differences in health care. Further efforts are needed to ensure that Italian women are properly informed about VVA and have access to appropriate health care and treatments.

Sexual arousal and lubrication problems in women with clinically diagnosed hypoactive sexual desire disorder: preliminary findings from the hypoactive sexual desire disorder registry for women

Sexual desire and arousal difficulties are often correlated in women. However, no studies have examined characteristics of women with clinically diagnosed hypoactive sexual desire disorder (HSDD) that increase the likelihood of co-occurring arousal difficulties. The authors examined combined HSDD and arousal/ lubrication problems using baseline cross-sectional data from the HSDD Registry for Women. Their analyses were restricted to women who could be classified with certainty as having arousal or lubrication difficulties by the Female Sexual Function Index (requiring sexually activity in the past 4 weeks). Results showed that among 426 premenopausal women with HSDD, 50.2% had arousal problems, 42.5% lubrication problems, 39.0% combination, and 46.2% neither. Among 174 postmenopausal women, prevalence percentages were 58.0% arousal, 56.9% lubrication, 49.4% combined, and 34.5% neither. The strongest predictor of combined arousal/lubrication problems was self-reported severity of HSDD. Among premenopausal women, race/ethnicity, depression, and lower relationship happiness were also associated with combined arousal/lubrication problems. Among postmenopausal women, surgical menopause and use of selective serotonin reuptake inhibitors were positively associated with arousal problems. Arousal and lubrication problems were present in approximately half of this subsample of HSDD Registry participants, with distinctions in prevalence and predictors by menopausal status and type of arousal difficulty (arousal vs. lubrication).

Stigma-reducing components in direct-to-consumer prescription ads: onset controllability, offset controllability, and recategorization

This study analyzed direct-to-consumer (DTC) print ads for stigmatized illnesses from 1998 to 2008. Attribution theory and recategorization theory were used as theoretical frames to assess whether those DTC ads contained message components to reduce stigma. DTC ads for 10 stigmatized illnesses in National Geographic, Better Homes and Gardens, Ladies' Home Journal, and Time were analyzed for the presence of onset controllability, offset controllability, and recategorization. Results showed that only 3.7% of ads offered the three message components together and, in fact, 21% of the ads did not contain any of the stigma-reducing message elements. Recategorization cue was the most prevalent component, while cues for onset and offset controllability were relatively less frequent, indicating the lack of educational components.

Impact of menopausal symptoms on quality of life 6 months after systemic breast cancer treatment: results from the Shanghai Breast Cancer Survival Study

Menopausal symptoms (MPS) after breast cancer treatment are associated with reduced health-related quality of life (QOL) among Caucasian women. Little is known about whether MPS similarly impact QOL in Asian women with breast cancer. QOL was assessed by using the generic quality of life instruments, Medical Outcome Study of Quality of Life Inventory (MOSQOL-74) or Short Form-36 Health Survey (SF-36) in 4,976 Chinese participants of the Shanghai Breast Cancer Survival Study who were treated for incident, non-metastatic breast cancer within the 6 months before the study interview. Relationships between MPS and QOL were assessed by multiple linear regression, controlling for potential confounders. About 71.4% of study participants experienced MPS, including hot flashes, night sweats, vaginal dryness, depressed mood, and/or dry skin. Women with MPS reported lower overall QOL than women without MPS [mean scores 61.0 vs. 64.0, respectively (MOSQOL-74) and 54.9 vs. 66.9, respectively (SF-36); P < 0.01]. Adjusted mean differences (beta) in overall QOL in the presence and absence of MPS were -3.1 (95% CI -3.8, -2.4) with the MOSQOL-74 and -12.3 (95% CI -13.8, -10.9) with the SF-36. Women with any MPS had lower scores for the MOSQOL-74 physical and psychological domains and for the SF-36 social and emotional subscales than those without MPS (P < 0.05 for all). Having several MPS predicted poorer QOL in all domains measured regardless of the instrument used (P (trend) < 0.01 for all). Our study indicates that in Chinese women recently treated for breast cancer, MPS adversely impacts QOL. Actively soliciting and treating MPS in these women should significantly improve their QOL.

[Disturbance experiences and vaginal symptom self-management among menopausal women]

The purpose of this qualitative research was to explore subjective experiences related to vaginal symptom disturbance and self-management experience of menopausal women. Semi-structured, in-depth interviews were used to collect data. Nineteen participants aged 49 to 68 were recruited. Data obtained from interview transcripts were analyzed using a constant comparative method. Two themes and six related categories emerged from interview data. Vaginal symptom disturbance experience fell into the three categories of sensation of vaginal symptoms; hesitation to share such with others and disturbance of daily life routines. Self-management of vaginal symptoms included unwillingness to visit physicians, self-seeking resources to deal with symptoms, and impacts and coping with sexual life. The impact of vaginal symptoms included distress on physical, mental and sexual life. Health providers should be more sensitive with regard to vaginal symptoms in menopausal women and take a more aggressive approach to provide health education to raise awareness and enhance self-management of vaginal symptoms among menopausal women. Hopefully, participant concerns/insights on vaginal disturbance will provide valuable references for application in teaching materials for health providers to improve menopausal care.

[Effects of kuntai capsule on quality of life, breast distending pain and vaginal bleeding in women at early stage of menopause]

OBJECTIVE

To study the effects of Kuntai Capsule (KTC), a Chinese herbal preparation, on the quality of life (QOL), breast distending pain and vaginal bleeding in women at early stage of menopause.

METHODS

A total of 104 women at early stage of menopause, 54 had their uterus existed (Ue) and 50 in-existed (Ui), were enrolled, and they were randomized to the KTC group and the control group, with equal cases of Ue and Ui in each. The KTC group was treated with KTC 4 capsules twice a day; the control group treated with premarin 0.45 mg per day and for those of Ue 2 mg medroxyprogesterone additionally, with the remedies medicated orally for 1 year. All the testees were asked to record everyday their own condition of breast pain and vaginal bleeding and followed-up every 3 months to fulfill the Menopause Specific Quality of Life questionnaire. Ultrasonic examination on pelvis and breast as well as endocrine hormone assays of estradiol (E2) and follicle-stimulating hormone (FSH) were performed before and after the medication term.

RESULTS

Effects of treatment in the two groups were different insignificantly in terms of QOL. The women were benefited in vasomotor and physical domains from the 3rd month of medication, and the psychosocial domain was also improved (for Ui initiating from the 3rd month and for Ue from the 6th month). In the domain of sexual life, KTC showed its favorable effect only on Ue beginning from the 9th month, but not on Ui; while all subjects in the control group had their sexual life improved from the 3rd month. In domain of breast pain, the occurrence at various time points between the two groups was insignificantly different, only that the severity in Ue of the control group was more significant from the 1st to 3rd month than that in the KTC group. As for the domain of vaginal bleeding, the uterine membrane was basically normal in both groups either before or after medication, but the incidence and lasting days from the 1st to 3rd month in Ue of the KTC group were significantly lower than those of the control group. Levels of E2 and FSH were not significantly changed after medication in the KTC group, while in the control group, E2 significantly increased and FSH significantly decreased in the women of Ue (P <0.05).

CONCLUSION

KTC could evidently improve the QOL of women at the early stage of menopause, and is of high safety, with less adverse reaction of breast pain and vaginal bleeding, and shows few impact on sexual hormones.

Psychosocial impact of chronic vulvovagina conditions

OBJECTIVE

To describe the degree of psychosocial impairment resulting from chronic vulvovaginal disorders (VVDs).

STUDY DESIGN

Seventy-five consecutive women suffering from a chronic VVD were recruited and classified using current International Society for the Study of Vulvovaginal Disease (ISSVD) classification criteria. They completed a 69-item, self-administered, comprehensive questionnaire to assess the impact of chronic VVD on psychosocial functioning and quality of life. Summary scores were calculated for 5 domains including pain, body image, relationships, emotion, quality of life and sexual function.

RESULTS

After adjusting for age and duration of vulvovaginal symptoms, women with vulvodynia were more likely than women with other chronic VVDs to score significantly worse on relationship (p < 0.001), emotion (p < 0.03) and physical activity (p = 0.001) areas. The majority of subjects suffered from a worsening impact of sexual function, and no differences were detected between the groups. The overall intensity of vulvar or vaginal pain correlated weakly with the degree of psychosocial impairment in the domains of relationships, emotion and physical quality of life.

CONCLUSION

Differences in quality of life exist between women with vulvodynia and those with other chronic VVDs. The presence, not the intensity, of vulvovaginal pain correlates with degree of psychosocial impairment.

Development and psychometric evaluation of the ICIQ Vaginal Symptoms Questionnaire: the ICIQ-VS

OBJECTIVES

To develop and validate a self-completion questionnaire for comprehensive assessment of the severity and impact of vaginal symptoms and related sexual matters, particularly those attributed to pelvic organ prolapse. To provide an instrument that can characterise the severity of these symptoms, measure their impact and evaluate treatment outcome.

DESIGN

Prospective development of the content of the questionnaire and testing of its psychometric properties including validity.

SETTING

Two hospital-based urogynaecology clinics and one community general practice in the South of England.

POPULATION

One hundred and forty-one urogynaecology clinic attendees with varying degrees of pelvic organ prolapse and 77 randomly selected women registered with a general practice.

METHODS

The questionnaire was developed through a literature review, consultation with clinicians and health scientists and structured interviews with patients. Content validity, construct validity, stability, internal consistency and sensitivity to change were examined by comparing the responses from the urogynaecology clinic with responses from the general community. Sensitivity to change was assessed using responses from women undergoing surgical treatment for pelvic organ prolapse before and 3 months after surgery. A final version of the questionnaire was obtained after factor analysis to assist item reduction and refinement of the scoring system.

MAIN OUTCOME MEASURES

Content validity, construct validity, stability (test-retest reliability), internal consistency and sensitivity to change.

RESULTS

The questionnaire exhibited good validity, reliability and sensitivity to change. Excellent internal consistency was demonstrated for vaginal (Cronbach's alpha 0.79) and sexual (Cronbach's alpha 0.84) symptoms. Reliability was good. The questionnaire was able to identify changes in symptoms following surgical treatment. The final ICIQ-VS questionnaire had 14 items and a simple scoring system. CONCLUSION; The ICIQ-VS self-completion questionnaire meets the need for a robust instrument for assessing a range of vaginal and sexual symptoms, in particular those of pelvic organ prolapse. It will be of use in both routine clinical practice and epidemiological research, particularly when there is a need to assess the severity of these symptoms or the efficacy of treatment.

Uterovaginal anomalies: diagnosis and current management in teens

Uterovaginal anomalies in the adolescent can be a challenging group of conditions. Not only is the understanding of normal embryologic development essential but also the appreciation that her immaturity and budding sexuality will influence the nature and success of her treatment is important. The ideal care for these young females requires a team approach of both medical and supportive professionals. Normalizing her reproductive tract surgically and supporting her psychologically can usually be accomplished and, in most situations, reproductive capacity is preserved.

Vaginal algometer: development and application of a device to monitor vaginal wall pressure pain threshold

We describe a device (which we have named a vaginal algometer) which can measure the pressure pain threshold (PPT) on the lateral walls of the vagina. The device was assessed in 63 healthy women and a normal range for this measurement was established. Each woman had her vaginal wall PPT measured and was asked about the acceptability of the procedure. We demonstrate that the vaginal algometer can provide a quantitative assessment of vaginal PPT and that the procedure is acceptable to most women.

Adverse behavioral and sexual factors in chronic vulvar disease

OBJECTIVE

We investigated the prevalence of adverse sexual, personal hygiene, and self-treatment behavior among women with chronic benign vulvar and vaginal disorders.

STUDY DESIGN

This study was carried out by means of a scientific clinical audit producing actuarial data by way of a semistructured questionnaire. Subjects consisted of a sample of 530 cases treated at a specialist clinic for vulvar diseases. In addition to clinical and laboratory investigations, the patients were interviewed by the clinic's psychologist, who used a structured interview schedule developed specifically for the study. Descriptive analysis and analysis of variance were used to investigate data.

RESULTS

Most patients remained sexually active in spite of arousal failure and discomfort and engaged in unlubricated and often painful sexual intercourse. Most women engaged in potentially harmful genital hygiene and self-treatment behavior. Adverse self-treatment practices but not adverse genital hygiene practices were associated with greater symptom duration.

CONCLUSIONS

Adverse practices should be addressed during the management of cases of chronic vulvar disease.

Vaginal changes and sexuality in women with a history of cervical cancer

BACKGROUND

In women with cervical cancer, treatment causes changes in vaginal anatomy and function. The effect of these changes on sexual function and the extent, if any, to which they distress women are not known.

METHODS

In 1996 and 1997, we attempted to contact 332 women with a history of early-stage cervical cancer (age range, 26 to 80 years) who had been treated in 1991 and 1992 at the seven departments of gynecological oncology in Sweden and 489 women without a history of cancer (controls) to ask them to answer an anonymous questionnaire about vaginal changes and sexual function.

RESULTS

We received completed questionnaires from 256 of the women with a history of cervical cancer and 350 of the controls. A total of 167 of 247 women with a history of cancer (68 percent) and 236 of 330 controls (72 percent) reported that they had regular vaginal intercourse. Twenty-six percent of the women who had cancer and 11 percent of the controls reported insufficient vaginal lubrication for sexual intercourse, 26 percent of the women who had cancer and 3 percent of the controls reported a short vagina, and 23 percent of the women who had cancer and 4 percent of the controls reported an insufficiently elastic vagina. Twenty-six percent of the women who had cancer reported moderate or much distress due to vaginal changes, as compared with 8 percent of the women in the control group. Dyspareunia was also more common among the women who had cervical cancer. The frequency of orgasms and orgasmic pleasure was similar in the two groups. Among the women who had cervical cancer, the type of treatment received had little if any effect on the prevalence of specific vaginal changes.

CONCLUSIONS

Women who have been treated for cervical cancer have persistent vaginal changes that compromise sexual activity and result in considerable distress.

Sexual functioning among stroke patients and their spouses

BACKGROUND AND PURPOSE

The aim of this study was to assess effects of stroke on sexual functioning of stroke patients and their spouses and to study the associations of clinical and psychosocial factors with poststroke changes in sexual functions.

METHODS

One hundred ninety-two stroke patients and 94 spouses participating in stroke adjustment courses sponsored by the Finnish Stroke and Aphasia Federation completed a self-administered questionnaire concerning their prestroke and poststroke sexual functions and habits. The main outcome measures were (1) libido, (2) coital frequency, (3) sexual arousal, including erectile and orgastic ability and vaginal lubrication, and (4) sexual satisfaction.

RESULTS

A majority of the stroke patients reported a marked decline in all the measured sexual functions, ie, libido, coital frequency, erectile and orgastic ability, and vaginal lubrication, as well as in their sexual satisfaction. The most important explanatory factors for these changes were the general attitude toward sexuality (odds ratio [OR] range, 7.4 to 21.9; logistic regression analysis), fear of impotence (OR, 6.1), inability to discuss sexuality (OR range, 6.8 to 18.5), unwillingness to participate in sexual activity (OR range, 3.1 to 5. 4), and the degree of functional disability (OR range, 3.2 to 5.0). The spouses also reported a significant decline in their libido, sexual activity, and sexual satisfaction as a consequence of stroke.

CONCLUSIONS

Sexual dysfunction and dissatisfaction with sexual life are common in both male and female stroke patients and in their spouses. Psychological and social factors seem to exert a strong impact on sexual functioning and the quality of sexual life after stroke.

Frequency and response to vaginal symptoms among white and African American women: results of a random digit dialing survey

The prevalence of vaginal symptoms and response to those symptoms in a nonclinic setting has not been previously described. Two thousand women living throughout the United States identified by random digit dialing completed a computer-assisted telephone interview about history of vaginal symptoms and use of healthcare services in response to these symptoms. The analysis was limited to 1698 white (WA) and 144 African American (AA) women (n = 1842). An episode of vaginal symptoms of any severity during 1995 was reported by 7.5% of WA women and 18.1% of AA women. Fifty-five percent of WA women and 83% of AA women with symptoms consulted a healthcare professional about their most recent episode. The racial difference in prevalence and consultation was not explained by marital status, education, employment, or lifetime number of sex partners. Most women purchased an over-the-counter antifungal preparation to treat their symptoms, whether or not a physician was consulted. The racial differences in prevalence and use of health services in response to vaginal symptoms observed here should be confirmed, and the potential causes should be explored.

Coping style and climacteric symptoms in a clinical sample of postmenopausal women

Hormonal changes as well as sociocultural and personal factors account for climacteric symptoms. The aim of this study is to investigate in a clinical population the correlation between the severity of hot flashes and vaginal dryness and the 'coping-ineffectiveness of coping' construct. Out of 120 women consecutively referring to the University Menopause Clinic, 85 subjects were evaluated for their climacteric complaints including anxiety and depression and for their coping style assessed with the Italian version of the Utrechtse Coping Lijst. Daily hot flashes and severe vaginal dryness were reported by almost half of the studied population, regression analyses were performed in order to investigate how much of the variance in such symptoms was explained by the psychosocial variables and by the coping mechanisms. A more recent menopause, a lower educational level and an active coping predict a higher severity of hot flashes; a longer time since last menstrual period and a coping of avoidance predict a higher severity of vaginal dryness. The present study suggests that the severity of hot flashes and vaginal dryness among a clinical sample of postmenopausal women is not only determined by biological and social variables, but personal resources also explain part of the variance of such climacteric complaints.

Sexual risk behaviour in women carriers of Mycoplasma hominis

OBJECTIVE

To study the sexual behaviour of women harbouring Mycoplasma hominis in the vagina.

SETTING

Two family planning clinics and a youth clinic for contraceptive advice.

METHODS

The vaginal flora of 996 women were investigated microbiologically, including culturing for M. hominis from the posterior vaginal fornix. Cultures and tests were also made to diagnose genital Chlamydia trachomatis infections, gonorrhoea, genital herpes, cervical human papillomavirus infection, trichomoniasis, genital warts and human immunodeficiency virus. The sexual behaviour of these women was investigated by structured in-depth personal interviews.

RESULTS

Of the 996 women, 123 (12.3%) harboured M. hominis in the vagina. The remainder (87.7%), who had a negative M. hominis culture, served as a reference group. Those with M. hominis were significantly more likely to have had more than 10 partners during their lifetime, had a greater frequency of more than one sexual partner during the preceding month and the last six months, and reported more frequent experience of "casual sex', including casual "travel sex'. More of them also had experience of group sex and were more likely to have been sexually abused than the women in the reference group. Fewer women with M. hominis had a current steady partner and were less often cohabitors, but more had had sexual intercourse during the previous week than those in the reference group. There was an association between the occurrence of M. hominis and bacterial vaginosis and genital chlamydial infection. Adjustment in multifactorial regression analyses therefore changed the results only marginally.

CONCLUSIONS

Women with M. hominis have almost the same sexual risk behaviour as women with classic sexually transmitted diseases.

Women's experiences of general practitioner management of their vaginal symptoms

BACKGROUND

Little is known about the management of vaginal symptoms despite their frequency. Most vaginal symptoms in non-menopausal women are managed as thrush, although bacterial vaginosis is commoner.

AIM

The aim of this study was to measure the experiences of women attending their general practitioner with vaginal symptoms including self-reporting of symptoms, duration and severity, informal support, over-the-counter remedies, sources of information, gender of doctor, expected and actual vaginal examination, and explanations and knowledge of common vaginal infections.

METHOD

A postal questionnaire survey was conducted of 490 patients presenting with vaginal symptoms aged between 18 and 48 years who had attended 10 general practices within the previous 3 months in the East Midlands of England.

RESULTS

A total of 85% of patients had suffered a previous episode, with 39% having had three or more infections in the previous year. Overall, 68% consult with each episode, and most consult within 7 days of onset of symptoms (median = 4 days). In all, 68% discussed their symptoms with partners, families or friends, but 32% relied solely on their doctor. Some 33% bought over-the-counter remedies. A total of 65% informed themselves further from encyclopaedias, leaflets and women's magazines, but there was a strong request for more information. Out of those questioned, 75% expected a vaginal examination, whereas 57% had such an examination performed. Most were told their symptoms were caused by thrush (78%), but patients' ideas on causation were varied. Most believed sexual transmission played a role in transmission of symptoms. Women were socially embarrassed by their symptoms, with 46% admitting to having the condition on their minds all or most of the time. Twenty-eight per cent of women wished to see a female doctor, with gender being unimportant to the remainder.

CONCLUSIONS

Vaginal symptoms were commonly recurrent, socially embarrassing and managed as candidiasis. Just over half the patients had a vaginal examination. There is a shortage of suitable information on vaginal infections available to patients, many of whom used over-the-counter medications.

Difficulties in the differential diagnosis of vaginismus, dyspareunia and mixed sexual pain disorder

This retrospective study was undertaken to investigate predictors of vaginismus, dyspareunia and mixed sexual pain disorder in respect of symptom profile and treatment history variables of female patients and their partners. The study sample consisted of 147 female patients attending a university hospital outpatient clinic for Psychosomatic Gynecology and Sexology. All patients met the DSM-III-R criteria of the diagnoses of vaginismus (n = 50), dyspareunia (n = 46), or of both diagnoses (n = 51). No univariate differences were found between members of the three groups or between their partners. It was not possible to make a multivariate prediction of group membership.

Behavioral responses to uterine or vaginal distension in the rat

Afferent fibers in the rat hypogastric and pelvic nerves supply the uterus and vagina, respectively, the former being responsive mainly to intense uterine stimuli, the latter to gentle and intense vaginal stimuli (Berkley et al. 1993c). If such responses result in sensory experiences, those produced by uterine and vaginal stimulation should differ, uterine stimuli being experienced mainly as pain and vaginal stimuli experienced in various ways, including pain. To test this hypothesis, 48 young virgin rats were first trained to make an operant response to escape a noxious tail-pinch stimulus. Latex balloons inserted into the rat's uterine horn or vagina were then distended to various volumes and the metestrous rat's detection behaviors and operant escape response probabilities measured. Approximately 26% of the 23 rats tested failed to respond to uterine stimulation, even when it produced ischemia. For the rest, detection and escape responses occurred only to ischemic stimuli and never to all of them, even at the highest volumes. In contrast, all 25 rats tested responded readily to vaginal distension, often to all of them at high volumes. Detection behaviors occurred at distension magnitudes lower than those that evoked escape responses. These results support the hypothesis that sensory consequences of uterine and vaginal stimulation differ. Because effective uterine stimuli were larger than any that would occur in a normal physiological state in non-pregnant/parturient rats, normally occurring uterine states in such rats are probably insensible. In addition, while the behavioral responses did indeed reflect differences in hypogastric and pelvic nerve response properties, the results also indicated that activity produced in those fibers, even by abnormal stimuli, does not inevitably result in behavior.

Self-esteem, problem solving, and sexual risk behavior among women with and without Chlamydia

Self-esteem and problem-solving appraisal were evaluated as an explanation of sexual risk behavior for the sexually transmitted disease (STD), chlamydia. Chlamydia, the most prevalent bacterial STD in the United States, is linked to a variety of problems which affect women, their offspring, and their sex partners. Data were collected by two nurse practitioners during scheduled gynecology visits for 105 military women. There was a statistical association among women with chlamydia (chi 2 = 3.623, df = 1, p = .057) and trichomonas (chi 2 = 12.83, df = 1, p = < .001) and a friable cervix. With a 10% prevalence of chlamydia, accurate diagnosis and treatment are imperative. No differences between the prevalence of chlamydia and self-esteem and problem-solving appraisal were noted. These findings support the strategies for diagnoses, treatment, and prevention of chlamydia recommended by the Centers for Disease Control.

Treatment of primary vaginismus: a new perspective

This paper challenges the efficacy of a cognitive-behavioral treatment model for women with primary vaginismus and proposes a conceptual shift from a focus on behavior to a focus on differentiation. Primary vaginismus is viewed as a somatic boundary, a symbolic description of an opportunity for differentiation. Four relevant themes are considered: 1) mastery versus incompetence; 2) autonomy versus dependence; 3) boundary versus fusion; and 4) the effect on the therapy of the therapist's level of differentiation. Change at this particular time in history involves shifts in clinical focus from sexual frequency to quality, from performance to experience, from compliance to mastery, and from utilization function to sexual potential. A case is made for sexual competence based on self-competence instead of on behavior. A reevaluation of what constitutes success, both behavioral and developmental, proposes an increase in differentiation in addition to symptom relief.

Vaginismus--iatrogenic precipitation and maintenance

Four cases of vaginismus are presented. Two of them illustrate an iatrogenic precipitation of vaginismus, one misdiagnosis of vaginismus, and one shows the use of unnecessary hymenectomy as the first choice of treatment of vaginismus. The etiology of vaginismus and the indications of first pelvic examinations are discussed.

Vulvovaginal conditions: social, psychological, and sexual considerations

Women experiencing vulvovaginal conditions are affected socially, psychologically, and sexually. Although vulvovaginitis is a common women's health problem, these considerations are overlooked in the literature and, unfortunately, often in practice, as well. This article presents a discussion of the social, psychological, and sexual issues to be considered when treating women with vulvovaginal conditions, including implications for practice.

Experience in Sheffield: follow-up of abnormal cervical cytology

Failure to re-attend for follow-up is a significant problem in patients attending genitourinary clinics. In this study, despite the efforts made to trac patients with cervical cytological abnormalities, adequate follow-up or further investigation was achieved in only 15.3% of women with inflammatory changes on initial cytology, 38.5% with herpes simplex virus changes, 34.5% with human papillomavirus changes, 60.8% with mild dyskaryosis, 79.9% with moderate dyskaryosis and 97% with severe dyskaryosis. Until the natural history of the minimal atypias is more fully understood, it may be that more vigorous surveillance in such women should be considered.

Origins of psychogenic vaginismus

Case histories of 22 women seeking psychotherapy for psychogenic vaginismus were examined for family patterns. Nearly all of the women had domineering, threatening fathers who were moralistic but also sexually seductive. The parents of these women had high levels of conflict and verbal and/or physical abuse in their marriages. The women with vaginismus were the 'good girls' of their families; obedient, unable to express anger and in constant need of approval. These women tend to choose partners who appear to be the opposite of their fathers; they seem kind, gentle and often passive. Both the women and their partners fear aggression. Women with vaginismus see intercourse as violation or invasion. The symptom serves to protect against violation. Most of the women either witnessed or experienced actual physical violation in their histories.

Prognostic variables in treating vaginismus

Twenty-three patients with vaginismus were seen in a Sexual Dysfunction Program over five years. Twenty of these patients continued in therapy and had successful outcomes. Length of therapy was analyzed and seen to be related to the following factors: duration of the dysfunction, and patient's conception of the etiology of the problem, history of previous attempts at operative treatment, motivational factors, the husband's degree of acceptance of the unconsummated marriage, previous organic abnormalities, extent of sexual knowledge, fear of sexually transmitted diseases, parental attitudes regarding sex, and the patient's attitude toward her genitalia. Follow-up of one to four years has revealed maintenance of sexual functioning in 95% of the couples. The three patients who dropped out and were considered failures all had had previous operative therapy and would not relinquish the idea that there was an anatomic abnormality causing their dysfunction. The method of therapy is reviewed.

Some aspects of sexuality and vaginal symptoms during menopause and their relation to anxiety and depression

Vaginal symptoms and and loss of libido are common presenting complaints among patients of menopause clinics. Very often the cause and effect model used to explain and treat these complaints is one of simple oestrogen deficiency. However, factors other than menopausal status may play an important part in sexual and vaginal problems. This study investigated the relationship between vaginal symptoms and factors such as affective state, the importance of intercourse, satisfaction with sexual activity and strength of desire among 274 peri-menopausal patients at a menopause out-patient clinic. While vaginal dryness affects enjoyment and desire for intercourse, only dyspareunia was associated with a reduction in the frequency of intercourse. Depression was found to be an important factor in loss of libido and anxiety was the most important influence on reduced frequency of intercourse.

Biofeedback as an adjunct to psychotherapy in the treatment of vaginismus

This exploratory study examines the use of biofeedback as an adjunct to psychotherapy in the treatment of vaginismus. A set of six Sims-type graded EMG probes was constructed to provide biofeedback from the vaginal sphincter and was tested on a pilot sample of nulliparous women prior to this study. Five sequential cases of vaginismus from a clinic waiting list participated in the program. All five couples completed the program and all reported successful intercourse at its conclusion. The number of sessions devoted to biofeedback probe insertion was almost halved in comparison to previous experience with Sims dilators. Overall treatment duration was not shortened. At follow-up 6 months later, two couples reported pregnancy, one couple was having regular intercourse, and two couples had ceased intercourse. The authors conclude that biofeedback is an effective aid to learning muscle control, is acceptable to patients, and may increase the success rate by minimizing dropouts. The importance of follow-up is stressed.

Dyspareunia and vaginismus

The understanding and treatment of vaginismus and dyspareunia have been greatly advanced by discoveries in sexual physiology and by the integration of the psychological sciences into clinical medicine. Historical evaluation of these problems should attend to their chronology, the impact on the individual and her relationships, and prior attempts at solution; and one should keep in mind common theories of etiology of sexual dysfunction. Physical examination, both as an educational instrument for the patient and as a means of localizing pain, can be most informative when undertaken with a thorough knowledge of the physiology of sexual response. Particular foci of dyspareunia may be amenable to various combinations of physical and psychological treatment.

[Vaginism - a surgical or consultative problem? (author's transl)]

For the last one hundred years or so doctors have been confronted with the phenomenon of vaginism as a functional sexual disturbance. 70 years ago the psychogenetic nature of this disturbance was recognized, and yet gynaecologists and surgeons are still suggesting and practising surgical and mechanical interventions at the vaginal orifice. This is indeed regrettable - and not only because such attempts remain unsuccessful: in this manner doctors are fixed on the idea of an organic cause of the disturbance instead of motivating the patients to undergo consultative treatment. Vaginism may even entail psychosocial advantages for the women in some cases.

[Advantages of short-term therapy in vaginal mycoses from a socio-psychological viewpoint]

As has become evident from an interview of 161 patients affected by vaginal mycosis, the subjective experience of the disease must be seen in relation to the sociopsychological problems involved. Assumed negative reactions to the disease in the patient's social environment as well as fear and uncertainty regarding the aetiology of the disease make it hard for the patient to accept her disease, which would surely favour a steadfast therapeutic behaviour. For the gynaecologist the finding of a "vaginal mycosis" represents an unproblematic affection since it is easily controllable with antimycotics. The result of this different approach to the disease by doctor and patient is non-compliance of the vaginal mycosis patient: the patient goes to see her doctor soon after the appearance of complaints, but tends to terminate treatment prematurely when the subjective complaints subside, in order to avoid a further confrontation with the disease. An adequate, short-term treatment of vaginal mycosis, the course of which is supervised both clinically and microbiologically, thus appears to be the right way of solving the problem of non-compliance.

The treatment of vaginismus by the gynecologist: an eclectic approach

Thirteen of 14 patients with vaginismus have been successfully treated using systematic in vivo desensitization and other simple but individualized behavioral techniques. Resolution of symptoms was usually effected within 3 to 4 weekly sessions with important supplementary home assignments. All but 1 patient were seen without partners. Neither mechanical dilators nor hymenotomy was employed. Primary orgasmic dysfunction was associated wih vaginismus in a minority of patients and was treated concomitantly. Vaginismus appears to be more frequent than the literature indicates and can be situational or absolute. Presenting symptoms include an inability to tolerate pelvic examination, severe superficial dyspareunia, and a history of unconsummated coitus. Although gynecologic experience with vaginismus has been generally limited, the gynecologist is seen as a potentially ideal therapist for establishing or confirming the diagnosis at that time of pelvic examination.

Observations on the psychological impact of diethylstilbestrol exposure and suggestions on management

The emotional impact of diethylstilbestrol (DES) exposure is described in a series of 50 mothers and daughters interviewed by psychiatrists. Patterns of response to this trauma and methods of resolution are discussed, and opportunities for preventive intervention by gynecologists are suggested. Specific, open dialogue about DES with the patient as a colleage can minimize the emotional sequelae of the experience.