Suffering in silence: The need for empirically validated options in the treatment of vulvodynia – Fellows’ seminar by Natalie Rosen

“Many women suffer in silence,” said Natalie Rosen. “One in five women suffer from vulvodynia, there’s an estimated prevalence of 8% in the general population, and only 60% seek any kind of help with only 50% of these receiving an accurate diagnosis. Many doctors don’t know about it and it can take, on average, visits with up to five health professionals before an accurate diagnosis is made.”

Rosen - 1STIAS Fellow Natalie Rosen during her seminar presentation on 6 September 2018

“I’m hoping that by using an interdisciplinary approach we can influence the development of better treatment options. There are too few published studies on female sexual dysfunction – we need more awareness and impact.”

Rosen, who is from the Departments of Psychology and Neuroscience and Obstetrics and Gynaecology at Dalhousie University in Canada and is a practicing Clinical Psychologist, was presenting a seminar at STIAS on ten years of research on vulvodynia. Her focus is specifically on the role of relationships in vulvodynia and her studies use innovative and sophisticated research methods – including daily experience sampling, behavioural observation and dyadic methods.

Rosen explained that vulvodynia is a chronic pain condition characterised by recurrent vulvovaginal pain without an identifiable cause. It is usually triggered by sexual intercourse and therefore negatively affects women’s and their partners’ quality of life, including their psychological, relationship, and sexual health and well-being.

“Often no physical causes are identified and the message given to women is that the pain must be inside their heads. This condition remains poorly understood, often misdiagnosed and ignored.”

And causative studies that involve women before the onset of this condition are difficult to design, manage and fund.

The condition has widespread consequences including anxiety, depression, guilt, shame, fear and isolation, relationship problems, reduced desire and reduced ability to achieve orgasm. Male partners also experience negative consequences with higher rates of erectile difficulties and lower sexual satisfaction.

“Despite the pain, 90% of women with vulvodynia still have intercourse. Often for reasons including meeting their partner’s sexual needs and avoiding conflict and guilt,” said Rosen.

Rosen is interested in the interpersonal aspects of the condition and, in particular, in the partner’s response to the pain, and the consequences for partner intimacy and communication. The goal of her research and treatment programme is to approach the condition from a couples’ perspective, improve coping and communication, reduce distress, and ultimately to increase pleasure and less pain and avoidance.

“The pain interferes with sexuality and romantic relationships — two highly valued aspects of life and central to defining identity—making interpersonal variables especially relevant.”

“We know from work in other chronic pain conditions that pain is a biopsychosocial condition influenced by multiple dimensions including social, psychological and physical factors,” she said.

“In the case of vulvodynia the partner can be the trigger for the pain (during intercourse) but also the witness,” she continued.

Developing a model

Based on her work, which has included daily diary studies and observational studies in women and couples, Rosen has identified partner responses which range from negative in which the partner expresses frustration or hostility; to facilitative in which the partner expresses affection and support for more adaptive coping strategies, such as changing to sexual positions that are less painful.

“A more facilitative response results in better sexual function and satisfaction, and lower pain. It helps to reduce anxiety and heightening intimacy,” said Rosen.

Based on these studies, Rosen and her colleagues have developed a theoretical model for understanding the role of interpersonal factors in this condition – the Interpersonal Emotion Regulation Model of Female Sexual Dysfunction. “What is lacking in the literature is an overarching theory to integrate these research findings and better inform prevention and treatment options,” continued Rosen, and this is what she has been working on whilst at STIAS. “I am developing a novel theoretical model to incorporate the cognitions, affect and behaviours of women with vulvodynia and their partners, and how they contribute to the development and maintenance of this condition.”

They have also developed a novel, cognitive-behavioral couple therapy for the treatment of vulvodynia. This involves psycho-educational as well as a number of treatment strategies that focus on skills such as communication, relaxation, enhancing sexual desire and arousal, and pain management. The pilot study, conducted with eight couples and involving 12 sessions, led to a reported 50% reduction in pain and increases in sexual functioning and satisfaction for both members of the couple.

“It’s about giving the couples the tools to manage the pain more effectively and reduce the interference of the pain to their sex lives and overall romantic relationship.”

The pilot study led to a grant for a randomized-controlled trial involving 105 couples at two Canadian centres with a six-month follow-up period. The couples are randomized to either the couple therapy or a medical arm which involves the use of lidocaine – an anaesthetic ointment. This trial is ongoing but provisional results are promising.

“The couple treatment aims to improve pain and outcomes. Enhancing couple communication appears to be one of the promising mechanisms of change,” said Rosen.

“Overall, this research contributes to providing much-needed, empirically validated psychological interventions for vulvodynia from a couples’ perspective,” she said.

In discussion, Rosen highlighted the lack of cross-cultural data and studies on this condition and female sexual dysfunction more generally.

“There is little cross-cultural data,” she said. “All the research has been in North America and Europe and in Caucasian, relatively well-educated women. We do know that Hispanic women have higher rates of vulvodynia, and that African-Americans and women are likely to experience higher (chronic) pain rates and generally have less access to treatment, compared to other ethnicities and to men.”

“In any work on female sexuality and dysfunction there is a link to how society perceives women as the recipients of sexual desire. Male sexual needs are often prioritised in some cultures,” she added.

Even the field of male sexual dysfunction has been approached differently. “There has been more medical treatment research for male sexual dysfunction,” said Rosen. “However, even though drugs are effective for male erectile dysfunction less than 50% of men refill their prescriptions. So, even with men, it’s more than biology. There are barriers beyond the physical. We need a lot more work on male sexual dysfunction as well.”

“Female sexual dysfunction is seen as more complex and harder to treat. I believe women should have the same options as men and that includes both drug-related and psychological approaches.”

Michelle Galloway: Part-time media officer at STIAS
Photograph: Christoff Pauw

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