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Genito-Pelvic Pain Disorder

Genito-Pelvic Pain Disorder provides an updated understanding of what were formerly two disorders: Vaginismus and Dyspareunia. Vaginismus described how women endure extreme muscle spasms and tension in the pelvis and around the vagina that interfere with sex. In dyspareunia, people experience pain at any of several points during sex: at the initial penetration, during or after intercourse. In reality, these two disorders occur together much more often than not, so it makes the most sense to diagnose and treat them as one, now called Genito-Pelvic Pain Disorder.

Women most often experience this disorder at two points in their lives: when they start being sexually active and when they go through menopause. The only earlier possible sign of an issue is if women experience pain when they begin using tampons during puberty.

Seeking treatment in the first place is a huge hurdle for a large number of women with this disorder. Feeling guilty and embarrassed are unfortunately common emotions for many people, and can be a serious stumbling block, preventing these women from getting help. However, an understanding partner and a close relationship with a primary care doctor can make all the difference.

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Causes and Risk Factors

Rates

Up to 15% of women in the U.S. experience sexual pain at some point in their lives. However, because this disorder is relatively new, the best estimates of how many people have it come from the older disorders that this new one replaces.

Abuse in childhood

Women who endure sexual abuse as children are twice as likely as average to develop issues with pelvic pain during sex as adults. Physical abuse as well as living in frequent fear of abuse, be it physical or sexual, also increases the chance of pelvic pain.

Emotional and mood factors

Pre-existing depression and anxiety also make the chances of having pain with sex about four times more likely than average. How people process any kind of pain in general also makes a big difference in how much the disorder affects them overall. Many people spend a lot of energy focusing on pain, have a lot of anxiety about it, or think that minor pains mean serious illness. When these people experience sexual pain, it hits their lives and relationships much, much harder. Additionally, people with these anxieties around pain often experience more intense pain than others.

Contributing medical conditions

A wide array of medical conditions can cause pelvic pain in women, usually by increasing sensitivity. Infections, cancers, and inflammatory issues can all make nerves in the area more reactive to pain. Endometriosis is one of the common culprits that affects over one in ten American women. Scars from episiotomies or vaginal trauma during childbirth as well as changes in hormone levels  (such as menopause) can also cause physical changes that lead to increased pain.

Debunked theories

Older ideas about what causes sexual pelvic pain often turned the blame on women. These (now disproved) concepts claimed that these women were just uptight and had a negative outlook on sex. They also suggested that lack of knowledge about sex and immaturity were contributing factors. Although we now know that these outdated notions are completely false, they created an attitude that prevented women from coming forward.

Diagnosing Genito-Pelvic Pain Disorder

The criteria

These women experience significant pain at the start of or during vaginal intercourse that interferes with their ability to have and enjoy sex. Pain may be so severe that it prevents not only sex but also things like using a tampon or getting a pelvic exam. Women can experience the pain in the external area of the vagina (the vulva) at the beginning of sex, or the pain may be deeper and more internal during sex. Sometimes the pain can last for a while after sex or can appear out of nowhere, without any triggers.

In addition to pain, women’s bodies can react by tensing the muscles of the pelvis (either consciously or unconsciously) which can add to the pain and prevent a pleasurable experience. If this happens consciously, some women may be able to relax enough for it to stop, but this is not always the case.

All these difficulties produce a great deal of anxiety around sex and may lead some women to avoid sex altogether. This disrupts relationships and leaves women feeling frustrated, unable to enjoy their bodies by themselves or with their partners. These problems last for at least six months, but for many women, this can be a years-long struggle.

Treating Genito-Pelvic Pain Disorder

Cognitive Behavioral Therapy

CBT helps women explore the emotional and mental factors behind their difficulties with sex. This includes education about the disorder in order to understand the unhelpful thought processes that contribute to painful sex. With an understanding therapist, they explore related anxieties and confront fears through guided exercises. Techniques learned in therapy include muscle relaxation methods and mindfulness, which involves staying mentally and emotionally aware in the present. CBT may also examine relationship factors by involving the individual’s partner in some of the sessions. CBT usually takes place over 10 to 20 sessions, and studies show that its positive effects last at least several years.

Pelvic physical therapy

This treatment focuses on physical therapy for the muscles of the pelvis and has a long history of successfully addressing painful sex, helping at least 70% of people. This kind of physical therapy includes massage and stretching techniques that help with muscle relaxation, increase blood flow, and reduce tension in the vagina and surrounding area. Physical therapists can also prescribe the use of progressively sized dilators that people can use at home as part of a stretching regimen. Physical therapy also employs mild electrical stimulation via TENS units, the same kind commonly used in treating other muscle and nerve pains throughout the body. Studies show that these adjustable, electrical pulses reduce pain and improve sexual functioning.

A surgical option

Surgery is a very effective treatment choice for women who have sexual pain from physical processes that cause the vagina to become extremely sensitive. The most common way this can happen is the growth of extra nerves in the area. People can be born with this condition, or it may develop during childhood or adolescence from inflammation or hormone imbalances. Surgery that reduces the number of these nerves reduces pain for almost nine out of ten women with this condition.

Pain relievers and other drugs

Botox injections are the most helpful procedure in this category and reduce pain during sex for women who suffer from tense pelvic muscles. These effects last a few months before people need repeat injections. Capsaicin and lidocaine can also be marginally helpful.

Managing Genito-Pelvic Pain Disorder

Patient partners

An understanding partner provides a key component to helping women who are experiencing sexual pain. It is important to note that sexual pain does not just affect women in heterosexual relationships, so whether the partner is male or female, the response to a woman’s suffering can play a major role. Partners who react with impatience or hostility hurt the situation and often lead the affected women to blame themselves or ignore the issue. On the other hand, when partners take a patient, compassionate tone, these women often experience less anxiety and less pain. Relationships and sex are more satisfying and pleasurable when partners take the time to process what their loved ones experience both emotionally and physically.

Stressed relationships

Sexual pain strikes deep at the heart of any satisfying sexual relationship. These women have less intense sexual desires, lower libido, and less frequent orgasms. They also may have more negative views of their own bodies, and may feel ashamed that they are dragging down the relationship. They feel alone with their pain and more emotionally distant from their partners. Their partners suffer as well, dealing with increased depression and their own sexual problems, such as erectile dysfunction.

Getting proper care

Only 60% of these women ever try to find a treatment for their suffering, and even then, only half of those ever get the correct diagnosis. Many women who consult with their primary care doctors find that they can be the least helpful out of all the health professionals whom they talk to about these issues. However, since they are the most available, they are often the only choice. As a result, it is little wonder that so many women, out of embarrassment or in despair over their situation, suffer silently rather than continue to seek solutions.

Fear of pain

Fear of pain during sex is the most prevalent reason that these women will avoid sex. These fears may become as powerful as phobias where the fear infects anything related to vaginal penetration. Women avoid gynecological exams, foregoing a major part of what should be regular healthcare. Any form of physical foreplay with a partner can also trigger this fear because of anxiety about it leading to sex. This aura of fear around sex strains relationships and can make women feel less in touch with their sexuality.

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References
  1. IsHak WW, Tobia G. (2013). DSM-5 Changes in Diagnostic Criteria of Sexual Dysfunctions. Reprod Sys Sexual Disorders 2:122
  2. American Psychiatric Association. (2013). Sexual Dysfunctions. In Diagnostic and statistical manual of mental disorders (5th ed.) [Citation is on Genito-Pelvic Pain/Penetration Disorder, Prevalence]
  3. Bergeron, S., Corsini-Munt, S., Aerts, L., Rancourt, K., & Rosen, N. O. (2015). Female Sexual Pain Disorders: a Review of the Literature on Etiology and Treatment. Curr Sex Health Rep, 7(3), 159–169. [Citation is on p.3]
  4. Bergeron, S., Corsini-Munt, S., Aerts, L., Rancourt, K., & Rosen, N. O. (2015). Female Sexual Pain Disorders: a Review of the Literature on Etiology and Treatment. Curr Sex Health Rep, 7(3), 159–169. [Citation is on p.3]
  5. Conforti, C. (2017). Genito-Pelvic Pain/Penetration Disorder (GPPPD): An Overview of Current Terminology, Etiology, and Treatment. University Of Ottawa Journal Of Medicine, 7(2), 48-53. [Citation is on p.50]
  6. Lahaie, M.-A., Boyer, S. C., Amsel, R., Khalifé, S., & Binik, Y. M. (2010). Vaginismus: A Review of the Literature on the Classification/Diagnosis, Etiology and Treatment. Womens Health (Lond Engl), 6(5), 705–719. [Citation is on p.1]
  7. American Psychiatric Association. (2013). Sexual Dysfunctions. In Diagnostic and statistical manual of mental disorders (5th ed.) [Citation is on Genito-Pelvic Pain/Penetration Disorder, Diagnostic Criteria]
  8. American Psychiatric Association. (2013). Sexual Dysfunctions. In Diagnostic and statistical manual of mental disorders (5th ed.) [Citation is on Genito-Pelvic Pain/Penetration Disorder, Diagnostic Criteria]
  9. American Psychiatric Association. (2013). Sexual Dysfunctions. In Diagnostic and statistical manual of mental disorders (5th ed.) [Citation is on Genito-Pelvic Pain/Penetration Disorder, Diagnostic Criteria]
  10. Bergeron, S., Corsini-Munt, S., Aerts, L., Rancourt, K., & Rosen, N. O. (2015). Female Sexual Pain Disorders: a Review of the Literature on Etiology and Treatment. Curr Sex Health Rep, 7(3), 159–169. [Citation is on p.5-6, Psychosocial treatments]
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  12. Bergeron, S., Corsini-Munt, S., Aerts, L., Rancourt, K., & Rosen, N. O. (2015). Female Sexual Pain Disorders: a Review of the Literature on Etiology and Treatment. Curr Sex Health Rep, 7(3), 159–169. [Citation is on p.5-6, Psychosocial treatments]
  13. Conforti, C. (2017). Genito-Pelvic Pain/Penetration Disorder (GPPPD): An Overview of Current Terminology, Etiology, and Treatment. University Of Ottawa Journal Of Medicine, 7(2), 48-53. [Citation is on p.52]
  14. Lev-Sagie, A., & Witkin, S. S. (2016). Recent advances in understanding provoked vestibulodynia. F1000Research, 5.
  15. Conforti, C. (2017). Genito-Pelvic Pain/Penetration Disorder (GPPPD): An Overview of Current Terminology, Etiology, and Treatment. University Of Ottawa Journal Of Medicine, 7(2), 48-53. [Citation is on p.53]
  16. Conforti, C. (2017). Genito-Pelvic Pain/Penetration Disorder (GPPPD): An Overview of Current Terminology, Etiology, and Treatment. University Of Ottawa Journal Of Medicine, 7(2), 48-53. [Citation is on p.51]
  17. Bergeron, S., Corsini-Munt, S., Aerts, L., Rancourt, K., & Rosen, N. O. (2015). Female Sexual Pain Disorders: a Review of the Literature on Etiology and Treatment. Curr Sex Health Rep, 7(3), 159–169. [Citation is on p.2]
  18. Bergeron, S., Corsini-Munt, S., Aerts, L., Rancourt, K., & Rosen, N. O. (2015). Female Sexual Pain Disorders: a Review of the Literature on Etiology and Treatment. Curr Sex Health Rep, 7(3), 159–169. [Citation is on p.1]
  19. Lahaie, M.-A., Boyer, S. C., Amsel, R., Khalifé, S., & Binik, Y. M. (2010). Vaginismus: A Review of the Literature on the Classification/Diagnosis, Etiology and Treatment. Womens Health (Lond Engl), 6(5), 705–719. [Citation is on p.1]
  20. Lahaie, M.-A., Boyer, S. C., Amsel, R., Khalifé, S., & Binik, Y. M. (2010). Vaginismus: A Review of the Literature on the Classification/Diagnosis, Etiology and Treatment. Womens Health (Lond Engl), 6(5), 705–719. [Citation is on p.3]