Stéphanie C. Boyer, PhD and Caroline F. Pukall, PhD
ONLINE: September 22, 2014 – The Journal of Sexual Medicine
While pelvic examinations (PEs) are important for women’s gynecological health, many patients approach them with anxiety and distress. These feelings may stem from past negative experiences with PEs.
The situation may be especially problematic for women with chronic sexual pain. These patients may need to have PEs more often, thereby making them more anxious. Women who have pain may also avoid having PEs altogether.
However, no research has specifically investigated the PE experiences of women in this category. Other studies have been limited due to nonrepresentative samples, few validated questionnaires, and descriptive approaches.
The goals of this study were to:
• Compare the PE experiences of women with chronic gynecological pain with those of women who did not have this pain.
• Investigate the factors that predicted negative PE experiences.
Three hundred ninety-six women completed the study.
Chronic pain was defined as pain during vaginal penetration attempts at least 50% of the time for a duration of at least 6 months.
The women were divided into groups based on the location of their pain:
• The vulvovaginal pain group (chronic pain during intercourse in the vulva, vaginal opening, and/or inside the vagina) included 90 women.
• The pelvic pain group (pain in the pelvic/abdominal area with or without accompanying vulvovaginal pain) included 89 women.
• A control group of 217 women did not experience pain during vaginal penetration.
The women were also categorized based on the presence and lifetime number of chronic gynecological diagnoses they had received.
Measures included in the study analysis were the following:
• Experiences with PEs. The Patient Affective Index (PAI) subscale of the Patient Reactions Assessment (PRA) was used to collect data on the most recent PE.
• Sexual Abuse. Patients who indicated sexual abuse were asked about the occurrence of six different types, from fondling to intercourse during childhood, adolescence, and adulthood.
• Sexual Function. Participants completed the Female Sexual Function Index (FSFI) and the Vaginal Penetration Cognition Questionnaire (VPCQ)
• Body Image. The Body Exposure During Sexual Activities Questionnaire (BESAQ) was used.
The questionnaires were completed online.
Main Outcome Measures
The participants rated their most recent PE in terms of pain, anxiety, and embarrassment. A ten point scale was used for each feature, with 0 indicating no pain, anxiety, or embarrassment and 10 indicating the worst pain or most extreme feelings of anxiety or embarrassment.
The women also rated the overall quality of the experience of their last PE from -2 (very negative experience) to 2 (very positive experience).
The women mostly identified with Canadian or American culture. Most of the participants were heterosexual and in a relationship at the time of the study. Women in the vulvovaginal and pelvic pain groups had been experiencing pain for an average of 9 and 9.03 years, respectively.
Group Differences in PE Experiences
Most of the women had had at least 16 previous PEs. The women in the vulvovaginal and pelvic pain groups were more likely to have ended a PE than the no pain group. Across the groups, the most common reasons for ending a PE were pain, anxiety, and fear.
Group Differences in PE Experiences
As the authors expected, women with chronic pain had a more negative last PE than those who had no pain. Interestingly, the women in the chronic pain groups had more pain even though they were less likely to have more physically invasive procedures, such as speculum insertion or a Pap smear.
The women in the pain groups also had more anxiety during PEs and were more likely to end a PE early. Increased anxiety was often attributed to the fear of finding a medical problem and fear of aggravated pain.
The researchers thought they might see more negative PE experiences in women with vulvovaginal pain when compared to those with pelvic pain, but this was not the case. There was no difference between these groups on this point, which might have occurred because of overlap between types of pain. For example, some women in the pelvic pain group also had pain in the external genitals.
“Overall, the current findings suggest that regardless of where the pain is located, women with pain during intercourse experience more pain and anxiety during PEs than women without pain,” the authors wrote.
The number of lifetime gynecological diagnoses was significantly associated with the women’s pain ratings. A greater number of diagnoses suggested more complex symptoms. The authors noted that even if pain during intercourse is not a woman’s chief complaint, any pain during a PE should be addressed.
Predictors of PE Experiences in Women With and Without Pain During Intercourse
Younger women had more negative PE experiences than older women, perhaps because of their degree of experience.
Childhood sexual abuse did not significantly affect PE ratings in either pain group, a finding that does not align with previous research. It’s possible that differences in study methods may account for these discrepancies.
In the pain groups, quality of the physician-patient interaction and first PE experience ratings affected the overall experience ratings. These factors also contributed to anxiety in women without pain.
Women without pain felt more anxiety with a male physician, but physician gender did not appear affect anxiety levels in the two pain groups.
Negative feelings about vaginal penetration predicted pain and anxiety in the two pain groups.
“Women who endorsed thinking that vaginal penetration would be painful, unsuccessful, out of their control, and would worsen in the future had more difficulty with pain and anxiety during their most recent PE,” the authors explained. It’s possible that having these negative thoughts about penetration could make pain and negative emotional states even worse.
Findings on body image were inconsistent. Women in the no pain group with more body image issues had higher anxiety ratings. In the pain group, BESAQ scores were negatively related to pain scores.
For the no pain group, sexual dysfunction (especially decreased lubrication, decreased arousal, and increased difficulty with orgasm) were linked to anxiety. It’s possible that these women worried that a medical condition would be discovered during the PE. They might also have had negative feelings about sexuality.
The authors acknowledged that their sample might have had a higher socioeconomic status than the general population. The sample was also quite homogenous.
Also, the study focused on the women’s most recent PE, which might have been different from previous PEs.
The retrospective ratings may have also affected the findings.
It’s possible that previous treatments or specific practices could have influenced ratings.
Some women with pain during intercourse may not seek treatment because PEs spark so much fear and anxiety. Experiencing pain brings distress. But anticipating pain can worsen this distress, as women are more aware of pain sensations and their pelvic floor muscles may tighten. Clinicians may consider using cognitive-behavioral approaches to help women work through their negative expectations and learn to relax.
Physicians may also think about ways they can make the PE experience more positive and help patients feel less anxious. Talking to patients about anatomy and sexuality and the PE itself may help. Giving patients some degree of control (using a lubricant or mirror) is another option.