Combined physical and psychosexual therapy for provoked vestibulodynia--an evaluation of a multidisciplinary treatment model.

Provoked vestibulodynia, formerly known as vulvar vestibulitis syndrome, is currently defined as a pain disorder confined to the vaginal opening with hypersensitivity to mechanical stimuli such as touch, pressure, and vaginal penetration (Moyal-Barracco & Lynch, 2004). It is the most frequent cause of superficial dyspareunia in young women (Harlow, Wise, & Stewart, 2001 ). The symptoms interfere with the patient's sexual function and psychological well-being, and the impact the disease has on the affected women may increase over time. Many affected women become sexually abstinent and often describe loss of sexual desire, which has usually accelerated as the symptoms become manifest (Graziottin & Brotto, 2004; Reissing, Khalife, Cohen, & Amsel, 2003; Van Lankveld, Weijenborg, & ter Kuile, 1996). Signs of anxiety and depression are also common features in the patients, but studies on involved psychological factors have not reached consistent results. Some studies report that women with vestibulodynia have higher rates of depression and anxiety than controls (Gates & Galask, 2001; Nylander-Lundqvist & Bergdahl, 2003). It is not clear, however, whether these differences reflect the cause or effect of the disease (Green & Hetherton, 2005; Meana, Binik, Khalife, & Cohen, 1997b; Van Lankveld et al., 1996).

Hypertonicity of the pelvic floor has been proposed to be an important factor for the maintenance of pain, and an increased tension of the pelvic floor is often found during a gynecological examination (Abramov, Wolman, & David, 1994; Reissing, Binik, Khalife, Cohen & Amsel, 2004; Reissing, Lord, Binik, & Khalife, 2005). Interventions to restore the function of the pelvic floor muscles using EMG-biofeedback or physiotherapy are also generally recommended (Bergeron et al., 2002; Danielsson, Torstensson, Brodda-Jansen, & Bohm-Starke, 2006; Glazer, Rodke, Swencionis, Hertz, & Young, 1995; Graziottin & Brotto, 2004; Haefner et al., 2005; Rosenbaum, 2005).

The etiology of provoked vestibulodynia is considered multifactorial, including both physical and psychosexual causes (Graziottin & Brotto, 2004). For some women, previous physical trauma to the mucosa, such as recurrent vulvovaginal candidiasis, may have initiated the dyspareunia, while for others a combination of negative experiences related to emotional, psychological, and sexual factors are more predominant causes (Gates & Galask, 2001; Harlow & Stewart, 2005; Meana, Binik, Khalife & Cohen, 1997a; Meana, Binik, Khalife, & Cohen, 1997b; Nunns & Mandal, 1997; Rylander, Berglund, Krassny, & Petrini, 2004; Sackett, Gates, Heckman-Stone, Kobus, & Galask, 2001).

Several studies investigating pain mechanisms in provoked vestibulodynia have observed an increased peripheral innervation in the vestibular mucosa (Bohm-Starke, Hilliges, Falconer, & Rylander, 1998; Bornstein, Goldschmid, & Sabo, 2004; Westrom & Willen, 1998). Quantitative sensory testing (QST) has been performed, suggesting a peripheral sensitization of the vestibular sensory nerves (Bohm-Starke, Hilliges, Brodda-Jansen, Rylander, & Torebjork, 2001; Pukall, Binik, Khalife, Amsel, & Abbott, 2002). Yet other studies have revealed an enhanced systemic pain perception with decreased pain thresholds in other parts of the body as well and frequently complain of bodily pain in women with vestibulodynia (Danielsson, Eisemann, Sjoberg, & Wikman, 2001; Granot, Friedman, Yarnitsky, & Zimmer, 2002; Pukall, Binik, Khalife, Amsel, & Abbott, 2002; Reissing et al., 2005).

The complex clinical features of prolonged dyspareunia, which in many cases severely affect the patients' psychosexual health, have to be addressed during treatment (Graziottin & Brotto, 2004). Few studies have been published concerning description and evaluation of psychosexual treatment models for women with provoked vestibulodynia or vulvar vestibulitis syndrome (Schover, Youngs, & Cannata, 1992; Wijma & Wijma, 1997; Wijma, Jansson, Nilsson, Hallbook, & Wijma, 2000; Bergeron et al., 2001). In our clinical work, more detailed or hands-on instructions regarding integrated physiological and psychosexual treatment models have been requested by colleagues and other health providers taking care of these patients. Vestibulectomy was initially the most common treatment with a success rate, including complete and partial response, of 50-100% (Bornstein, Goldik, Stolar, Zarfati, & Abramovici, 1997; Bornstein, Maman, & Abramovici, 2001; Haefner, 2000). Lately there has been an urge for more individualized treatments, and the importance of pain management, pelvic floor rehabilitation, and the impact of psychosexual factors has increasingly been acknowledged (Graziottin & Brotto, 2004; Haefner et al., 2005). A multimodal approach including pelvic floor relaxation, pain management, sex therapy, and cognitive behavioral therapy (CBT) are often recommended, but there is limited documentation on how these treatments should be carried out (Haefner et al., 2005; Wijma, Jansson, Nilsson, Hallbook, & Wijma, 2000). The purpose of this study was therefore to standardize and evaluate a combined physical and psychosexual therapy for women with provoked vestibulodynia. The main outcome measures were coital pain and intercourse frequency. Sexual functioning, stressors in life, and general treatment outcome were also evaluated.

Materials and Methods

The study is an evaluation of 27 women who were treated with a combination of physical and psychosexual therapy for provoked vestibulodynia during 1999-2004. All the women were referred to a vulvar open care unit due to superficial dyspareunia. The inclusion criteria for the study follow: (a) provoked pain confined to the area around the vaginal opening, (b) severe pain at most intercourse attempts, and (c) duration of symptoms for at least 12 months.

Exclusion criteria follow: (a) vulvo-vaginal infection (b) vulvar dermatosis (c) unprovoked vulvar pain (d) other ongoing treatment for vestibulodynia, and (e) medication or therapy for major medical or psychiatric illness.

Twenty-seven women were recruited for the treatment, of which 24 carried out the whole treatment program. Three women dropped out at an early stage mainly due to lack of motivation. Approximately one out of five patients who were invited to join the study declined to participate. The main reason for not participating was lack of motivation to see the counselor. The mean age and duration of dyspareunia did not differ between drop-outs and those completing the treatment.

The study was approved by the Local Ethics Committee, and the participants gave their informed consent.

Procedure and Treatment Model

All patients were seen by the same gynecologist at their first visit to the vulvar clinic. A careful vulvo-vaginal examination was performed with wet-amount and cultures if needed to exclude a vulvo-vaginal infection or other physical causes to the pain. After the diagnosis of provoked vestibulodynia was confirmed, the patients were invited to join the study. Only five to six patients were able to participate in the treatment during the same time. After one had completed the treatment, the subsequent vestibulodynia patient at the vulvar clinic fulfilling the inclusion criteria was asked to join the study. A standardized questionnaire concerning demographic, reproductive, and medical history was filled out. The treatment was performed in collaboration between a psychosexual counselor and a midwife trained in physical therapy for the pelvic floor. The psychosexual counselor had a bachelor of social work degree. She had also a comprehensive education and training in clinical sexology corresponding to the requirement for authorization as a clinical sexologist established by the Nordic Association for Clinical, Sexology (NACS). Every session lasted 60 minutes with the counselor and 30 minutes with the midwife. Initially the patient had a weekly appointment, but these were gradually reduced to once a month. At the first visit the patient was informed about the treatment modalities. After each session, the psychosexual counselor and the midwife discussed the patient's individual progress and planned the next appointment. The gynecologist was regularly informed about the patient's progress. There was no time limit set for the length of the treatment.

All the women involved in a committed relationship were given the possibility to invite the partner to join one session, which included information about vestibulodynia and the treatment program. No couple therapy was performed.

Psychosexual Counselor

The aims for the psychosexual counselor were to (a) increase the patient's awareness about the interaction between her thoughts and somatosensory responses and (b) improve the patient's sexual functioning as expressed in her subjective experience of her sexual response, that is, lubrication, orgasm, and satisfaction. During the first two sessions a careful evaluation was carried out regarding the patient's family history, working situation, current relationship, issues of self-esteem, past and present sexual desire, sexual functioning, and the quality of the current sexual relationship. Each patient needed her specific level of counseling and support concerning problems in the areas mentioned. An assessment was also made regarding the degree of control the patient needed in her overall life. The basis of the sexual counselor's treatment is listed in Table 1. Throughout the treatment the approach was to encourage the patient and reinforce any progress. The counselor worked with the patient's coping skills to help improve her sexual desire and function, diminish the negative focus on her genitals, and in the end decrease the coital pain. This was done by introducing a cognitive model of the interaction between thoughts and coital pain, guiding the patient toward a more positive view of her pain disorder and sexual possibilities.

Midwife

The midwife's aims were to (a) increase the patient's knowledge about her genital anatomy and function, (b) desensitize the mucosa and thus reducing pain, and (c) decrease the tension and restore the function in the pelvic floor muscles. The basis of this treatment was to obtain a desensitization of the vestibular mucosa by smearing and finger penetration exercises assigned as homework between visits; see Table 2. The midwife instructed the patient (using a handheld mirror) how to gently smear the affected areas with a mild lubricant ointment without causing pain sensations. To avoid stress, the patient was not given prior notification about the next step of the treatment. When the patient was fully able to maintain one step of the desensitization hierarchy, she was introduced to the next by the midwife. All visits started with a discussion of the patient's status and thoughts regarding her vestibulodynia and were thereafter followed by an inspection of the vestibule. After each visit, the midwife documented any erythema present and the level of pelvic floor tension using digital palpation.

Both the sexual counselor and the midwife emphasized the positive improvements achieved throughout the treatment. When the patient was able to have penetrative intercourse, the focus was to encourage the patient's positive feelings about her future well-being. The patients were considered well when they could resume either pain-free intercourse or only experienced occasional or mild pain not preventing them from having intercourse. Women without an available partner were defined as cured when they could insert two fingers into the vagina without pain.

Evaluation of the Treatment

A comprehensive questionnaire (multiple choice items) for treatment evaluation was constructed. Part of the questionnaire was filled out prior to the treatment and the rest at a minimum of 6 months after the treatment was completed (i.e., the follow-up time). The patients had to rate their coital pain prior to the treatment and at the follow-up as follows: (a) never painful; (b) occasional or mild pain, not preventing intercourse; (c) moderate pain, sometimes preventing intercourse; and (d) moderate to severe pain, most times preventing intercourse. Data on intercourse frequency was obtained from the time before the symptoms of vestibulodynia began, just prior to the treatment, and at the follow-up. General outcome of the treatment, was evaluated as follows: (1) complete recovery, (2) major improvement, (3) minor improvement, (4) no difference, or (5) deterioration. The women were asked about their sexual functioning, sexual desire, and the attitude toward their own sexuality. General stressors in life and specific stressors related to the working situation were also evaluated; see Table 5. The women were asked if they experienced any change in the sexual demands either from their partner or themselves and if the amount of time devoted to concerns about pain and discomfort of the vestibule had changed after ending the treatment program.

Statistics

A t test was used to compare age and duration of symptoms between women completing the treatment and drop-outs. Categorical data were dichotomized before Fisher's exact test was used to compare differences in outcome. Correlation between duration of vestibulodynia and treatment length was analyzed with a Spearman rank correlation coefficient. The level of significance used was 0.05.

Results

The patients' mean age was 24.5 years (range 17-32), and the mean duration of vestibular pain was 5.5 years (range 1.5-13). Seventeen percent had primary vestibulodynia, and 33% had been treated for more than 10 candida infections. Tension headache and dysmenorrhea were commonly reported. Further characteristics of the patients are listed in Table 3.

The mean number of appointments until cure according to the criteria mentioned was 11 (2-23) to the psychosexual counselor and nine (2-18) to the midwife. The total mean number of sessions for treatment was 12 (4-24) by the counselor and 15 (9-26) by the midwife. When the patients became familiar with the treatment and started to improve, they did not always continue to see the counselor and the midwife at joint sessions. This explains the discrepancy between the number of appointments to the counselor versus midwife. Approaching the end of the treatment, some patients needed further reassurance from mainly the midwife that they were well or had improved, which explains the higher number of appointments to the midwife. The average treatment time was 53 weeks (19-92). The mean follow-up time after the treatment was 19 months (range 6-34).

Three women considered themselves completely recovered, and 16 experienced a major improvement following treatment. Five women were somewhat improved. When the treatment outcome was dichotomized in number of patients reporting major improvement/cure versus no major improvement, a significant improvement using Fisher's exact test was obtained, p < 0.001. Three of the five patients who were only somewhat improved, however, needed additional treatment. Two underwent vestibulectomy with satisfactory results. One patient needed cognitive-behavioral therapy for a stress condition mainly related to her working situation and received this treatment outside the hospital.

No correlation was found between the duration of provoked vestibulodynia and the length of treatment, Spearman rank correlation coefficient [r.sub.s]=0.046 (p > 0.05). The women previously treated for more than 10 candida infections did not differ in treatment outcome as compared with the women without recurrent infections (p > 0.05), Fisher's exact test.

There was a significant increase in intercourse frequency after completing the treatment. The number of patients who had intercourse a few times per month or several times per week increased from five prior to the treatment to 16 at the follow-up (p<0.001); see Table 4. A reduction of coital pain was also reported at the follow-up. All of the 24 patients had severe vestibulodynia and were most of the time unable to have intercourse prior to the treatment. At the follow-up, 16 women (67%) reported occasional or mild pain not interfering with intercourse; three women (12%) reported moderate coital pain, sometimes preventing them from intercourse; and for another five (21%) intercourse was still most of the time very painful (p = 0.02); see Table 4. If coital pain occurred during the follow-up time, 14 women (58%) sometimes regarded it as a problem, whereas for 10 women (33%) it was often or always a concern. Seventeen women (71%) reported that the mental intention was not focused on the vestibular pain and discomfort as much as prior to the treatment.

A significant number of patients reported a major improvement in their sexuality at the follow-up. Fifteen patients regarded their general sexual functioning as much improved, as compared with nine who reported an improvement or no difference (p<0.001). The majority of the women also experienced more desire (p<0.001) and less sexual demands (p<0.01) from their partners. A more positive attitude toward their own sexuality was reported by 20 women (p < 0.01); see Table 5. General life stressors and stressors at work were considered reduced by a significant number of the women at the follow-up (p<0.001); see Table 5.

Eighteen women (75%) were in a committed heterosexual relationship at the start of the treatment, and 13 (55%) were still in the same relationship when ending the treatment. Eight of those 13 women reported that the relationships had improved after the treatment, whereas three did not experience any difference (two missing values). Four partners, out of 18, accepted the offer of a joint information session with the counselor and the midwife.

Eighteen patients (75%) experienced an improvement in their ability to establish psychological limits regarding work, social life, family, and toward their partner; p < 0.001. The ability to establish sexual limits was also better or much better in 19 patients, p<0.001, at the follow-up.

All 24 patients considered the combined physical and psychosexual treatment to be effective. Twenty-one patients reported that if any coital pain occurred after ending the treatment, they were helped by using the smearing technique of the vestibule in combination with the psychological coping skills developed during the treatment. None, except for two patients who underwent vestibulectomy, had made any visits to the gynecologist regarding symptoms of dyspareunia during the follow-up time.

Discussion

All the women who took part in the treatment modalities described in this study had severe penetration pain at most intercourse attempts at the beginning of the treatment. Clinically, most women also had a hypertonicity of the pelvic floor and a mechanical hypersensitivity of the vestibular mucosa. There is a link between vaginismus and vestibulodynia, and for the outcome of the rehabilitation it is important to restore the function of the pelvic floor muscles (Abramov et al., 1994; Reissing et al., 2004). The majority of our patients had secondary vestibulodynia and had therefore previously experienced pain-free intercourse. We agree with the theory previously described, that the dysfunction of the pelvic floor in these women is a reactive and protective response to painful vaginal penetration rather than a primary cause (Reissing et al., 2005). For women with primary provoked vestibulodynia, the role of vaginsimus is more difficult to evaluate. In some cases these two conditions could be difficult to differentiate (Wijma et al., 2000). Reissing et al. (2004) reported that women diagnosed with vaginismus do not always present a vaginal spasm during pelvic examination, which is a diagnostic criterion, according to the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV-TR). The result of the study also showed an overlap in pain measurements and hypertonicity of the pelvic floor in women with vaginismus and in women with provoked vestibulodynia, which further emphasizes the difficulties in separating these two disorders in some cases. Fear of pain and behavioral avoidance toward vaginal penetration, however, were common in vaginismus patients (Reissing et al., 2004). In our material only four women reported pain since first intercourse. These women had previously been able to, despite the pain, complete vaginal penetration and were diagnosed with primary vestibulodynia. Poorer surgical outcome has been reported in women with primary vestibulodynia as compared with women with acquired symptoms, suggesting two different entities of the same disease (Bornstein et al., 1997; Bornstein et al., 2001). One may speculate whether psychosexual vulnerability plays a more important etiological role in women with primary vestibulodynia and if these women will respond better to a psychosexual and behavioral approach in general as compared with a medical or surgical treatment. It would have been interesting to compare the treatment outcome in primary versus secondary vestibulodynia patients in the present study. The material was too small, however, to separate into subgroups, and statistical analyses would not have been reliable.

In our treatment model, the smearing and penetration exercises were specially designed for desensitization of the vestibular mucosa in addition to restoring the function of the pelvic floor. The pace for going through the hierarchy training was set individually. Initially the patients were generally reluctant to touching and smearing their genital area. Many of the patients were not aware of this avoidance, and counseling support was needed. The desensitization exercises served many purposes. By touching her own genitalia during daily training, the patient was helped psychologically to integrate her genitals with the rest of her body image and to get a better knowledge about how the pelvic floor muscles operate. Positive feedback was achieved when the mucosal hypersensitivity and the muscular hypertonicity decreased and the patient could continue with the next step of the program. Issues of avoidance were simultaneously addressed at the appointments with the psychosexual counselor. At the end of the treatment, the patients felt capable of counteracting this avoidance. The combined physical and psychosexual therapy has many features in common with a cognitive behavioral treatment model for vaginismus describing a systemic desensitization to the phobic situation using the patient's fingers (Wijma & Wijma, 1997).

Low sexual arousal and desire along with low frequency of sexual activity is commonly associated with dyspareunia (Meana et al., 1997a; Reissing et al., 2003). It has also previously been proposed that women reporting lifelong dyspareunia might in fact be suffering from concomitant low libido, arousal disorders, or both, and those women with negative sexual experiences from the beginning often need a more complex treatment including psychotherapeutic and sexual support (Graziottin & Brotto, 2004). In theory, if women are having vaginal penetration with poor physiological sexual arousal, this will result in pain due to increased mucosal friction. For the majority of the women taking part in the

treatment model, the sexual functioning had improved simultaneously as the pain gradually diminished.

Other major issues addressed by the counselor were the patients' need for control of their private and professional lives and difficulties in setting limits. The majority of the patients were university graduates and many held high professional positions with long working hours in a stressful environment. The high stress level also had an impact on the women's relationships and sexual functioning. After the treatment, most women found sex as less demanding and their sexual lives more rewarding concerning both quality and frequency. In order to alleviate the stress level, some women changed occupation during the treatment or tried body massage for relaxing general muscle tension.

The overall outcome of the treatment is comparable with the results of surgery (Haefner, 2000). The major limitation of this study however, is that it is not a randomized controlled trial. There are very few such studies published regarding provoked vestibulodynia, and the outcome of different treatments, therefore, has been difficult to compare. The instruments used for evaluation of treatment outcome also vary, and a standard protocol with precise definitions of inclusion criteria and appropriate outcome measures would be helpful in accomplishing better treatment studies in the future.

The mean length of treatment is longer compared with a study where women with vestibulodynia were randomized to surgery, EMG biofeedback, or to CBT in group for 3 months (Bergeron et al., 2001). The group CBT treatment package, however, was similar to our treatment, including education and information of vestibulodynia and its impact on sexual functioning, as well as vaginismus exercises and developing coping strategies. We have continued to use the combined treatment for women with severe vestibulodynia, and the duration of treatment is approximately the same. The treatment program is time consuming, and economical aspects also have to be taken into consideration. Due to staff limitations, there are restricted numbers of patients who can join the program at the same time. On the other hand, the treatment outcome was found to be good, and the majority of the women did not need further support during the follow-up and have not returned to the clinic afterward. Furthermore, the close collaboration among the counselor, midwife, and gynecologist increased the general knowledge about women with vestibulodynia for everyone involved in the treatment procedures. We believe it is a great advantage to work as a "team" around these patients without having to refer them out of the office for consultations.

In this study, we have tried to standardize and evaluate a combined physical and psychosexual therapy for women with severe provoked vestibulodynia. For many patients the primary problem is the physical pain around the vaginal opening, and it might be difficult for them to see an association between the pain and possible psychosexual distress (Sackett et al., 2001 ). This difficulty was emphasized in those vestibulodynia patients who declined to join the study. The main reason for not joining the study was a reluctance to see the counselor. The multidisciplinary approach described in this article is only one example of a treatment model addressing both the physical pain and psychosexual impairment in the patients. Similar models or modifications of the treatment may work just as well, but we believe that sufficient time for rehabilitation is needed to obtain a lasting improvement. The results of this study emphasize that not only persistent coital pain should be evaluated but also the effect on the patient's psychosexual well-being and quality of life. To conclude, women with provoked vestibulodynia will benefit from a multidisciplinary model including desensitization of the vestibular mucosa, rehabilitation of the pelvic floor, and psychosexual adjustments.

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Helene Backman, Marta Widenbrant, and Nina Bohm-Starke

Karolinska Institutet, Department of Clinical Sciences, Division of Obstetrics and Gynaecology, Danderyd Hospital

Lars-Gosta Dahlof

Department of Psychology, Goteborg University

The study was supported by grants from EXPO 2003, project number 0378. The coauthors acknowledge the memory of Helene Backman for her great contribution to help women with vulvar pain.

Correspondence should be addressed to Nina Bohm-Starke, Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, S-182 88 Stockholm, Sweden. E-mail: [e-mail]

Table 1. The Psychosexual Counselor's Treatment

1. Information about the impact of vestibulodynia on sexual
   function and desire and how to make improvements.

2. Evaluations and discussion of the overall view of sexuality,
   e.g., beliefs, attitudes, values, eroticism, and activities.

3. Help to establish psychological limits regarding work, social
   life, family, and partner.

4. Help to create an overall lust-filled life.

5. Stress elimination.

6. Physical and psychological practice to improve issues of
   self-esteem.

7. Psychological training to change the focus and thoughts
   regarding vestibulodynia.

Table 2. Exercises to Desensitize the Mucosa and Reduce Pelvic
Floor Tension Instructed by the Midwife

1. Education about genital and pelvic floor anatomy.

2. Touching and smearing the painful area in the vestibule once a
   day.

3. Touching and smearing the painful area in the vestibule twice a
   day.

4. Touching and smearing the painful area in the vestibule twice a
   day with pressure.

5. Contraction and relaxation exercises for pelvic floor muscles.

6. Let one finger slowly enter the vagina, keep it still for a
   moment and then withdraw it.

7. Let two fingers slowly enter the vagina, keep it still for a
    moment and then withdraw them.

8. Penetration exercises in combination with daily light massage of
   the painful area.

9. Encouraging the patient to use tampon during menstruation.

10. Encouraging the patient to have intercourse.

Table 3. Patients' Characteristics

                                      Mean or Number
Variables                             (Range) n = 24     %

Age                                   24.4 (17-23)       --
University studies > 3 years          17                 71
Current partner (married,             18                 75
  cohabiting, dating)
Ever being pregnant                    2                  8
Parity                                 0                 --
Duration of vestibulodynia, years      5.5 (1.5-13)      --
Primary vestibulodynia                 4                 17
Previous sexual threat or violence     3                 13
Previous genital infections
  Candida infection                   19                 79
  > 10 Candida infections              8                 33
  Herpes                               2                  8
  Condyloma                            3                 12
Bodily pain
  Tension headache                    14                 58
  Migraine                             4                 17
  Muscle pain                          6                 25
  Gastritis                            4                 17
  Back pain                            6                 25
  Dysmenorrhea                        21                 88

Table 4. Intercourse Frequencies and Coital Pain

                                       Before
                                    Symptoms of    Prior to      At
                                   Vestibulodynia  Treatment  Follow-up
Variables                              n = 24       n = 24     n = 24

Intercourse frequency
  --several times/week (1)               15            0          4
  --few times/month (1)                  2             5         12
  --few times/year (2)                   2             7          7
  --never (2)                            0            12          1
  --(missing value)                     (5)           --
Coital pain
  0 Never pain (3)                       --            0          0
  I Occasional or mild pain, not
    preventing intercourse (3)           --            0         16
  II Moderate pain sometimes
    preventing intercourse (4)           --            0          3
  III Moderate to severe pain,
    most times preventing
    intercourse (4)                      --           24          5

Intercourse frequency was dichotomized in high (1) and low, (2) and
coital pain is pain not preventing intercourse (3) and pain that
sometimes or most times prevents intercourse. (4) An increase in
number of women with high intercourse frequency (p=0.001) and a
reduction of women with frequently coital pain (p = 0.02) was
reported at the follow-up as compared with prior to treatment
(Fisher's exact test).

Table 5. Evaluation of Sexual Variables and Stress After the Treatment
Variables

Variables                              At follow-up n=24 (%)

General sexual functioning
  --major improvement                      15 (63)
  --improvement                             7 (29)
  --no difference                           2  (8)
Sexual desire
  --major improvement                       8 (33)
  --improvement                            12 (50)
  --no difference                           4 (17)
Sexual demands
  --much less                               9 (38)
  --less                                   12 (50)
  --no difference                           3 (12)
Attitude towards own sexuality
  --much more positive                     10 (42)
  --more positive                          10 (42)
  --no difference                           3 (12)
  --more negative                           1  (4)
General stressors in life
  --much less                               6 (25)
  --less                                   12 (50)
  --no difference                           5 (21)
  --more                                    1  (4)
Stressors at work
  --much less                               4 (17)
  --less                                   11 (46)
  --no difference                           7 (29)
  --more                                    2  (8)
Psychological limits
  --major improvement                       3 (12)
  --improvement                            15 (63)
  --no difference                           6 (25)
Sexual limits
-major improvement                          5 (21)
  --improvement                            14 (58)
  --no difference                           5 (21)