In Spanish primary care, about one in nine women had genito-pelvic pain/penetration disorder. In a trial with 97 women, both group cognitive-behavioral therapy and topical steroid reduced pain, and group therapy was superior at 6-month follow-up; and a meta-analysis of 11 trials found psychological and medical treatment effects equal.
This text brings together three sources: a systematic review and meta-analysis on these disorders in Spanish primary and community care, a randomized trial with 97 women with provoked vestibulodynia, and a meta-analysis of 11 trials on psychological treatment for vaginal pain. The limitation of each finding is stated next to that finding. The purpose is scientific information, not diagnosis or treatment choice.
In Spanish primary care, the percentage of women with genito-pelvic pain/penetration disorder was 11.23%, with a 95% confidence interval from 0% to 29%. This interval is very wide and makes the estimate uncertain.
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This number comes from a systematic review and meta-analysis. Of 551 records identified, 11 studies met inclusion criteria. In the same data, vaginismus was 5%, penetration pain 8.33%, and dyspareunia 16.45%.
The authors say these percentages may differ in other countries and lie in the upper part of European country data (9 to 11.9%). There is also wide variability among studies worldwide on the prevalence of these disorders.
Limitations stand next to this finding: the review covered only Spanish primary and community care publications, the confidence interval is very wide, heterogeneity among studies is high, and the abstract does not explain why the dyspareunia percentage is higher than the overall percentage. [Needs further review: this review’s prevalence data cover only Spanish primary care and its confidence interval is very wide.]
What did group cognitive-behavioral therapy show compared with a topical steroid?
In a randomized trial with 97 women with provoked vestibulodynia, both group cognitive-behavioral therapy and topical steroid reported significant reductions in pain. At 6-month follow-up, pain reduction on the pain questionnaire was significantly greater in the cognitive-behavioral therapy group.
This type of pain is the most common form of dyspareunia. 97 women were randomly assigned to 2 groups and the trial lasted 13 weeks. Assessments before treatment, after treatment, and 6 months later were conducted by interview and questionnaire and measured pain, sexual function, psychological adjustment, and treatment satisfaction.
Both groups improved in psychological adjustment, and the cognitive-behavioral therapy group had a greater reduction in pain catastrophizing, that is, catastrophic thinking about pain, immediately after treatment. Sexual function improved in both groups from baseline to after treatment and at follow-up, and the cognitive-behavioral therapy group was superior at that follow-up. Treatment satisfaction and reported improvement in pain and sexuality were also greater in this group.
The authors say this treatment may positively affect more dimensions of dyspareunia than a topical steroid, and that the findings support recommending it as first-line treatment for provoked vestibulodynia. Limitations: it is only one trial, includes only women with this type of pain, assessments were conducted by interview and questionnaire, and the abstract gives no numerical effect size.
In clinical experience (not a finding of these studies), many women tolerate pain for years because they do not know this pain can be talked about and can be assessed. Our editorial position is clear: pain during intercourse is not a sign of weakness and is not a reason to endure it in silence.
For treatment selection, should the cause of pain be considered medical or psychological?
Based on a meta-analysis of 11 randomized trials, the effects of psychological treatments and medical treatments were equal, and the effect sizes of psychological arms were comparable across different types of vaginal pain. The authors concluded that the presumed cause may not be a useful guide for treatment selection.
In the new edition of the psychiatric classification, genito-pelvic pain/penetration disorder includes dyspareunia and vaginismus. The meta-analysis authors say that the classification of vaginal pain in medical or psychiatric diagnostic systems relies largely on the presence or absence of a presumed medical cause; however, treatment efficacy was equal regardless of this presumed cause.
Limitations: the abstract of this meta-analysis gives no numerical effect size and no participant count, and it does not provide separate numbers for each type of pain. This finding does not mean medical evaluation is unnecessary; that is a clinical suggestion, not a finding of these studies.
When should one see a doctor and a therapist?
These sources report no fixed timeline. The general recommendation is that if pain during intercourse recurs or persists, medical evaluation and, if needed, referral to a therapist should be undertaken. This is a clinical suggestion, not a finding of these studies.
From a clinical perspective (not a finding of these studies), medical evaluation clarifies the physical condition, and a therapist can address dimensions measured in the trials: pain, sexual function, psychological adjustment, and treatment satisfaction. The choice among treatments is made by clinical evaluation.
The decision to start treatment is made by individual evaluation, not by a general rule. From a clinical perspective, if pain has persisted or suffering is considerable, seeking care earlier is more reasonable than waiting; this is also a suggestion, not a finding of these studies.
Not completely. The new edition of the psychiatric classification places both under one heading, genito-pelvic pain/penetration disorder, but the review reported their prevalence separately: vaginismus 5% and dyspareunia 16.45%.
Does group therapy replace topical treatment?
This trial did not make such a claim. Both groups reported significant pain reduction, and only at 6-month follow-up did the cognitive-behavioral therapy group show superiority on the pain questionnaire. The choice among options is made by clinical evaluation.
Does this percentage apply to women in other countries?
The authors themselves say it may differ. Those percentages cover only Spanish primary and community care and lie in the upper part of European country data (9 to 11.9%); for other countries, no number is given in this abstract.
Should medical evaluation be done before psychotherapy?
The sources above did not examine the order of evaluation and treatment. From a clinical perspective (not a finding of these studies), when pain recurs, medical evaluation is a reasonable step and psychotherapy can come alongside it or after it. The order is determined by clinical evaluation.
Conclusion
In the Spanish primary care review, the percentage of women with genito-pelvic pain/penetration disorder was 11.23%, with a 95% confidence interval from 0% to 29%; a very wide interval. In the trial of 97 women with provoked vestibulodynia, both group cognitive-behavioral therapy and topical steroid reported pain reduction, and group therapy was superior at 6-month follow-up. In the meta-analysis of 11 trials, the effects of psychological and medical treatment were equal. These three findings relate to three different groups and cannot be pooled; therefore, pain during intercourse is a matter for evaluation and discussion, not a sign of failure.
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Berenguer-Soler M, Navarro-Sánchez A, Compañ-Rosique A, et al. Genito Pelvic Pain/Penetration Disorder (GPPPD) in Spanish Women-Clinical Approach in Primary Health Care: Review and Meta-Analysis. J Clin Med. Epub 2022 Apr 22; 11(9):2340. PMID: 35566467. DOI: 10.3390/jcm11092340
Bergeron S, Khalifé S, Dupuis MJ, McDuff P. A randomized clinical trial comparing group cognitive-behavioral therapy and a topical steroid for women with dyspareunia. J Consult Clin Psychol. Epub 2016 Jan 4; 84(3):259-268. PMID: 26727408. DOI: 10.1037/ccp0000072
Flanagan E, Herron KA, O’Driscoll C, Williams AC de C. Psychological treatment for vaginal pain: does etiology matter? A systematic review and meta-analysis. J Sex Med. Epub 2014 Oct 20; 12(1):3-16. PMID: 25329756. DOI: 10.1111/jsm.12717
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