REVIEW

CURRENT
OPINION Female sexual pain disorders: dyspareunia and
vaginismus
Chiara Simonelli a, Stefano Eleuteri a, Filippo Petruccelli b, and
Roberta Rossi c

Purpose of review
To analyze literature on sexual pain disorders and to review and summarize the articles published
throughout 2013 which contribute to the current knowledge on this subject.
Recent findings
By age 40, 7.8% of women reported vulvar pain. Diagnostic and Statistical Manual of Mental Disorders,
fifth edition, has combined vaginismus and dyspareunia into the same diagnostic label. The research
reviewed in this article seems to differently point toward two conditions, focusing on different aspects both
on the etiological and on the treatment area. Higher levels of partner-perceived self-efficacy and lower
levels of partner catastrophizing were associated with less pain intensity in women with entry dyspareunia,
independent of women’s pain perception and self-efficacy. Alexithymia and fear were found to be
important etiological factors in vaginismus.
Summary
The present findings did not provide clear evidence in support of the superiority of any treatment and
highlight the need for randomized, placebo-controlled trials that compare treatments in the future. A lot of
work remained to be done to understand such a complex and multifaceted disturbance as genital sexual
pain, but the articles examined showed that we are slowly adding more knowledge on the etiological
cause and treatment models for such conditions.
Keywords
dyspareunia, sexual disorder, sexual pain, vaginismus

INTRODUCTION their practice and refer mostly for treatment failure.

‘Genito-pelvic pain/penetration disorder (GPPD)’ is
a common, distressing complaint in women of all
ages that is underrecognized and undertreated. The
incidence of such dysfunction has been studied only
& &
fragmentarily [1 ]. Harlow et al. [2 ] found that, by
age 40, 7.8% of women reported vulvar pain (see
Table 1).
This condition has broad implications for a
Vaginismus, now included in GPPD, was also con-
sidered the cause of unconsummated marriages, even
if recent findings suggest that the female difficulty
should not be seen as the primum movens but as a
potential contributory cause together with partner
sexual difficulties [5].
Given the high prevalence of chronic genital
pain and the relative lack of knowledge about this
&

woman’s well-being. It can impact her mental and
physical health, relationships, ability to work
and more; additionally, women with provoked
vestibulodynia (PVD) report significantly lower
levels of sexual functioning in comparison with
control women [3]. As most people in the general
population – and many healthcare professionals
(HCPs) – are unaware of the severity and wide-
ranging effects of dyspareunia, affected women
may have a difficult time obtaining support. A recent
survey [4], for example, revealed that physicians are
moderately comfortable treating vulvodynia within
condition within the medical community [6 ],
this review could be important to gain a compre-
hensive understanding of this condition.
a
Sapienza, University of Rome, bUniversity of Cassino and Southern
Lazio and cInstitute of Clinical Sexology, Rome, Italy
Correspondence to Professor Chiara Simonelli, Sapienza, University
of Rome, Via Savoia 78, 00198 Rome, Italy. Fax: +39 06 85356118;
e-mail: chiara.simonelli@uniroma1.it
Curr Opin Psychiatry 2014, 27:406–412
DOI:10.1097/YCO.0000000000000098

www.co-psychiatry.com Volume 27  Number 6  November 2014


KEY POINTS
 Because of the marked overlap in symptoms,
vaginismus and dyspareunia have been combined in
the DSM-5 into ‘GPPD’.
 Psychosocial, cultural, sexual and biological factors
can, independently or in combination, cause the
establishment and maintenance of GPPD.
 There is no evidence in support of the superiority of any
treatment for GPPD.
DIAGNOSIS, ASSESSMENT AND
DIAGNOSTIC AND STATISTICAL MANUAL
OF MENTAL DISORDERS, FIFTH EDITION,
DISCUSSION
In the Diagnostic and Statistical Manual of Mental
Disorders, fourth edition, text revision (DSM-IV-TR)
[7], vaginismus and dyspareunia were considered as
two different diagnostic entities. The significant
overlap between vaginismus and superficial dyspar-
eunia on symptom dimensions reported in literature
made it almost impossible to reliably differentiate
one from the other, leaving the clinicians to
consider whether they might lie on the same con-
tinuum with superficial dyspareunia sometimes
extending to vaginismus [8]. Because of this marked
overlap in symptoms, they have been combined in
the DSM-5 into GPPD [9].
&&
The new diagnostic criteria [10 ] describe the
following different symptoms: difficulties with
vaginal penetration during intercourse; vulvovagi-
nal or pelvic pain during vaginal intercourse or
penetration attempts; fear or anxiety about vulvo-
vaginal or pelvic pain in anticipation of, during or as
a result of vaginal penetration; tensing or tightening
of the pelvic floor muscles during attempted vaginal
penetration. Sungur and Gündüz [9] report that
overall, merging superficial dyspareunia and
Table 1. Different sexual pain conditions
Condition Clinical feature
Dyspareunia Genital pain experienced just before, during or
after sexual intercourse.
Vaginismus Involuntary spasm of the perineal and levator
muscles, hypertonicity,
impossibility of penetration, fear of pain.
Vestibulodynia Severe pain upon touch or attempted
vaginal entry, within the vulvar vestibule,
physical findings limited to vestibular erythema.
Vulvodynia Chronic pain in the vulvar area of at least
3–6 months duration.
0951-7367 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Female sexual pain disorders Simonelli et al.
vaginismus into GPPD in DSM-5 is welcomed by
many professionals, whereas some debate that they
can be different entities on the same continuum,
with lifelong and generalized vaginismus associated
with high anxiety and avoidance at one end of the
spectrum and painful intercourse with high pelvic
floor tension on the other end [11].
Despite these diagnostic changes, all the articles
published last year that we considered for this
review continue to refer to these problems as differ-
ent conditions and with different terms.
Vulvodynia is an umbrella term to define genital
pain that has no clear etiology and treatment.
Subtypes are often defined on the basis of their pain
location: localized vulvodynia refers to pain in a
particular part of the vulva, such as the vestibule
(i.e., vaginal entrance) or clitoris, and generalized
vulvodynia (GVD) refers to pain affecting the entire
vulvar region. The pain can be further specified
according to when it occurs: provoked (the pain
occurs in response to external stimulation, e.g.,
pressure), unprovoked (spontaneous pain, occurs
independently of stimulation) and mixed (a combi-
nation of provoked and unprovoked pain presen-
tation). Two common subtypes of vulvodynia have
been identified and studied: PVD, previously known
as vulvar vestibulitis syndrome and sometimes
termed localized provoked vulvodynia, and GVD.
The primary differences of such conditions with
vaginismus were the presence of fear/avoidance as
well as muscle tension being so pronounced to
&
prevent penetration [6 ]. Recent research has indi-
cated that women with vaginismus respond differ-
ently to sexual stimuli compared to women with
dyspareunia and women with pain-free intercourse.
They express lower ratings of pleasant feelings
and greater endorsement of negative emotions, such
as annoyance, threat, disgust, anxiety, in response
to erotic films and slides depicting intercourse
&&
[12 ,13].
A study [14] using functional MRI was con-
ducted to examine whether women with vaginis-
mus show stronger convergence in their responses
toward sexual penetration and disgust-related pic-
tures compared to sexually asymptomatic women
and women suffering from vulvar pain. At a sub-
jective level, both clinical groups rated penetration
stimuli as more disgusting than asymptomatic
women. Surprisingly, the brain responses to
penetration stimuli did not differ between groups.
The authors assume the alleged female ambiguity
toward penetration can be a possible explanation for
the lack of vaginismus-specific brain responses: a
default disgust response tendency could, generally,
prevail in women in the absence of sexual-specific
interest and readiness.
www.co-psychiatry.com 407
Sexual disorders

Women with dyspareunia reported more limi- Recent studies have focused on different etio-
& && &
ted sexual desire and lubrication and fewer positive logical factors for dyspareunia [15 ,16 ,17,18 ,
& && &&
penetration-related cognitions compared to the 19,20] and for vaginismus [1 ,21 ,22 ].
women with vaginismus; they also reported greater
sexual anxiety than the control group [13].
In general, several guidelines should be kept in Dyspareunia and vulvodynia
mind when assessing these conditions. HCPs should An association was found between dysmenorrhea
encourage their patients to begin by describing how and noncyclic pelvic pain, suggesting that men-
and when they noticed their pain developing, strual pain is an etiological factor in noncyclic pelvic
&
how it progressed and what their current set of pain [15 ].
symptoms looks like. Rating the severity on a scale Moreover, two important studies revealed that
from 0 (no pain at all) to 10 (worst pain ever felt) is aspects of sexual self-schema (negative self-image
useful for assessment as well as for treatment cognitions about vaginal penetration, negative
monitoring. It is also relevant to discern how the body image and negative genital self-image) are
patient has already tried to alleviate the pain. In associated with increased pain intensity, sexual dys-
&&
addition to ascertaining a woman’s current pain function and sexual distress [16 ,17].
&
profile, HCPs should establish what situations are Three Canadian studies [18 ,19,20] examined
most likely to cause pain. For all women with the role of partner-perceived self-efficacy and
vulvodynia, there might be certain external factors
that trigger the pain, such as stressors or mood. For Table 2. Physical conditions causing genital sexual pain
women with GVD, it is important to know whether
their pain is constant or fluctuating and when those Physical condition Effect on sexual pain
fluctuations are most likely to occur. For women
Endometriosis Predominant cause of deep dyspareunia.
with PVD, it is important to know whether their
Pelvic inflammatory Abdominal adhesions with chronic pain
pain is evoked by certain types of contact/penetra-
disease including deep dyspareunia.
tion (e.g., manual vs. phallic, intercourse position,
Estrogen deficiency Common cause of dyspareunia in
arousal/anxiety levels). Identifying such factors postmenopausal women due to
assists in selecting treatment options and goals that vulvovaginal atrophy.
target each woman’s particular pain profile. Pelvic organ prolapse, Do not seem to affect sexual function,
Although a woman’s self-reported symptoms and urinary incontinence but patients should be informed about
history are the most relevant source of such infor- potential deleterious impacts
mation, HCPs should take care to confirm their after surgery.
reports, whenever possible, either through medical Interstitial cystitis Commonly reported in patients with
records, performing their own physical examin- dyspareunia.
ation, or through third-party informants (e.g., a Female genital Aside from dyspareunia, other severe
mutilation adverse effects occur and for many
woman’s partner). In addition to identifying pain
women, lifelong suffering.
characteristics and history, it is important to isolate
Gynecological cancer Pelvic radiation and chemotherapy causes
other psychosocial factors that might exacerbate the therapy fibrosis and atrophy of the lower genital
pain. The identification of such factors could be tract, hampering lubrication and
ascertained during both clinical interviews and causing dyspareunia.
&
the administration of validated questionnaires [6 ]. Cancer chemotherapy Causes atrophy of the vaginal mucosa;
local estrogen therapy is cautioned in
women with breast cancer.
ETIOLOGY Graft vs. host reaction Reported adverse effect in the vagina after
The etiology of GPPD is multifaceted. Psychosocial, systemic immunosuppressive treatment.
cultural, sexual and biological factors can, inde- Malformations Vaginal septum, congenital abnormalities.
pendently or in combination, cause the establish- Hidradenitis Chronic scarring in severe cases.
&
ment and maintenance of GPPD [1 ]. No single suppurativa
etiology has been identified, and different women Uterine fibroid Pressure pain of the bladder and intestine,
mainly deep dyspareunia.
suffering from similar pain presentations will often
Irritable bowel Comorbid in women with localized
describe very different pain development patterns.
syndrome provoked vulvodynia.
Similarly, those describing parallel etiologies may
& Pelvic radiation Causes atrophy, agglutination, decreased
report very different pain presentation [6 ]. lubrication and dryness, superficial as
To provide an overview of the most common well as deep dyspareunia.
somatic disorders causing genital sexual pain see
&
Table 2. Adapted from [1 ].

408 www.co-psychiatry.com Volume 27  Number 6  November 2014


partner catastrophizing in the experience of pain,
sexual functioning and sexual satisfaction of
women with entry dyspareunia and with PVD.
Higher levels of partner-perceived self-efficacy and
lower levels of partner tragic attitude were associ-
ated with less pain intensity in women with entry
dyspareunia, independent of women’s pain percep-
&
tion and self-efficacy [18 ]. Rosen et al. [19], studying
women with PVD, found that participant’s tragic
feeling and self-efficacy partially mediated the
association between higher participant-perceived
solicitous responses and higher pain intensity.
Similarly, partner catastrophizing and self-efficacy
partially mediated the association between higher
partner-perceived solicitous responses and
higher pain intensity in women with PVD. Solici-
tous partner responses may have opposing effects.
On one hand, they can generate cognitions that
the pain is uncontrollable and may lead to further
avoidance of sexual activity: partner solicitousness
may encourage avoidance of sexual intercourse
and/or exacerbate vulvovaginal pain by increasing
catastrophizing and decreasing self-efficacy. On the
other hand, solicitous responses may lead to greater
sexual satisfaction because women interpret these
responses as reflecting partner sensitivity and under-
standing of their pain, resulting in greater sexual
satisfaction. In contrast, women may interpret nega-
tive partner responses as a lack of sensitivity to their
pain, thereby creating a detrimental context for
sexual activity, resulting in lower sexual satisfaction.
Dyadic adjustment partially mediated the associ-
ation between higher participant-perceived solici-
tous responses and higher sexual satisfaction, and
fully mediated the association between higher
participant-perceived negative responses and lower
sexual satisfaction.
A third study [20] labelled male partner
responses to painful intercourse into three different
kinds of responses: solicitous (attention and sym-
pathy), negative (hostility and frustration) and
facilitative (encouragement of adaptive coping).
The findings suggest that facilitative male partner
responses may improve sexual functioning, whereas
solicitous and negative responses may be detrimen-
tal.
Vaginismus
&&
An Italian study [21 ] aimed to measure the preva-
lence of alexithymia and emotional dysregulation
in women with vaginismus. The cumulative per-
centage of patients with alexithymic trend was
51.1%, indicating that a considerable number of
women with vaginismus react in such a way as to
suggest that their capacity for emotional processing
0951-7367 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Female sexual pain disorders Simonelli et al.
is partly or completely absent. In contrast, the
cumulative percentage of alexithymic and border-
line scores in the control group was just 18%, sig-
nificantly lower than in the patient group. In terms
of relative risk, women suffering from vaginismus
thus have a 3.8 times higher probability of showing
alexithymia than healthy women. The subanalysis
showed a significant difference between the groups
for TAS-20 subscale F1 (difficulty identifying feel-
ings), F2 (difficulty in expressing feelings) and F3
(externally oriented thinking). Women with vagi-
nismus essentially demonstrated poor cognitive-
emotional processing, which seemed to be indica-
tive of a tendency to somatization. This group also
tended to have a concrete, logical cognitive think-
ing style not mediated by any reflective function.
However, there was no significant difference
between the groups in describing feelings, such as
joy or uneasiness, to others. Because of the high
incidence of alexithymia, it must thus be considered
as a risk factor in some patients affected with vagi-
nismus, as this personality trait could exacerbate
and perpetuate this psychogenic sexual dysfunc-
tion.
&&
Melles et al. [22 ], supporting the importance of
fear in vaginismus, found that women with such
dysfunction showed relatively stronger fear associ-
ations with sexual stimuli at the subjective (delib-
erate) level but not at the more automatic level. The
initial (automatic) appraisals are proposed to follow
from the direct activation of simple associations in
memory, whereas the more deliberate appraisals are
assumed to be the result of more controlled, reflec-
tive processes. Moreover, women with vaginismus
also showed less positive self-reported global affec-
tive associations with sexual stimuli, whereas at the
automatic level, they showed similarly positive
global affective associations with sexual stimuli as
women without vaginismus.
Vaginismus, in contrast to superficial vulvody-
nia, is probably best described as a phobic defense
mechanism – perhaps often elicited by psychosex-
&
ual negative experiences [1 ].
IMPLICATIONS FOR TREATMENT
Literatures have been studied and different treat-
ment issues have been proposed for dyspareunia
& & & & & && && &
[1 ,2 ,6 ,18 ,23 ,24 ,25 ,26 ,27 ] and for vaginis-
&
& & && && & &
mus [1 ,6 ,21 ,22 ,28 ,29,30 ].
Dyspareunia and vulvodynia
The multifactorial nature of vulvodynia therefore
often calls for a multidisciplinary approach to estab-
lish a valid diagnosis and appropriate treatment
www.co-psychiatry.com 409
Sexual disorders
&
strategy [1 ]. Almost half of these women never seek
&
treatment [23 ], and more than 50% of them who
sought care with known healthcare access received
&
no diagnosis [2 ].
&
Nguyen et al. [23 ] tried to investigate one
of the possible causes that could lead women
not to seek care for chronic vulvar pain: the per-
ceived stereotyping. The hypothesis was that
perceived stereotyping regarding vulvar pain
sufferers, which may ultimately lead to stigma,
could contribute to estrangement from healthcare
providers. The results of the study do not suggest
that the perception of stereotyping from physicians
or other people was the barrier to seeking care. In
fact, women who sought care were more likely to
have a poor perception of physicians’ stereotyping
opinions. These findings suggest that other causes
influencing the failure to seek care for chronic
vulvar pain should be investigated.
&&
A Canadian study [24 ] was carried out to assess
changes over a 2-year period in pain, depressive
symptoms and sexual outcomes in women with
PVD and examine changes based on treatment(s)
type. They took into consideration various types of
treatment (physical therapy, sex therapy/psycho-
therapy, medical management, surgery, acupunc-
ture, other, multiple, no treatment) finding that
all treatments except acupuncture, which showed
a minor efficacy, were associated with significantly
lower pain levels after 2 years, including the ‘no
treatment’ group.
Considering that there appears to be a signifi-
cant advance in pain over time without treatment,
it is imperative that randomized trials yield an
improvement above and beyond what appears to
be the natural progression of PVD. Although pain
reduction is an important goal in treatment of PVD,
once the pain is reduced, further treatment tailored
to the individual or couple may be needed to
improve other aspects of quality of life. This may
be a way in which some of the treatments outper-
form the no treatment group, as the no treatment
group did not progress significantly on any psycho-
sexual measures, whereas other treatment groups
did.
A multimodal pain-driven management model
is recommended, although the treatment literature
is still sparse. Treatment aims should be decided
upon collaboratively and may extend beyond pain
relief.
Psychotherapy can be used to target specific
cognitive, emotional, relational and behavioral
goals related to the experience of chronic pain. It
is of particular benefit as it is noninvasive and does
not cause unwanted side-effects. Psychotherapy
is recommended if patients report unwanted
410 www.co-psychiatry.com
cognitions or behaviors, have a difficult time
emotionally and/or experience sexual and relation-
ship difficulties. There are many different types of
psychotherapy that could be applied to vulvodynia,
although few have received rigorous research
attention. In general, a flexible treatment approach
that addresses both pain and sexuality issues
should be applied, as each patient brings a unique
pain profile, and may experience the impact of
&
the pain in varying ways [6 ].
The practice of mindfulness-based cognitive
therapy has also garnered attention in the treatment
&&
of dyspareunia [25 ]. Techniques that help patients
remain in the moment and find ways to tolerate and
accept their pain have been growing in popularity.
Such approaches also assist patients to become more
attuned to the factors that increase or decrease their
pain and encourage them to also attend to positive
events in their life and relationship. Finally, some
patients would greatly benefit from sex or couples
therapy. Ideally, the therapy would target the
pain in a collaborative manner. Such a practice
could involve improving communication, reducing
feelings of guilt or shame and building positive
sexual encounters while managing pain. Partners
can be instructed in assisting with mindfulness
or distraction to cope with the pain. Elements of
couples therapy could be incorporated into indivi-
dual therapy if the patient does not wish to have her
partner present at every session. Addressing dyadic
factors early in the management course of entry
dyspareunia may improve the success of therapeutic
&
interventions [18 ].
There is limited evidence that antidepressants
and anticonvulsants are helpful for women with
& &
vulvodynia [26 ,27 ]. Some have hypothesized that
such medications might be more useful for women
with GVD as their pain is more constant, and others
suggest that further research is required to deter-
mine particular combinations of medical therapy to
treat specific pain presentations. If a patient has a
comorbid mood and/or anxiety disorder, the admin-
istration of appropriate medication may assist in
reducing symptoms of those disorders, which might
in turn improve a patient’s pain experience. It is
optimal to offer pharmacotherapy in concert with
&
psychotherapy [6 ].
Vaginismus
Psychotherapeutic techniques targeting phobias
can be adapted to situations that evoke such a fear
response and avoidance in women with vaginismus
&
[6 ]. Although there is currently no conclusive evi-
dence on this area of debate, the reasonable
evidence that cognitive behavioral therapy may
Volume 27  Number 6  November 2014

alleviate or eliminate ‘vaginismus’ appears to
support the relationship between vaginismus and
phobia. Fear of pain should be addressed as it can be
an important component of vaginismus. Further-
more, screening for depression and anxiety is
&
recommended [1 ]. Counselling could help explore
the alexithymic trait as part of an integrated
&&
treatment regime for vaginismus [21 ]. Exposure
therapy was found to be very effective in reducing
symptoms of vaginismus and in amplifying the self-
reported global positive affective associations with
sexual stimuli, whereas the automatic associations
&& & genital pain.
remained unaffected [22 ,28 ]. Sex therapy based
on cognitive behavioral methods has resulted in
success [29].
&
A preliminary study [30 ] indicates that physical
therapy may also be a promising intervention in the
treatment of vaginismus, even if prospective treat-
ment outcome studies are necessary.
CONCLUSION
DSM-5 has combined vaginismus and dyspareunia
into the same diagnostic label. The research
reviewed in this article seems to differently point
toward two conditions, focusing on different aspects
both on the etiological and on the treatment areas.
The present findings did not provide clear evidence
in support of the superiority of any treatment and
highlight the need for randomized, placebo-
controlled trials that compare treatments in the
&&
future [24 ]. A lot of work remained to be done
to understand such a complex and multifaceted
disturb like female GPPD, but the articles examined
showed that we are slowly adding more knowledge
on the etiological cause and treatment models for
such conditions. In line with emergent findings on
the differences between vaginismus and dyspareu-
nia, the results of this review may call into question
a combination of the disorders into GPPD.
Acknowledgements
None.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
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women not to seek care for chronic vulvar pain.
www.co-psychiatry.com 411
Sexual disorders
24. Davis SN, Bergeron S, Binik YM, Lambert B. Women with provoked vesti-
&& bulodynia experience clinically significant reductions in pain regardless of
treatment: results from a 2-year follow-up study. J Sex Med 2013; 10:3080–
3087.
An important study comparing results from different kind of treatments for
vestibulodynia.
25. Rosenbaum TY. An integrated mindfulness-based approach to the treatment
&& of women with sexual pain and anxiety: promoting autonomy and mind/body
connection. Sex Relation Ther 2013; 28:20–28.
A criticism on the treatment approach for women with sexual pain.
26. Leo RJ, Dewani S. A systematic review of the utility of antidepressant
& pharmacotherapy in the treatment of vulvodynia pain. J Sex Med 2013;
10:2497–2505.
This is a systematic review on the utility of antidepressant pharmacotherapy in the
treatment of vulvodynia.
412 www.co-psychiatry.com
27. Spoelstra SK, Borg C, Weijmar Schultz WCM. Anticonvulsant pharmacother-
& apy for generalized and localized vulvodynia: a critical review of the literature.
J Psychosom Obstet Gynecol 2013; 34:133–138.
An important review synthesizing data on anticonvulsant pharmacotherapy in the
treatment of vulvodynia.
28. Ter Kuile MM, Melles R, de Groot HE, et al. Therapist-aided exposure for
& women with lifelong vaginismus: a randomized waiting-list control trial of
efficacy. J Consult Clin Psychol 2013; 81:1127–1136.
A study highlighting the effect of exposure therapy for vaginismus.
29. Ozdel O, Tumkaya S, Levent N, et al. Effects of sex therapy based on cognitive
behavioral methods on sexual problems of women with vaginismus and their
spouses. Anadolu Psikiyatri Derg 2013; 14:129–135.
30. Reissing ED, Armstrong HL, Allen C. Pelvic floor physical therapy for women
& with lifelong vaginismus: a retrospective chart review and interview study.
J Sex Marital Ther 2013; 39:306–320.
A preliminary study proposing pelvic floor physical therapy for vaginismus.
Volume 27  Number 6  November 2014