Female dyspareunia . . . may be one of the earliest recognized sexual dysfunctions . . . the most
common . . . possibly the most underreported . . . and the sexual dysfunction most linked to physiological
pathology. Perhaps one of the reasons why the literature . . . is filled with absolutes is
because of one further distinction - it is clearly the most underinvestigated . . .
Meana and Binik, 19941
A 32-year-old nurse was seen in consultation with her 35-year-old husband. They
were married seven years and had two children. Their sexual experiences had always
been pleasurable and free of problems until two years ago. Immediately after the
birth of their second child, she experienced persistent pain whenever intercourse
was attempted. The pain was located at the entrance to her vagina and became evident
only with entry. Before her vaginal pain began, the frequency of intercourse was
several times each week but now was reduced to once or twice each month. She and
her husband remained sexually interested and sexual activity (excluding, by agreement,
attempts at intercourse) occurred several times each week.
The use of tampons had never been a source of difficulty for her but she stopped
using them after her last childbirth. Vaginal examinations by her doctor were uncomfortable
in the past but now they were associated with great pain. At her request her
husband stopped inserting his finger into her vagina during sexual experiences. On
examination by a gynecologist, there was vaginal spasm at the introitus and mild
reddening in the 4 to 9 o’clock area of the vestibule. The cotton swab test (see Figure
13-2 and `Physical Examination’ below in this Chapter) showed exquisite tenderness
in this same region, indicating a diagnosis of vulvar vestibulitis.
Anesthetic ointment relieved her pain temporarily but also diminished pleasurable
feelings. Vaginal dilators helped relieve the vaginal spasm so that when intercourse
occurred it was less painful. Surgery was discussed with her and while she
and her husband viewed this as a possible option, they preferred to wait until other
approaches were exhausted.
A 23-year-old school teacher was seen with her husband of eight months because
intercourse was attempted on many occasions but had never actually occurred
(either during her marriage or before). She
reported experiencing vaginal discomfort
when intercourse was attempted. Both were born of families that emigrated
from Asia and had known each other since childhood. The marriage was born of a
love relationship rather than having been arranged but they nevertheless refrained
from including intercourse in their sexual activities before their wedding because of
family, religious, and cultural proscriptions. Both families were applying not-sosubtle
pressure on the couple to have children. No one else knew of their inability
to have intercourse. She was terrified of pain and expected to experience pain with
anything entering her vagina (or going out, hence also her fear of childbirth). Her
dread of pain with intercourse was so strong that she cried out when he neared her
vulva (a reaction that made him progressively less enthused about making any
attempt at vaginal entry).
In an initial inspection-oriented pelvic examination, the patient was in a semireclining
position and watched the procedure with a handheld mirror. Cotton swab
test was negative. When on a subsequent occasion the end of the physician’s finger
was introduced into the patient’s vagina, the physician could feel a ring of surrounding
muscle. The diagnosis of vaginismus was made and the patient and her
husband began a treatment program. About four months later, intercourse occurred
successfully on many occasions, and when last seen she was pregnant.
Terminology problems have more to do with health professionals than with patients
or the lay public. Vulvodynia is a general term recommended by the International
Society for the Study of Vulvar Disease (ISSVD) to describe any chronic discomfort
or pain in the vulvar region regardless of etiology and not necessarily related to
sexual activity.2 Dyspareunia is more specific in describing pain associated with sexual
intercourse. Dyspareunia could be felt at the point of vaginal entry, associated with
the back and forth movements of intercourse, or deep within the patient’s vagina.
Insofar as pain with intercourse is discussed, this chapter concerns itself principally
with the first.
However, patients may complain of vaginal “discomfort,” rather than pain, when
intercourse occurs. Whether such discomfort always represents mild pain, does so
sometimes, or is something else altogether is unclear. The multiplicity of problems
that are inherent in the present use of the word “dyspareunia” were outlined by
Meana and Binik and include issues such as unclear definition, disagreement over
the inclusion or exclusion of certain disorders (such as vaginismus and postmenopausal
vaginal dryness), confusion about the role of physical and psychological factors
in the etiology, and the meaning of not finding abnormalities on pelvic examination.
1 Another source of confusion can be found in the use of the word vaginismus,
which in the literature describes (1) a physical sign accompanying various casuses
of painful intercourse and (2) a specific disorder. (In this Chapter, the words “vaginal
spasm” will be used to describe the former, and “vaginismus” will refer to the
Vulvar vestibulitis (VVS) is a specific diagnostic term that is defined and discussed
below in this chapter.
While the heading “Sexual Pain Disorders” was not carried over from DSM-IV3 to
DSM-IV-PC4, both classification systems continue a tradition of asking clinicians to
think of two disorders (dyspareunia and vaginismus), and to do so in an either/or fashion.
The criteria for both are summarized in the PC version respectively as follows:
“recurrent or persistent genital pain . . . before, during, or after sexual intercourse,
causing marked distress or interpersonal difficulty” (p. 117) and “recurrent or persistent
involuntary spasm of the musculature of the outer third of the vagina that interferes
with sexual intercourse, causing marked distress or interpersonal difficulty” (p. 118).4
In relation to the problem of pain, discomfort, and/or fear of intercourse in women,
DSM-IV-PC4 definitions and accompanying clinical information often conflict with
clinical experience and result in confusion when trying to distinguish dyspareunia and
vaginismus. The two often occur together. For example, when intercourse is attempted
in the context of vaginismus, patients usually complain of pain (although fear of pain
may be much more prominent). Likewise, when persistent painful intercourse occurs
for reasons other than vaginismus, it is clinically commonplace to see associated vaginal
spasm. In such instances, vaginal spasm seemingly functions as a symptomatic and
defensive (usually involuntary) reaction of the woman to protect herself against anticipated
Theoretically, the subclassification of disorders that cause fear, discomfort, or painrelated
difficulties with intercourse in women involve the assessment of whether the
problem is lifelong or acquired, situational or generalized. In clinical practice, the first
two patterns described below are most commonly seen; the third probably occurs
frequently in the community but is uncommonly presented to health professionals.
The assessment of pain, discomfort, or fear associated with attempts at intercourse in
women is outlined in Figure 13-1.
When hearing that pain or fear associated with attempts at intercourse have always
existed, the history is often that of an unconsummated marriage. Not only has a man’s
penis never entered her vagina, but the same story is also heard concerning her own,
or her partner’s fingers, tampons or a physician’s fingers or speculum. Alternatively,
vaginal entry of a current or previous partner’s penis may have taken place but pain
persisted through much of the experience of intercourse. Prior to intercourse attempts
(e.g., in the premarital period when a woman resolutely decides against having intercourse
before marriage), she often found herself sexually interested, wet, and possibly
orgasmic. While this response may have continued in the short run (e.g., after marriage),
the pattern may have altered in the long run as a result of pain and fear connected
to present attempts at penile entry. In such a situation, women typically feel
self-deprecatory, saying that they feel “abnormal” as women and as a marital and sexual
partner. In a frenzy of ambivalence, she may have explicitly suggested to her partner
that he “find himself someone else” while simultaneously fearful that he will do exactly
that. The agony of feeling unable to become pregnant through intercourse is often the
final straw that drives her to the humiliating admission that help is necessary to accomplish
what television, magazines, and billboards shout is a common event for the rest
A 22-year-old woman saw her family doctor because she had married three weeks
before but was unable to have intercourse despite numerous attempts. It was evident
that she was fearful of vaginal entry but it was not evident whether she also
experienced pain when intercourse was attempted. She and her husband were sexually
active with one another in the three years of their courtship but decided for
religious reasons that intercourse should be included only after they married. Their
sexual practices did not include vaginal insertion of his fingers, and, as well, she
never had intercourse with a previous sexual partner, did not like the idea of tampons,
and never had a vaginal examination from a physician. Neither she nor her
husband described any other difficulties with their sexual function.
A pelvic examination was scheduled for the following day when the physician
could allocate a greater amount of time. The external vulvar examination revealed
no structural pathology and a negative swab test. The physician then explained her
diagnostic impression of vaginismus and aspects of the anatomy and physiology of
the patient’s vagina, reassured the patient that there were no apparent structural
problems impeding intercourse, described the importance of control by the patient
in relation to vaginal insertion, and encouraged the patient to insert her own and
then the doctor’s finger part-way into her vagina. With patience and encouragement
from the doctor, finger insertion took place. The patient was enormously
pleased and felt a sense of accomplishment. She was encouraged to guide her husband’s
penis into her vagina in the same manner as her own finger. When seen one
week later, the patient related that intercourse occurred on three occasions, the
last two times without any difficulty.
A 38-year-old woman was seen alone because of a lifelong inability to have intercourse.
Her first marriage was annulled after five years, primarily because of “nonconsummation.”
She had pleasurable sexual experiences since her separation ten
years before but she always managed to avoid attempts at intercourse. Over the
years, she was unwilling to accept suggestions made by her family physician (aware
of the problem because of the impossibility of vaginal examinations) for referral to
a sex therapist. Presently, she was in the midst of a serious relationship and was
contemplating marriage. However, she was also fearful of the implications of her
inability to engage in intercourse. Her partner was accepting of this limitation but
at the same time was encouraging her to obtain medical care.
A vaginal examination, conducted by a consultant, resulted in a negative swab
test, and it was possible to only partially insert a single finger because of enormous
fear of pain and severe muscular tightness at the vaginal entrance. A suspected
diagnosis of vaginismus was confirmed. She remained unwilling to consult
a sex therapist and insisted on not involving her partner in the treatment program,
explaining that she had this problem long before their relationship began.
She was unable to insert the smallest dilator and felt pessimistic about the benefit
of this approach. When last seen she had remarried and was sexually active without
In this syndrome, the most commonly heard story concerning vaginal pain with intercourse
is that the woman had no prior difficulty. Typically, her previous sexual enthusiasm,
ease of arousal, and orgasm contrasts sharply with her present reticence. The
current experience of pain tends to be associated with anything entering her vagina
(penis, fingers, a vaginal speculum), and the discomfort is particularly located at the
vaginal entrance and especially in the “horseshoe” 4 to 8 o’clock area. The intercourse
pain is described as “tearing” and occurs with initial vaginal entry but is sometimes
characterized as burning and connected more with the friction of continuous coital
movement. Discomfort may continue for several hours after the sexual experience.
A 27-year-old woman, married four years, was seen by her family physician because
of pain associated with intercourse. She related that before the past two years, she
only rarely experienced pain during intercourse and it lasted only a matter of seconds
and was relieved by change in position. Her sexual interest was equal to that
of her husband and other male partners before she married, she had no difficulty
becoming vaginally wet when interested, and would easily come to orgasm. Since
the past two years, all of this had changed. Pain associated with vaginal entry had
become gradually more common and increasingly severe and as a result she found
herself only marginally interested in sexual activities, often used an artificial lubricant
because of insufficient vaginal lubrication, and only occasionally would come
to orgasm. She described the pain as in the 6 o’clock area of her introitus, burning
in character, and somewhat relieved by the cessation of intercourse, although the
discomfort after would necessitate her sitting in a bath to obtain some lessening of
the feeling of irritation.
On examination, the swab test was positive in many locations and a diagnosis
of vulvar vestibulitis (VVS) was made. With an initial focus on her diminished
sexual desire, psychologically oriented treatment was begun. Counseling also
focused on helping her and her husband explore other sexual practices other than
intercourse. Intercourse occurred periodically and was eventually experienced with
little or no discomfort on her part. Despite improvement on many levels, her lack
of sexual enthusiasm did not change and more aggressive treatment of her VVS at
that time was not something she thought desirable.
In contrast to the lifelong form, the history reveals intercourse without difficulty in the
past, and in contrast to the generalized form, only vaginal entry of a man’s penis in the
present results in discomfort (rather than tampons, fingers, and speculum). Other features
of the syndrome may include the following:
• Variability in appearance of the pain, age of patient (youth), sexual
• The presence of psychosocial explanatory factors
• The lack of pathological findings with pelvic examination
None of these features are pathognomonic.
A 19-year-old single woman was concerned that since about six months ago, intercourse
was associated with pain—a facet of her sexual experiences that had never
occurred before in previous relationships. Although dyspareunia was frequent now,
it was also quite irregular. Her relationship with her boyfriend of ten months was
frequently stormy, and on two occasions they decided to stop dating. She was still
unsure about continuing the relationship and had not told him of her sexual discomfort.
She had no difficulty using tampons now or in the past during her menstrual
periods, and likewise, experienced no problems with pelvic examinations by
a physician. The pain that she experienced was not localized, would arise only with
vaginal entry, and disappeared when his penis left her vagina. Pelvic examination
revealed no structural pathology and the swab test was negative. When seen three
months later, she had begun a relationship with another man with whom she was
in love and found that her dyspareunia had disappeared.
In the general population study conducted by Laumann and his colleagues, respondents
were asked the following question: “During the last 12 months, has there ever been a
period of several months or more when you experienced physical pain during intercourse?”
5 (p.371) Overall, this was answered with a “yes” by 14% of the women (in
contrast to 3% of the men). The age group in which this was most commonly reported
was 18 to 24 (22%) and was least commonly reported in those over 50 (7% to 9%). As
with other sexual problems, pain with intercourse was positively correlated with the
respondent’s health status (p. 373) (9% of women who’s health status was “excellent”
compared to 23% of those in “fair” health). There was also a positive
correlation with “happiness” (p. 374) in that pain with intercourse was
reported by 12% of those who were “extremely happy” versus 28% of
those who were “unhappy most times.” While intercourse pain is obviously
common among women in the general population, vaginismus as
a specific disorder seems unusual. Subtypes of pain associated with intercourse,
and the subject of unconsummated marriages, were not addressed
in the Laumann5 or Kinsey6,7 studies.
When asked the question: “During the
last 12 months has there ever been a
period of several months or more when
you experienced physical pain with
intercourse?”5 14% of the women
Meana et al. completed a descriptive study of a nonclinical sample of 112 women
recruited by newspaper advertisement and ranging in age from 19 to 658 with pain
relating to intercourse. Subjects underwent thorough psychological and gynecological
examinations. The subjects were eventually grouped under four diagnostic subheadings:
• The largest (46%) were diagnosed as having vulvar vestibulitis
• The next largest (24%) had no dyspareunia-related physical findings
• The third (17%) was “mixed” (described by the authors as a “catchall”)
• The fourth (13%) was the vulvar/vaginal atrophy group
Apart from community studies, Goetsch provided information on the prevalence of
dyspareunia and vulvar vestibulitis in an unreplicated study of a general gynecology
practice.9 All patients (n = 10) seen by her in a six month period were questioned and
their examination included a swab test. Twenty percent described symptoms of pain
and all except three had a positive swab test. Thirty-one patients (15% of the entire
group) were diagnosed as having vulvar vestibulitis. Affected patients were typically
Information about the epidemiology of vulvar/vaginal atrophy (typically found in
postmenopausal women) and its consequences was assessed in a general population
study conducted in Sweden on a random sample of 5990 women ranging in age from
46 to 62 (five birth cohorts).10 Subjects were sent a questionnaire (response rate 76%)
that included questions on various climacteric symptoms. Vaginal dryness was reported
by 21% overall and showed a linear increase (4% to 34%) in each cohort. In spite of
lubrication difficulty, approximately 60% had a “regular sex-life” and only 8% of the
entire sample reported that vaginal dryness was the reason for the absence of sexual
activity (although 32% of the 62-year-old women said so).11 It is instructive to note
that in another study which involved the transition to menopause, one third of premenopausal
women reported vaginal dryness, thus indicating that factors other than
hormones can have a major influence on vaginal lubrication.12 In addition, a study of
48 postmenopausal women that included psychophysiological measurements supported
the notion that vaginal dryness in postmenopausal women might well be related to
nonhormonal sexual arousal problems.13
In a review of the incidence and prevalence of sexual dysfunctions in “sex clinics,“
vaginismus was found to vary from 12% to 17% “of the females presenting with problems
in sexual dysfunction clinics . . . reflecting a rather stable rate.”14 In the same
review, dyspareunia rates were estimated at 3% to 5% but the authors wondered if this
complaint was more often made to family physicians and gynecologists than sex therapists.
Support for this was given by the Laumann data5, and, as well, a survey of
physicians15 who reported that “dyspareunia, or painful intercourse” was the sixth most
common sexual problem seen out of a list of 20 items.
Entry dyspareunia that lasts for a short period of time (days to weeks) is probably common
and may result from vaginal irritation as a consequence of infection or allergy.
Although there are many explanations for more persistent entry dyspareunia,16 three
problems probably account for most cases of pain, discomfort, or fear of intercourse in
• Vulvar vestibulitis
• Postmenopausal vulvar/vaginal atrophy and consequent vaginal
Friedrich17 coined the term vulvar vestibulitis (VVS) and described three
criteria for the diagnosis:
1. Severe pain on vestibular touch or attempted vaginal entry
2. Tenderness to pressure localized within the vulvar vestibule
3. Physical findings confined to vestibular erythema of varying degrees
Women with VVS are typically in their 20s and 30s and of Caucasian origin. Goetsch
(see Epidemiology above) provided details of her 31 subjects (plus seven who were
diagnosed with VVS before the beginning of her six month study).9 The median length
of the complaint was 8.5 years and half of the respondents first noted pain with tampon
use rather than with sexual intercourse. Half of the women always had pain dating
from the first attempt at intercourse (often designated as “primary”). A significant subgroup
(21%) experienced dyspareunia in the postpartum period, and delivery by cesarean
section made no difference in its appearance.
The etiology of VVS is unknown, giving rise to several theories.17-19 Infectious agents
have received much attention. Some observers note a high rate of repeated vaginal and/
or urinary tract infections (such as candidiasis). Human papillomavirus (HPV) is also
suspected. A majority of Goetsch’s patients had no known association with HPV. However,
“unusually large doses of fluorouracil cream . . . had caused severe chemical
burns in two patients and evolved into the most severe cases of vestibulitis seen in the
survey.”9 “The only infectious agent found to directly cause or worsen vestibulitis was
group B streptococcus” in two patients.9 Eighty percent of patients in the Goetsch study
who always had pain and who had sisters knew of a female relative with dyspareunia or
intolerance of tampons. There was no such association in those whose
pain began later. Investigators into the psychological status of patients
with dyspareunia generally found evidence of more symptoms than nopain
matched controls.8 However, no differences were found when
those who specifically had VVS were separated from other subtypes.
Goetsch concluded that swab testing demonstrated a continum
from those who were positive but had no clinical pain to those who
were dysfunctional.9 Likewise, she indicated that when pain was present,
it was “minor for many, and accommodation was aided even by
getting an explanation of the problem.”9 Last, she noted that many had
sensitivity that predated sexual exposure.
Three problems probably account for
most cases of pain, discomfort, or fear
of intercourse in women:
• Vulvar vestibulitis
• Postmenopausal vulvar/vaginal atrophy
and consequent vaginal dryness
Goetsch concluded that swab testing
demonstrated a continuum from those
who were positive but had no clinical
pain to those who were dysfunctional.9
Likewise, she indicated that when pain
was present, it was “minor for many,
and accommodation was aided even by
getting an explanation of the problem.”9
Vaginal lubrication largely depends on estrogen stimulation of the vaginal mucosa and,
therefore, vaginal dryness is usually considered to be associated with
the diminution of estrogen that accompanies menopause. Atrophic
alterations occur to the vaginal epithelium in the absence of estrogen
and are associated with increased vaginal pH, decreased vaginal fluid,
and decreased vaginal blood flow.20 Exogenous estrogens appear to
reverse these changes. However, a woman’s level of sexual activity
(including masturbation) and her circulating androgens have also been
demonstrated to influence the extent of vaginal atrophy.21 While vaginal atrophy and
dryness is often reported as uncomfortable, the extent to which actual pain is experienced
during intercourse is unclear.
Vaginismus represents an involuntary spasm of the muscles surrounding the outer third
of the vagina, resulting in narrowing of the vaginal entrance and inability or difficulty
in allowing vaginal entry in the waking state. The sex-related result of vaginismus is
the inability to engage in intercourse (either at all or without significant discomfort).
The history is usually lifelong (that is, since the patient tried to put anything into her
vagina) but not all such lifelong histories represent this disorder. A similar story may
be given in some instances of vulvar vestibulitis (see Vulvar Vestibulitis above).9
Patients give various explanations for vaginismus including22:
1. Thinking sexual activity to be sinful or offensive
2. Fear of pregnancy or childbirth
3. Lack of anatomical awareness
4. Homoerotic feelings
5. Dislike of semen
6. Aversion to a man’s penis or men in general
Some specialists view such phenomena as symptoms rather than
causes.23 As counterintuitive as it might seem, a history of genital
trauma or sexual violence in the histories of women with vaginismus is
unusual.24 When patients were asked their opinions about possible
causes, they placed fear of pain and fear of intimacy high on the list.25
Patients may describe pain with intercourse attempts but fear of vaginal
entry rather than the actual experience of pain may be the principal
factor that interferes with intercourse. Other sexual difficulties (e.g., a desire disorder)
may be present in the patient and may have antedated awareness of intercourse trouble.
History is only one element, albeit an essential one, in defining fear, discomfort, or
pain in women associated with intercourse attempts, and in many instances, helping to
delineate the cause. Issues to inquire about and suggested questions include:
While vaginal atrophy and dryness is
often reported as uncomfortable, the
extent to which actual pain is experienced
during intercourse is unclear.
When patients were asked for possible
causes of vaginismus, they placed pain
and fear of intimacy high on the list.
Patients may describe pain with intercourse
attempts but fear of vaginal
entry rather than the actual experience
of pain may be the principal factor that
interferes with intercourse.
1. Duration (see Chapter 4, “lifelong versus acquired”)
Suggested Question: “How long has this been a problem for you?”
Alternative Suggested Question if Intercourse Occurred in the Past: “Have you even
been able to have intercourse without experiencing pain?”
2. Intravaginal experience in the past (see Chapter 4, “generalized versus situational”)
Suggested Question: “What has been your experience with tampons?”
Suggested Question: “What has been your experience with inserting
your own finger into your vagina?”
Suggested Question: “What has been your experience with a sexual
partner inserting a finger into your vagina?”
Suggested Question: “What has been your experience with doctors
performing a pelvic examination and using fingers or a speculum?”
Suggested Question: What has been your experience with wearing
tight clothes such as jeans?
3. Intravaginal experience in the present (see Chapter 4, “generalized versus situational”)
Suggested Question: “What is it like for you now when a sexual
partner attempts to insert his penis (or his finger) into your
Additional Suggested Question: “Does it matter if you are with a different
4. Location of the pain (see Chapter 4, “description”)
Suggested Question if Intercourse Occurs: “Where do you actually feel
the pain? At the entrance? Within your vagina during intercourse?
Or deep inside?”
Additional Suggested Question for Entry Pain: “If you were to compare
the opening to your vagina to a clock, at which point on
the clock do you feel pain?”
Additional Suggested Question to Determine if Pain is Associated with Thrusting: “Is
the pain felt on the inside of your vagina as he is moving in
Additional Suggested Question to Determine if the Pain is Deep: “When he
inserts his penis deeply, does it feel as though he is poking
5. Character of the pain (see Chapter 4, “description”)
Suggested Question: “Sometimes a person experiences fear of intercourse
more than actual pain. Does this ever happen to
Additional Suggested Question if Intercourse Occurs: “What does the pain
feel like? For example, does it feel as though it is tearing or
6. Factors that result in improvement or worsening (see Chapter 4, “description”)
Suggested Question: “Is there anything that makes the
Additional Suggested Question: “Is there anything that
makes the pain worse?”
Additional Suggested Question if Intercourse Occurs: “What does
it feel like when he ejaculates?”
Any complaint of persistent pain associated with vaginal entry requires
a complete physical examination, which need not take place on the
first visit or be completed on one occasion. For example, in the context
of vaginismus, a vaginal examination might well be terrifying to the
patient and, as well, impair the physician-patient relationship. A speculum
examination under such circumstances may have even more severe consequences.
Rafla described a case in which a vaginal examination in the context of vaginismus
resulted in physical injury and a blood loss of 1000 ml.26 Considerably more time (and
patience) is usually required than in a more “ordinary” pelvic examination (see “Physical
Examination” in Chapter 6).
When the patient’s history is one where intercourse has never occurred because
attempts resulted in pain, discomfort, or fear, it is reasonable to engage in a preparatory
process before an actual intravaginal examination.27 The patient touches herself as
close to the introitus as possible, daily, in private, and for five to ten minutes. While
this is taking place, she is asked to imagine herself being examined, view her genitalia
with a mirror, and is shown how to insert her own fingertip around the anterior vaginal
Any complaint of persistent pain associated
with vaginal entry requires a complete
physical examination, which need
not take place on the first visit or be
completed on one occasion.
Considerabily more time (and patience)
is usually required for a pelvic examination
involving persisitent pain associated
with vaginal entry than is required in a
more “ordinary” pelvic examintion.
wall using diagrams or models. This preparation is meant to convey to the patient that
she will be in control of the examination when it does occur.
The actual pelvic examination in such a patient begins with an inspection of the
external genitalia. In the syndrome of vulvar vestibulitis, inspection may reveal varying
degrees of erythema of the vestibular mucosa.17 On this first occasion, there is no
necessary reason to extend the examination beyond inspection and explanation. However,
if the patient permits, the examiner can also gently probe the
vestibular openings to major and minor gland ducts (the “swab test”)
with a sterile water-moistened cotton-tipped applicator, to exclude the
possibility of vulvar vestibulitis (Figure 13-2). (The vestibule is bordered
medially by the hymenal ring, laterally by Hart’s line, anteriorly
by the frenulum of the clitoris, and posteriorly by the fourchette. The
area contains opening of major [Bartholin’s, Skene’s, and periurethral]
and minor vestibular glands.)28
When the swab test is positive, colposcopy might be “helpful in identifying discrete
lesions, which [are] often difficult to see without aceto-white staining and
When the swab test is negative, examination of the interior of the vagina might then
take place. One method of allowing the patient control over this part of the examination
is to have her hold the physician’s wrist while she slowly introduces one of the examiner’s
fingers into her vagina. This process may extend over several visits. Speculum and
Speculum and bimanual examination of
the patient with a history of lifelong
vaginismus should be delayed (barring
some urgent reason) until a later time
when vaginal entry is no longer associated
with pain, discomfort, or fear.
bimanual examination of the patient with a history of lifelong vaginismus should be
delayed (barring some urgent reason) until a later time when vaginal entry is no longer
associated with pain, discomfort, or fear.
Valins provided a vivid and poignant first-person account of the pelvic/vaginal
examination of a woman with vaginismus with a description of how her gynecologist
approached the examination29 (pp. 203-210).
When vaginal infection is considered, several tests can be done to eliminate the possible
presence of various pathogens. In addition, biopsy of the vulvar epithelium on
a patient with suspected vulvar vestibulitis often shows evidence of chronic inflammation.
However, the normal histology of this area has not been well described. In a
comparison of tissues obtained by punch biopsy done on women with VVS and normal
controls, both showed evidence of inflammation, thereby casting doubt on the
value of finding evidence of inflammation on histological examination of vulvar epithelial
Most women who have the lifelong and generalized form of vaginal pain or fear to the
extent that intercourse has never occurred will likely be diagnosed as having vaginismus
(although some will have primary vulvar vestibulitis [see below]). Drenth suggest
that when considering the treatment of vaginismus, couples should separate the issues
of wanting to overcome the intercourse difficulty from wanting to become pregnant,
decide which is of higher priority, and focus on that goal.31 In any
instance, primary care treatment may be sufficient.
Both partners should be involved in treatment, although the apparent
passivity of many husbands of women with vaginismus (noted by
many authors) may contribute to his relatively small contribution.32
(p. 34). On an impressionistic basis, many women with vaginismus
seem to have difficulty talking about their thoughts and feelings,
which in turn makes insight-oriented psychotherapy with them difficult.
With couples where the man is passive and the woman unexpressive,
visits are often brief and the focus is on progress using
dilators and other functional aspects of their care.
When the diagnosis is vaginismus and pregnancy is the principal
objective, Drenth suggests artificial insemination using (1) the husband’s
semen (AIH) and (2) the insemination procedure performed
by the couple themselves.33 When overcoming the fear/pain associated
with attempts at intercourse is the principal objective, couples
are initially advised to stop attempting to insert the man’s penis into
the woman’s vagina (or anything else such as his finger), and even to
not consider any form of vaginal entry even if the circumstances
seem favorable. (Emphasis on thoughts are crucial, since it is the
When overcoming the fear or pain associated
with attempts at intercourse is the
principal objective, couples are initially
advised to stop any form of vaginal
insertion even if the circumstances seem
favorable. (Emphasis on thoughts are
crucial, since it is the anticipation that
leads to worry.)
The word “dilator” is a misnomer when
used in the treatment of vaginismus
since dilatation does not occur and in
any case is not the purpose of the procedure.
The problem is not with the
structure of the muscle surrounding the
vaginal opening but rather with its
anticipation that leads to worry.) At the same time, they are encouraged to continue
enjoying the sexual activities other than intercourse that previously occurred.
After the diagnosis of vaginismus is confirmed and VVS excluded, as well as insufficient
knowledge of sex-related anatomy and physiology, vaginal dilator use could be
considered. (Flesh-colored, silicone dilator sets of four are available at 1-800-621-1278
through Milex Products, 5915 Northwest Highway, Chicago, ILL 60631). Although
recommended decades ago for this same purpose, vaginal dilators have become a
therapeutic mainstay since they were suggested by Masters and Johnson in 1970.34
The word “dilator” is a misnomer when used in the treatment of vaginismus since
dilatation does not occur and in any case is not the purpose of the procedure. The
problem is not with the structure of the muscle surrounding the vaginal opening but
rather with its function. A “dilator” works rather as an “accommodator” in providing
an opportunity for the woman to become used to having something in her vagina
without fear or pain, and entirely in her control.
Supervision of dilator use through the progressively larger sizes in a set can be readily
undertaken in a primary care setting. Insertion of dilators should occur daily for the
longest period of time that the patient can manage, and when she is alone so that the
process remains entirely under her control (rather than at the urging of her partner).
The largest dilator in the set that does not also cause discomfort should initially be
used. Liberal amounts of over-the-counter water-soluble jelly (e.g., K-Y Jelly) should
be applied to the dilator. Progression to the next size should only take place when
there is complete absence of discomfort with the size currently used. Eventually, when
she is comfortable with a size that approximates her partner’s erect penis, she should
be instructed to insert his penis almost as if it were another dilator. Since intromission
by the woman is accomplished relatively easily when she is in the superior position,
the couple should practice using that position before penile insertion is actually
If this appears to be a mechanical approach, it probably is a correct perception, but
only from the health professional’s viewpoint. Much more than mechanical manipulations
are taking place from the couple’s perspective. While hope extends backward to
the time the physician’s finger was first inserted into the patient’s vagina, only her
actual experience of painless penile insertion represents concrete evidence of change.
Paradoxically though, patients tend to be more subdued when describing the first
occasion of intromission than is the treating health professional. The explanation
might be an absence of confidence that the remainder of the therapeutic tasks can be
successfully completed. However, it is well to remember at this point that penile insertion
may not be immediately translated into feelings of pleasure for either person. This
depends on the extent of sexual freedom that the couple enjoyed before. Some couples
absorb the newly found sexual skills quickly and zealously. In other instances, pleasure
for the women may take place in an evolutionary way, extending over a period of time
and in the context of the confidence that is linked with not having to think about the
placement of body parts. Confidence in that circumstance tends to occur with repeated
Most observers use intercourse (consummation) as the sole criterion for success in
the treatment of vaginismus. Masters and Johnson describe excellent treatment results
(100%) in their five-year follow-up.34 Van de Wiel et al. conducted a meta-analysis on
treatment results involving 20 surveys and 17 case studies published between 1960 and
1990.35 They conclude that several treatment approaches appear to be equally effective
(except surgery, which was not a subject of a published report) and that the average
rate of success was about 80%. Some describe a more modest outcome. Drenth et
al. reports on a questionnaire survey of 57 patients (response rate 86%) diagnosed with
“primary vaginismus.”33 Consummation occurred in 54% overall. In couples who
wanted to become pregnant, consummation occurred in 74% compared to 33% who
sought treatment only for the intercourse difficulty. Problems encountered in the treatment
of vaginismus31 include the following:
1. Lack of clarity around therapeutic aims
2. Intimacy difficulties on the part of the woman and consequent unwillingness to
involve her partner
3. The emergence of other fears
Desire for a child may be a stronger motivating factor for the treatment of vaginismus
than desire for intercourse. The survey by Drenth et al. also provided information on
obstetrical issues.33 Almost one half (25) of the patients became pregnant (10 as a
result of artificial insemination and 15 through intercourse). Patients who chose selfinsemination
did so for reasons that include the pressure of time (resulting from a delay
in seeking treatment) or slow therapeutic progress. The authors felt that insemination
by a physician represented “unnecessary medicalization” and, furthermore, might
unduly influence any ambivalence toward pregnancy experienced by the couple.
When self-insemination (also known as home insemination or AIH [artificial insemination
by husband] is undertaken, it, may be helpful for a physician to provide technical
advice to the couple and to review methods of ovulation detection. Briefly, the
insemination process is as follows*: The man ejaculates [volume of ejaculate is usually
in the range of 2 to 6 cc] into a clean, dry, plastic or glass container such as a urine
collection bottle from a medical laboratory. Regular condoms are undesirable for collecting
semen because they may contain a spermicidal agent. The semen is kept at
body temperature for about 10 minutes (the sample is then more liquid) and then is
drawn, with minimal accompanying air, into a narrow syringe (as small as 1 cc in
instances of severe vaginismus but perhaps as large as 10 to 12 cc). The syringe is
inserted as deep into the woman’s vagina as possible and the semen is deposited by
pushing on the plunger. During this process, the woman’s hips should be slightly elevated
with a pillow and she should remain in this position for about 20 to 30 minutes.
The same process can be repeated in about 24 hours.
Drenth et al. also reported on 26 deliveries and found that assisted deliveries were
10% higher in patients with vaginismus than in their clinic population.33 Reasons
included the presence of vaginismus and the (older) age of the mother. However, they
concluded that having vaginismus does not, in itself, require special precautions during
labor and delivery. They also observed that: however counterintuitive the notion might
be, childbirth does not automatically result
in pain- and fear-free intercourse. “Obviously,
a pushing out movement is experienced quite differently from a pushing-in
*Personal communication, Stacu Elliott, M.D., Co-director, Vancouver Sperm Retrieval Clinic, VHHSC,
As outlined above (see Etiology in this chapter), vulvar vestibulitis and vulvar/vaginal
atrophy probably account for the majority of patients seen with the acquired and generalized
form of dyspareunia. When such disorders are resistant to definitive treatment
within the health care system, active involvement of the patient in her own care may
be necessary and beneficial. Membership in the National Vulvodynia Association
(NVA) may prove useful, especially since the organization produces an informative and
patient-oriented newsletter. (The NVA can be reached through its Web site [see
Appendix IV], by telephone at  299-0775, or by mail at P.O. Box 4491, Silver
Spring, MD 20914-4491)
Bergeron and her colleagues19 reviewed the treatment of VVS and grouped the existing
studies into three categories:
• Surgical intervention
• Medical management
• Cognitive-behavioral/pain management therapy
Surgical interventions consist of vestibulectomy and laser therapy. Vestibulectomy has
been the most investigated VVS treatment and the one reported as having the best
outcome. Laser treatment is described as controversial and sometimes associated with
negative consequences. Surgery is usually undertaken after the failure of medial management.
The surgical procedure is typically described as a modified perineoplasty,
which is performed as day surgery under general anesthesia. Surgical success usually
has been measured through a one-time self-report rating of pain with intercourse, and
rates vary from 43% to 100%, with the majority more than 60%.19
Schover et al. reports an improved outcome when surgery is combined with sexual
counseling.18 They describe an eight-month follow-up study on the evaluation and
treatment of a group of 45 women with VVS. All were treated by conservative local
excision of the vulvar lesions. One of the factors that indicated a better outcome included
willingness to engage in initial psychological evaluation and brief post-operative sexual
counseling. Of 32 such patients, 50% reported that they were much improved. Other
positive predictors were higher socioeconomic status and localized (versus diffuse) areas
of pain. The authors hypothesize that women who could accept that their dyspareunia
and vulvar pain was multifactorial in origin took an active role in rehabilitative efforts
after surgery, and, as a result experienced a better outcome. They hypothesize that
patients who could not do so might be poor surgical candidates.
Medical management of VVS typically involves the use of topical ointments (including
anesthetics, antifungals, and antibiotics), systemic medications, and other treatments
such as interferon.19 Topical anesthetics are of limited value, since their effect is shortterm
and allergic reactions may occur. Nonscented lubricants are also of short-term
value but do not have adverse effects. Other topical ointments (antibiotics, antifungals,
antiviral, and corticosteroid creams) are considered to be ineffective but have not been
carefully studied. Acyclovir (oral), capsaicin (topical), and calcium citrate tablets have
been reported to be beneficial to some patients. Alpha interferon is not recommended if
colposcopy or biopsy lesions do not show evidence of HPV changes.
Pain management of VVS has consisted of biofeedback, behavior
and sex therapy, cold application, and acupuncture.19 Some patients
have found benefit from each of these four approaches. Since vaginal
spasm (often referred to as vaginismus in the literature) is often found
during the pelvic examination of a patient with VVS, some have found
the inclusion of vaginal dilators to be a treatment adjunct.36
Bergeron et al. compared treatment results for 78 patients with VVS
who were randomly assigned to surgery (vestibulectomy), biofeedback,
or sex therapy/pain management.37 Measurements were made pre- and
post-treatment and at six-month follow-up. Self-reported coital pain
was significantly improved in all groups from before and after treatment and from before
to 6 month follow-up. However, the vestibulectomy group was significantly better than
the sex therapy/pain management group post-treatment. All groups improved significantly
when the frequency of intercourse was compared post-treatment to 6 months
later. In summary, patients from all three groups reported significantly more subjective
improvement from post-treatment to 6 month follow-up. However, the vestibulectomy
group was significantly better than the sex therapy/pain control group.
Estrogen replacement therapy generally reverses the vaginal changes associated with
menopause. However, restoration of vaginal tissue function may require up to 18 to 24
months. The long duration may explain the reason for continued vaginal dryness and
dyspareunia (if the woman is sexually active) in spite of hormonal and cytologic return
to premenopausal values.38 However, only a distinct minority of postmenopausal
women use hormone replacement therapy (HRT). Reasons include the following:
• Personal preference
• Adverse side effects
• It is contraindicated
In addition, some women find that even with HRT, there is little urogenital benefit.
Thus local (vaginal) forms of treatment have been developed to counter vaginal dryness
in women who are not on HRT or who need supplemental therapy for urogenital
Vaginal creams containing estrogen represent one example of a local form of treatment.
Since estrogen is absorbed from the vaginal mucosa, a fact that may limit its
acceptability in some patients, attempts have also been made to find nonhormonal
agents, or, alternatively, to minimize the absorption of estrogen.
The estradiol vaginal ring represents a second local treatment option
for vaginal dryness and other urogenital consequences of estrogen loss.
The development of the ring is based on the notion that compared to
the amount of estrogen necessary to reverse vasomotor symptoms (50
mg/day), the amount of estrogen necessary to alleviate urogenital atrophy
is much smaller (7 to 10 μg/day).39 The ring delivers a low dose of
“The ring provides a safe and effective
method of pharmacological therapy for
women who require treatment for symptoms
of urogenital aging.”40
Patients from three groups (vestibulectomy,
biofeedback, and sex therapy/pain
management) reported significantly
more subjective improvement from post
treatment to 6 month follow-up. However,
the vestibulectomy group was significantly
better than the sex therapy/
pain control group.
17 β-estradiol directly to the urogenital tissues and has a low level of systemic absorption.
Bachmann reviewed the results of 11 clinical trials with the estradiol vaginal
ring.40 She found that it reversed urogenital atrophy, induced minimal stimulation of
the endometrial lining, had few adverse side effects, and that a single ring was efficacious
for three months of continuous use. Of the 946 postmenopausal women with
treatments up to 96 weeks, “there were cytological, physiological, physician rating and
patient reporting of either elimination or amelioration of urogenital atrophy signs and
symptoms.”40 She concluded that” the risk/benefit ratio has a clear preference to benefit
with risks being very low. Therefore, the ring provides a safe and effective method
of pharmacological therapy for women who require treatment for symptoms of urogenital
A vaginal moisturizer is a third local treatment option. “Replens” is a nonhormonal
nonsystemic vaginal moisturizing gel that has a low pH, appears to bind to vaginal
tissue, and is applied three times per week. Replens is based on a polymer (called polycarbophil),
which becomes saturated with water, diffuses into vaginal epithelial cells,
and then is sloughed off with epithelial cell turnover.41 This substance has been studied
in nonhuman primates41 and humans.42-44 In two open-label studies of women, Replens
was compared to a locally applied estrogen cream and found to be safe and effective.
42,43 In one of the studies, both therapies exhibited statistically significant increases
in vaginal moisture, vaginal fluid volume, and vaginal elasticity with a return of the
premenopausal pH state. Replens has also been compared to a water-soluble lubricating
placebo in a double-blind study of women with a history of breast cancer and
similarly found to be effective.44
A fourth local treatment form that has been used for many years is an over-thecounter
lubricating gel (e.g., K-Y Jelly).
Little is known about this syndrome except from patients who describe the problem
of vaginal discomfort with intercourse in the past, and who have watched it disappear
with the advent of a new relationship. On the assumption that the difficulty relates
to interpersonal or intrapersonal psychosocial conflicts, the most reasonable therapeutic
course of action is (1) reassurance to the woman about the integrity of her genitalia
and (2) psychotherapy, either individual or couple-related depending on the
1. The evaluation of persistent pain associated with intercourse should always
include a physical/pelvic examination. Thus, medical consultation should always
be included when a patient with dyspareunia has been evaluated only by a nonmedical
2. Lifelong vaginismus can often be successfully treated by primary care health
professionals regardless if the goal is sexual or reproductive. Consultation with
a physician should take place if the treating health professional is not a MD
to eliminate the possible coexistence of VVS. When artificial insemination
(AIH) is desired, the couple should be referred to a physician for advice and
possible assistance. When treatment that is aimed at overcoming vaginismus
becomes problematic, the couple should be referred to a sex therapist for
3. Primary (lifelong) VVS may be amenable to explanation and brief sexual counseling
within primary care. Consultation with a gynecologist for the purpose of
confirming the diagnosis may be helpful. The time and skills of a sex therapist
may be particularly useful when intercourse has never occurred in the past
because of discomfort, and for patients who are otherwise experiencing significant
4. Secondary (acquired) VVS varies in the degree of pain experienced. The greater
the extent of pain and sexual complications, the more a primary care professional
would want to engage the assistance of other health professionals such as
gynecologists and sex therapists.
5. When dyspareunia in a postmenopausal woman persists despite adequate vaginal
lubrication, consultation with a sexual medicine specialist would be desirable to
consider the possibility of other contributing factors.
Penile-vaginal intercourse is sometimes accompanied in women by persistent pain, discomfort,
or fear. Pain can exist at the point of entry, or deep in the vagina. This chapter
is concerned with the former. Vulvodynia is a term that encompasses vulvar pain
regardless of etiology, whereas dyspareunia is specific to pain that occurs with intercourse.
DSM-IV suggests that “dyspareunia” and “vaginismus” should be separated.
However, if a clinician considers that “vaginismus” as described in the literature includes
both the disorder as well as vaginal spasm occurring in the context of several vaginal
disorders, then in fact, vaginismus and dyspareunia often occur together and separation
becomes clinically difficult.
In community studies, about 15% of women say they have experienced pain with
intercourse for a few months during the last year. When dyspareunia is lifelong and
generalized, the causes are usually vaginismus (the disorder) or vulvar vestibulitis
(VVS). When acquired and generalized, the etiology is usually VVS (the most common
cause in premenopausal women) or vulvar/vaginal atrophy with associated vaginal
dryness (the most common cause in postmenopausal women). When acquired and
situational, the genesis of dyspareunia is most often related to interpersonal or intrapersonal
The assessment of persistent vaginal pain involves a history and a physical/pelvic
examination. The latter should include a swab test whenever vulvar vestibulitis is considered.
In cases where vaginal entry has never occurred or where there is severe
introital pain, the pelvic examination may require more than one visit and a lengthy
period of time to complete.
Early or mild instances of vaginismus may respond to education and supportive
counseling. Treatment of patients who are not helped by such an approach depends
heavily on the use of dilators and the support of the patient’s partner and health care
clinician. Sometimes the couple is primarily interested in reproduction rather than
solving the intercourse problem. In such an instance, assisting in the process of artificial
insemination using the husband’s sperm (AIH) may be most productive.
Vulvar vestibulitis is sometimes amenable to explanation, but in other instances it
may be difficult to treat. Several medical, surgical, and sex therapy/cognitive-behavior
therapy methods have been suggested. Surgery (vestibulectomy) has received the most
attention in the VVS treatment literature and studies indicate this form of treatment to
provide the best results.
At least five approaches can be used in the treatment of women with dyspareunia
resulting from vulvar/vaginal atrophy and associated vaginal dryness: oral hormone
replacement therapy (HRT), estrogen cream, the estradiol vaginal ring (Estring), a
nonhormonal vaginal moisturizer (“Replens”) and nonhormonal and nonscented
1. Meana M, Binik YM: Painful coitus: a review of female dyspareunia, J Nerv Ment Dis
2. Paavonen J: Diagnosis and treatment of vulvodynia, Ann Med 27:175-81, 1995.
3. Diagnostic and statistical manual of mental disorders, ed 4, Washington, 1994, American
4. Diagnostic and statistical manual of mental disorders, ed 4, Primary Care Version, Washington, 1995,
American Psychiatric Association.
5. Laumann EO et al: The social organization of sexuality: sexual practices in the United States,
Chicago, 1994, The University of Chicago Press.
6. Kinsey AC, Pomeroy WB, Martin CE: Sexual behavior in the human male, Philadelphia and
London, 1949, W.B.Saunders.
7. Kinsey AC et al: Sexual behavior in the human female, Philadelphia and London, 1953,
8. Meana M et al: Dyspareunia: sexual dysfunction or pain syndrome?, J Nerv Ment Dis
9. Goetsch MF: Vulvar vestibulitis: prevalence and historic features in a general gynecologic
practice, Am J Obstet Gynecol 164:1609-1616, 1991.
10. Stadberg E, Mattsson L-A, Milson I: The prevalence and severity of climacteric
symptoms and the use of different treatment regimens in a Swedish population, Acta
Obstet Gynecol Scand 76:442-448, 1997.
11. Stadberg E, Mattsson L-A, Milson I: Womens attitudes and knowledge and the
climacteric period and its treatment. A Swedish population-based study, Maturitas
12. Larson B, Collins A, Landgren A-M: Urogenital and vasomotor symptoms in relation to
menopausal status and the use of hormone replacement therapy (HRT) in healthy
women during the transition to menopause, Maturitas 28: 99-105, 1997.
13. Laan E, van Lunsen RHW: Hormones and sexuality in postmenopausal women: a
psychophysiological study, J Psychosom Obstet Gynecol 18:126-33, 1997.
14. Spector IP, Carey MP: Incidence and prevalence of the sexual dysfunctions, Arch Sex
Behav 19:389-408, 1990.
15. Burnap DW, Golden JS: Sexual problems in medical practice, J Med Educ 47:673-680,
16. Abarbanel AR: Diagnosis and treatment of coital discomfort. In LoPiccolo J, LoPiccolo L
(editors): Handbook of sex therapy, New York, 1978, Plenum Press.
17. Friedrich EG: Vulvar vestibulitis syndrome, J Reprod Med 32:110-4,1987.
18. Schover LR, Youngs DD, Cannata R: Psychosexual aspects of the evaluation and
management of vulvar vestibulitis, Am J Obstet Gynecol 167:630-636, 1992.
19. Bergeron S et al: Vulvar vestibulitis syndrome: a critical review, Clin J Pain 13:27-42,
20. Semmens J, Wagner G: Estrogen deprivation and vaginal function in postmenopausal
women, JAMA 248:445-448, 1982.
21. Leiblum SR et al: Vaginal atrophy in the postmenopausal woman: the importance of
sexual activity and hormones, JAMA 249:2195-2198, 1983.
22. Blazer JA: Married virgins: a study of unconsummated marriages, J Mar Fam 26: 213-214,
23. Dawkins S, Taylor R: Non-consummation of marriage: a survey of seventy cases, Lancet
24. Barnes J: Primary vaginismus (part 2): aetiological factors, Irish Med J 79:62-65, 1986.
25. Ward E, Ogden J: Experiencing vaginismus: sufferers’ beliefs about causes and effects,
Sexual Marital Ther 9:33-45, 1994
26. Rafla N: Vaginismus and vaginal tears, Am J Obstet Gynecol 158:1043, 1988.
27. Basson R: Lifelong vaginismus: a clinical study of 60 consecutive cases, Soc Obstet Gynecol
Can 18:551-561, 1996.
28. Marinoff SC, Turner MLC: Vulvar vestibulitis syndrome: an overview, Am J Obstet Gynecol
29. Valins L: When a woman’s body says no to sex: understanding and overcoming vaginismus, New York,
1992, Viking Penguin.
30. Lundqvist EN et al: Is vulvar vestibulitis an inflammatory condition? A comparison of
histological findings in affected and healthy women, Acta Derm Venereol (Stockh)
31. Drenth JJ: Vaginismus and the desire for a child, J Psychosom Obstet Gynecol 9:125-137, 1988.
32. Friedman LJ: Virgin wives: a study of unconsummated marriages, London, 1962, Tavistock
33. Drenth JJ et al: Connections between primary vaginismus and procreation: some
observations from clinical practice, J Obstet Gynecol 17:195-201, 1996.
34. Masters WH, Johnson VE: Human sexual inadequacy, Boston, 1970, Little, Brown and
35. Van de Wiel HBM et al:Treatment of vaginismus: a review of concepts and treatment
modalities, J Psychosom Obstet Gynecol 11:1-18, 1990.
36. Abramov L, Wolman I, David MP: Vaginismus: an important factor in the evaluation and
management of vulvar vestibulitis syndrome, Gynecol Obstet Invest 38:194-197, 1994.
37. Bergeron S et al: A randomized controlled comparison of vestibulectomy, electromyographic biofeedback,
and group sex therapy/pain management in the treatment of dyspareunia resulting from vulvar vestibulitis.
Paper presented at the meeting of the Society for Sex Therapy and Research, Fort
Lauderdale, March, 1998.
38. Semmens JP et al: Effect of estrogen therapy on vaginal physiology during menopause,
Obstet Gynecol 66:15-18, 1985.
39. Heimer G, Samsioe G: Effects of vaginally delivered estrogens, Acta Obstet Gynecol Scand
40. Bachmann G: The estradiol vaginal ring: a study of existing clinical data, Maturitas
41. Hubbard GB et al: Evaluation of a vaginal moisturizer in baboons with decreasing ovarian
function, Lab Anim Sci 47:36-39, 1997.
42. Nachtigall LE: Comparative study: Replens versus local estrogen in menopausal women,
Fertil Steril 61:178-180, 1994.
43. Bygdeman M, Swahn ML: Replens versus dienoestrol cream in the symptomatic
treatment of vaginal atrophy in postmenopausal women, Maturitas 23:259-263, 1996.
44. Loprinzi CL et al: Phase III randomized double-blind study to evaluate the efficacy of a
polycarbophil-based vaginal moisturizer in women with breast cancer, J Clin Oncol