West of Scotland Sexual Health MCN Dyspareunia Workshop November 2018

facilitators Dr John Ewan Dr Kay McAllister Introduction

Welcome Round table introductions Format of afternoon: Case studies/discussions Vaginismus Vulvodynia Tea break Lichen sclerosis GUM/Gyn cases

Housekeeping - toilets and fire alarms/exits How does the woman present?

 What does she mean?  Pain  Urinary and/or bowel dysfunction  Relationship difficulties  Subfertility  Overtly or covertly with , depending on her sexual attitudes – religious, cultural, parental, life experiences Responses to sexual pain

 Embarrassment  Anxiety  Anger  Depression  Fear

Impact on sexual behaviour and function PLISSIT model Raising sexual issues Type of Question Example Generalising Many people are worried about...

Routine questioning I always ask about

Normalising It's quite normal to worry about your after this diagnosis...

Focussed Do you feel you have a problem with sex?

Open ended Would you like to tell me more about it?

Simple advice It's okay to masturbate with this condition Your partner is not at risk of catching this through (e.g.) kissing Limited information

 Never assume what others know about sex – misconceptions are rife.

 Education can be delivered by most clinicians but other knowledge may be more specialised. Examples include: 'normal' sexual functioning and the impact of conditions/treatments on sexual function.

 It is important to recognise and dispel any underlying myths – this could be done on an individual or couple basis. The use of well phrased written information (or other media) can be very useful. Specific suggestions

 these will clearly relate to the underlying difficulties and a problem-solving approach is common. Examples could include advice on alternate sexual techniques or positions, enhancing couple intimacy, the use of medication or recommending particular 'self-help' books.

 Some behavioural techniques may be utilised for specific problems, such as vaginal trainers for vaginismus or perhaps suggesting the use of anaesthetic in the management of rapid .

 If not discussed already, this would be an appropriate time to address any unrealistic expectations held by the individual or couple, such as the effect of ageing on sexual function and desire. Case Study Vaginismus  GP referral  32 year old mother of three children  Intercourse has become painful over last 3 years  10 years ago went onto COC because of acne, stayed on for 3 years  3 years ago had 3 outbreaks of “thrush” Case Study Vaginismus

Observation and listening • Smartly dressed with impeccable hair and makeup • Little eye contact • Arms crossed across her chest • Frequently checks the time on her phone • Gives a non-emotional account of her story  She describes meeting an old friend, drinking too much and having rough sex and becoming frightened, having a panic attack and now flashbacks of being held down  Doctor reflections: that sounds really scary I wonder if that happened before your pain started.  Discussion of loss of control Describes having regular sex with partner which is painful. She sees this as her duty “to keep the family together” She does not get aroused and finds it mildly disgusting

Doctor reflection: sex sounds like a chore with no pleasure in it for you “but he is so good with the kids” She feels that she can control her emotions and just wants to be able to have pain-free sex She shows how she can control her thumb – hyperextending it to her wrist with no pain •The use of the genital examination as a psychosomatic event

•She looks anxious her legs adduct slightly “Is this what it is like during sex”

•I wonder what you think is causing the pain •“please examine me and sort me out”  Slight vestibular tenderness at 4 and 7 o’clock  One finger is inserted and feels snug slight discomfort  The pelvic floor muscles feel tense and tender, she is unable to contract them more or relax them  Doctor: Isn’t it interesting that you are so flexible in some parts of your body but so tense down here.  Tears, I just need to control this pain  Doctor: I think perhaps you do know what is wrong  appears thoughtful Doctor-Patient relationship

 Doctor empathic listener  Patient defences  Doctor struggling to get to any feelings  Moment of vulnerability during the examination to start to look at feelings  Reduced tension in the room Doctor-Patient relationship

• Teaching Doctor Discussion of Mind-Body Interaction

 Importance of Arousal •  Acceptance of impact of affair  Emotional avoidance as a defence since  Need for emotional reconnection  Increased shared understanding  Reclaiming sexuality for herself Vaginismus

“Vaginismus occurs when the muscles around the outer third of the contract involuntarily when vaginal penetration is attempted (during ).”

 Primary  Non-consummation

 Secondary  Follow trauma or other cause

Managing a consultation

 Take a history: 1. Superficial or deep? 2.Associated symptoms? 3. Underlying conditions? 4.Duration of symptom? 5.Does anything help? 6.Previous investigations/treatment?

. Examine  Explain  Plan future management Psychosexual Medicine

Psychosexual Medicine is psychosomatic medicine applied to sexual disorders.

It offers a type of brief therapy, based on psychoanalytic skills.

It is a unique practice that helps to understand how emotional factors, not always experienced at a conscious level, can interfere with sexual performance and enjoyment. IPM Training

 Seminar group training  Case discussion  Analysis of the clinician-patient relationship to identify the effect of unconscious patterns and learned behaviours on sexual well-being THE SKILLS OF PSYCHOSEXUAL MEDICINE

Fundamental to IPM work is a patient approach that is different from the traditional.

The practitioner is not the expert but learns particular skills enabling the patient to develop an insight into their own problem THE SKILLS OF PSYCHOSEXUAL MEDICINE

 Observation and listening  The study and interpretation of the practitioner/patient relationship  The use of the genital examination as a psychosomatic event Vulvodynia case study

July 11 recurrent thrush premenses pain, soreness, no swabs Aug 11 started on 6/52 suppression Mar 13 rec thrush fluconazole, canesten, gyno-daktarin vaginal pain with SI, SHS and micro neg Apr 13 burning/irritation, introital pain self help via VPS website May 13 AMT commenced Oct 13 emails from Vietnam Sep 15 pain worse premenses. Lignocaine gel Dec 15 Physio. Unprovoked pain AMT, pregabalin, GABA, disc CHC VAS 3-5, raised PFT desensitisation//breathing Jan 16 POP-pain May 16 Physio. VAS 2-5. Disc instillagel Sep 16 Physio – no change - acupuncture Aug 17 SHS – CMP Jan 18 Gyn – osteopath, chiropractor, SPS requests Botox Mar 18 , , ED – no issues Mild vaginismus May 18 Botox Aug 18 No improvement Depomedrone 40mg If no improvement – Duloxetine

FU arranged for Nov 18 ISSVD Presidential address

Vulvodynia:

a syndrome of unexplained vulvar pain, psychological disability and sexual dysfunction

PJ Lynch 1986 2015 Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia - ISSVD

A. Vulvar pain caused by a specific disorder  Infectious (e.g., recurrent candidiasis, herpes)  Inflammatory (e.g., LS, LP, immunobullous disorders)  Neoplastic (e.g., Paget disease, SCC)  Neurologic (e.g., postherpetic neuralgia, nerve compression or injury, neuroma)  Trauma (e.g., FGM, obstetrical)  Iatrogenic (e.g., postoperative, chemotherapy, radiation)  Hormonal deficiencies (e.g., GSM, lactational amenorrhea)

B. Vulvodynia  vulvar pain of at least 3 months' duration, without clear identifiable cause, which may have potential associated factors. Diagnosing vulvodynia

History  Burning,irritating,itching  Exacerbated by tampons/intercourse  Chronicity  Descriptors – localised/provoked/tempo ral pattern/onset

Examination  Vulva usually unremarkable  Q tip test positive

30 31 Activities that worsen Activities that reduce pain pain

 Intercourse  No underwear   partner touch Loose clothing  Ice  tight clothing  Lying down  sitting  Distraction by activity  Tampon use  cycling  washing Vulvodynia

20 years ago Now

 Rare  Not rare  Mainly Caucasian women  As likely in African-  Psychological causes American and Hispanic important  Psychological issues minor  Probably infectious factor aetiology  No infectious aetiology proven  May not be life-long ‘Just how bad can it be?’

30

25

20

# of women 15

10

5

0 1 2 3 4 5 6 7 8 9 10 Worst pain ever (1-10)

Reed, Neuroimmunology alterations in vulvodynia, N = 94 33 Years with vulval pain

16 14 12 10 8

# of wom of # 6 4 2 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 19 23 27 28 29 Years with vulvar pain Reed, Neuroimmunology/cytokines associated with vulvodynia - 2003, N = 66

34 Treatments for vulvodynia

 Peripherally-acting medications eg lignocaine gel, injectable steroids  Centrally-acting medications eg SSRIs, SNRIs*  Physiotherapy  Psychosexual counselling  CBT  Botulinum toxin  Surgery • *www.paindata.org • *www.paintoolkit.org

35 Relationship between Vulvodynia and chronic co-morbid pain conditions

questionnaire-based screening tests for 4 pain conditions completed by 1890 women with and without vulvodynia population-based survey 27% with multiple conditions Interstitial cystitis 7.5% 6.2 – 9.0 Vulvodynia 8.7% 7.3 – 10.4 IBS 9.4% 8.1 – 11.0 Fibromyalgia 11.8% 10.1 – 13.7

Presence of vulvodynia increased association with the other conditions

RR 2.3 – 3.3 (p<0.001)

Reed B et al. Obstetrics & Gynecology:120(1): 2012;145–51 LS case study

20 Vulval discomfort – thrush Rx 22 Dyspareuia – referred to SPS – DNA 23 Thrush Rx x2 24 Dyspareunia – gyn referral – vulvodynia 25 BV Rx x1 26 AMT – no help, thrush Rx x1, BV Rx x1 27 SPS – mild vaginismus 28 clinical Dx of LS History

 “What was the first thing you noticed wrong in the genital area”  How does it affect you now?  When did you last have a swab taken  Have you ever had a biopsy  Any other investigations  What are you putting on it  How do you clean the area  When did you last use any thrush treatment  Any extragenital dermatoses/atopy/allergies

38 Lichen Sclerosis

‘An inflammatory scarring dermatosis, characterized by a lymphocytic response, that has a predilection for the genital skin’

 Burning  Soreness  Itching  Dyspareunia

39 Signs of Lichen sclerosis 40

 Pallor  Hyperkeratosis  Purpura  Erosions  Fissures  Scarring Lichen sclerosis

 Common  Characterised by ivory papules which coalesce into pale plaques

Women up to 3% Men/boys up to 0.07%

41 Lichen sclerosis– future malignancy risk

 1 – 5 % of women with LS will develop squamous-cell carcinoma  Mean age of SCC 14 years older than LS diagnosis  ? Patients at risk

. Previous SCC or differentiated VIN . > 60 yrs old . Hyperkeratosis . (poor control)

42 Lichen sclerosis treatment Soap substitute / emollient / vulval care Patient information

Topical therapy  Bland emollients – act as soap substitute, moisturiser, barrier e.g. aqueous cream, Dermol 500, Diprobase  Active preparations – steroids, tacrolimus

Systemic therapy  Retinoids, steroids, methotrexate

43 GUM case - age 35

 Pain with sex over last 6-8 months  Relationship with male for 10 years, sex was pain free until 8 months ago  No pressure from partner  Recurrent candida over last 12 months and on suppressive treatment which is working  Examination consistent with vaginismus  Vaginal trainers Causes of superficial dyspareunia

Infectious: • Candidiasis • HSV • Trichomoniasis/bacterial vaginosis

Dermatological: • Eczema • Psoriasis • Contact dermatitis • Lichen sclerosis • Lichen planus • Behcets Gyn case

26 yrs old Endometriosis Dx 2009 by laparoscopy – age 15

Since then, been on COC, continuously for past 2 years

Referred with deep dyspareunia Gyn case

RMP 6 years, lived together for 3 years Pain free and enjoyable intercourse for first 2 years

No penetration for 4 years and/or intimacy every few months Reduced / non-existent libido Avoiding intimacy “I worry about something going inside me” Gyn case

Smear 2017 – “I wonder how you managed to have that”

Single finger VE Swab tube Digital self examination Size 1 trainer Gyn case follow-up

Bought own dilators – managing first 2 sizes

Managed orgasm x2 Aware of slight return to libido RMP not managing mutual “He’s used to seeing to himself”

“I need to accept a messy or smelly down there after sex” Round up / Summary of afternoon

 Questions???