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P-047 - Psychological Modalities for the Management of Localized Provoked Vulvodynia: A Scoping Review of the Literature from 2010 to 2023.

POSTER ABSTRACT
Location:  Exhibit Hall
Abstract Title: Psychological Modalities for the Management of Localized Provoked Vulvodynia:
A Scoping Review of the Literature from 2010 to 2023.


Background: Chronic pain is a significant public health burden affecting physical, social, and emotional functioning of those living with it.1 Vulvodynia is a complex, chronic vulvar pain condition of unknown origin lasting at least three months.2 Some estimates indicate that 10-28% of people with a vulva experience vulvodynia in their lifetime. 3,4 Localized provoked vulvodynia (LPV) is the most common vulvodynia subtype.3 Individuals with LPV experience pain at the vulvar vestibule, provoked by contact, including vaginal penetration.5 Pain can negatively impact sexual intimacy, relationship quality, and the ability to conceive a child.6,7 Patient-stated goals for treatment may include improved sexual functioning, as well as other quality of life goals, such as comfort with sitting, exercise, clothing, and menstrual product use.8



Psychological interventions for chronic pain often target maladaptive pain cognitions and their resultant behaviors, which frequently compromise quality of life. 9 Cognitive behavior therapy (CBT), evolved from behavior therapy, encourages challenging negative cognitions, thereby altering behaviors and emotions, improving distress and coping. Subsequent CBT-adapted therapies include mindfulness-based cognitive therapy (MbCT), where mindfulness is learning awareness of negative thought patterns and intentionally responding more constructively, and acceptance and commitment therapy (ACT) emphasizes willingness to engage in desired activities despite pain.

Purpose/Objectives: Given the negative impact of LPV on the psychological wellbeing and quality of life of those living with LPV and their partners,10 the application of psychological interventions for other chronic pain conditions in LPV management is an area of emerging research. We conducted a scoping review that aimed to map the landscape of contemporary research related to the efficacy and effectiveness of psychological interventions for LPV. To capture the current research landscape, we searched the literature for articles published after 2009. We highlight interventions that show beneficial effects, discuss gaps in the LPV treatment literature and provide recommendations for future research.


Methods: We conducted a scoping review using Arksey and O’Malley’s11 five-step method to identify, organize, and summarize research that investigated the efficacy or effectiveness of interventions in the management of LPV from 2010 to 2023. The inclusion and exclusion criteria and the search strategy were developed by subject experts in collaboration with a health science librarian. A PubMed search used controlled vocabulary and keyword terms relating to LPV, that were then translated into other databases. The initial search was conducted in June 2021 and updated in March 2023, with both reviews following the same screening and analysis process. All citations were uploaded to Covidence. Duplicates were removed. Titles and abstracts were screened for relevance. The remaining articles were subject to a full text review followed by a hand search of eligible articles. Screening was conducted independently by two team members with conflicts resolved by the content experts, by consensus when indicated. Study details were extracted and reported narratively. Treatment modalities were categorized as physical, psychological, pharmacological, or interdisciplinary/multimodal and reported separately. This abstract reports on the efficacy or effectiveness of psychological interventional studies only.


Results: Of the 88 included articles published between January 2010 and March 2023, 15 reported on the efficacy/effectiveness of psychological treatments for LPV. The studies were conducted in Canada (n=6), Norway (n=4), Sweden (n=3), UK (n=1), and US (n=1). Five were conducted at multiple healthcare centers, and ten were single-center. The most common study design was quasi-experimental (n=8) variously described by investigators as pilot, proof-of-concept, single case experimental or feasibility studies, followed qualitative studies (n=4) and RCTs (n=3). Sample populations were mostly young, white, partnered, heterosexual, and well-educated.



CBT-based therapies were the most common psychological treatments studied for LPV. Two small quasi-experimental trials studied group-delivered couples-based CBT.12,13 One study showed mixed results while the other found improved outcomes for both those affected with LPV and their partners. For both studies, authors considered their studies to lay the groundwork for larger RCTs.



There were 5 publications based on 3 trial interventions, all of group delivered MbCT.14-18 Two studies compared MbCT with CBT, one study compared MbCT to waitlist, then MbCT and two studies were qualitative assessments. All groups, including waitlist, experienced in some significant improvements. While M-gCBT showed superior outcomes compared with CBT in some instances, confidence is limited by study design.



All three trials of remotely delivered ACT19-21 reported improvements. One RCT20 appears adequately powered to support significant dyspareunia reduction. High drop-out rates were problematic.



There were four studies of somatocognitive therapy (SCT). 22-25 SCT combines CBT principles with Mensendieck physiotherapy, focusing on body awareness, cognitive retraining, and coping.22 Two qualitative studies showed positive results while two small quasi-experimental studies showed mixed results. Investigators concluded more research is needed to establish the value of this intervention.



One quasi-experimental study evaluating group education seminars showed benefits for LPV.26



Overall, CBT and MbCT have only been evaluated in in-person group settings, while ACT has only been evaluated as an individual online intervention. Group therapy and education alone both showed benefits. Challenges remain in terms of community access to some interventions and lack of ongoing support after treatment. Consideration of intimate partners or those affected by LPV without partners is limited.



Conclusions/Implications for future research and/or clinical care: LPV remains an under-studied chronic pain condition. When compared with other LPV interventions, investigation of psychological treatments is a relatively new area of study and there are outstanding gaps in existing evidence. Several of the psychological intervention studies showed promising but inconclusive results as a treatment for LPV. Only one RCT evaluating the efficacy of acceptance and commitment therapy for LPV management appeared adequately powered to demonstrate significant improvement in dyspareunia. Several studies include psychoeducation as a component of the intervention making it difficult to assess the effect of the therapy separate from the education. Additionally, mode of delivery may affect treatment efficacy.



A scoping review is not intended to guide clinical practice or policy but to offer recommendations to guide future research on LPV. Specifically, larger, rigorously designed studies conducted with heterogeneous populations are recommended to assess potential treatment efficacy/effectiveness of psychological interventions for LPV.


References: 1. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain. 2006;10(4):287-287. doi:10.1016/j.ejpain.2005.06.009

2. Bornstein J, Goldstein AT, Stockdale CK, et al. 2015 ISSVD, ISSWSH and IPPS consensus terminology and classification of persistent vulvar pain and vulvodynia. Obstet Gynecol. 2016;127(4):745-751. doi:10.1097/AOG.0000000000001359

3. Harlow BL, Kunitz CG, Nguyen RHN, Rydell SA, Turner RM, MacLehose RF. Prevalence of symptoms consistent with a diagnosis of vulvodynia: population-based estimates from two geographical regions. Am J Obstet Gynecol. 2014;210(1):10.1016/j.ajog.2013.09.033. doi:10.1016/j.ajog.2013.09.033

4. Pukall CF, Goldstein AT, Bergeron S, et al. Vulvodynia: definition, prevalence, impact, and pathophysiological factors. J Sex Med. 2016;13(3):291-304. doi:10.1016/j.jsxm.2015.12.021

5. Lev-Sagie A, Witkin SS. Recent advances in understanding provoked vestibulodynia. F1000Res. 2016;5:2581. doi:10.12688/f1000research.9603.1

6. Ekdahl J, Flink I, Engman L, Linton SJ. Vulvovaginal pain from a fear-avoidance perspective: a prospective study among female university students in Sweden. Inter J Sex Health. 2018;30(1):49-59. doi:10.1080/19317611.2017.1404543

7. Sadownik L, Seal B, Brotto L. Provoked vestibulodynia - a qualitative exploration of women’s experiences. British Columbia Medical Journal. 2012;54:22-28.

8. LePage K, Selk A. What do patients want? A needs assessment of vulvodynia patients attending a vulvar diseases clinic. Sexual Medicine. 2016;4(4):e242-e248. doi:10.1016/j.esxm.2016.06.003

9. J. A. (2014). Psychological therapies for the management of chronic pain. Psychology Research and Behavior Management, 7, 115–124. https://doi.org/10.2147/PRBM.S44762

10. Thornton AM, Drummond C. Current concepts in vulvodynia with a focus on pathogenesis and pain mechanisms. Australas J Dermatol. 2016;57(4):253-263. doi:10.1111/ajd.12365

11. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19-32. doi:10.1080/1364557032000119616

12. Corsini‐Munt S, Bergeron S, Rosen NO, Mayrand M, Delisle I. Feasibility and preliminary effectiveness of a novel cognitive–behavioral couple therapy for provoked vestibulodynia: a pilot study. J Sex Med. 2014;11(10):2515-2527. doi:10.1111/jsm.12646

13. Engman L, Ter Kuile MM, Linton SJ, Ekholm E, Tuijnman-Raasveld CC, Flink IK. An initial proof of concept: A replicated single-case study of a CBT group treatment with partner involvement for vulvodynia. Cogn Behav Ther. 2022;51(6):503-519. doi:10.1080/16506073.2022.2086907

14. Brotto LA, Basson R, Carlson M, Zhu C. Impact of an integrated mindfulness and cognitive behavioral treatment for provoked vestibulodynia (IMPROVED): a qualitative study. Mindfulness in Sexual and Relationship Therapy. 2013;28(1-2): 3–19, http://dx.doi.org/10.1080/14681994.2012.686661

15. Brotto LA, Basson R, Smith KB, Driscoll M, Sadownik L. Mindfulness-based group therapy for women with provoked vestibulodynia. Mindfulness. 2015;6(3):417-432. doi:10.1007/s12671-013-0273-z

16. Brotto LA, Bergeron S, Zdaniuk B, et al. A comparison of mindfulness-based cognitive therapy vs cognitive behavioral therapy for the treatment of provoked vestibulodynia in a hospital clinic setting. J Sex Med. 2019;16(6):909-923. doi:10.1016/j.jsxm.2019.04.002

17. Marsh A. Storying the Impact of Participating in a Psychological Treatment Intervention for Provoked Vestibulodynia, 5 Years Later: A Narrative Inquiry. University of British Columbia; 2021. doi:10.14288/1.0402635

18. Guillet AD, Cirino NH, Hart KD, Leclair CM. Mindfulness-based group cognitive behavior therapy for provoked localized vulvodynia: a randomized controlled trial. J Low Genit Tract Dis. 2019;23(2):170-175. doi:10.1097/LGT.0000000000000456

19. Chisari C, McCracken LM, Cruciani F, Moss-Morris R, Scott W. Acceptance and commitment therapy for women living with vulvodynia: a single-case experimental design study of a treatment delivered online. J Context Behav Sci. 2022;23:15-30. doi:10.1016/j.jcbs.2021.11.003

20. Hess Engström A, Bohm-Starke N, Kullinger M, et al. Internet-based treatment for vulvodynia (EMBLA) – a randomized controlled study. J Sex Med. 2022;19(2):319-330. doi:10.1016/j.jsxm.2021.11.019

21. Maathz, P. Application of the psychological flexibility model in the context of vulvar pain and sexual dysfunction. Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Social Sciences 194. 60 pp. Uppsala: Acta Universitatis Upsaliensis. ISBN 978-91-513-1412-9. Published online 2022. Accessed April 22, 2024. https://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-467369

22. Kaarbø MB, Danielsen KG, Haugstad GK, Helgesen ALO, Wojniusz S. Feasibility and acceptability of somatocognitive therapy in the management of women with provoked localized vestibulodynia—ProLoVe feasibility study. Pilot Feasibility Stud. 2022;8(1):68. doi:10.1186/s40814-022-01022-2

23. Danielsen KG, Dahl-Michelsen T, Håkonsen E, Haugstad GK. Recovering from provoked vestibulodynia: Experiences from encounters with somatocognitive therapy. Physiother Theory Pract. 2019;35(3):219-228. doi:10.1080/09593985.2018.1442540

24. Danielsen KG, Kaarbø MB, Groven KS, Helgesen ALO, Haugstad GK, Wojniusz S. Towards improved sexual health among women with provoked vestibulodynia: experiences from a somatocognitive therapy approach. Eur J Physiother. 2024;26(1):51-61. doi:10.1080/21679169.2023.2168749 [published online Jan 20, 2023]

25. Haugstad GK, Wojniusz S, Kirschner R, Kirste U, Lilleheie I, Haugstad TS. Somatocognitive therapy of women with provoked vulvodynia: a pilot study. Scand J Pain. 2019;19(4):725-732. doi:10.1515/sjpain-2019-0011

26. Brotto LA, Sadownik L, Thomson S. Impact of educational seminars on women with provoked vestibulodynia. J Obstet Gynaecol Can. 2010;32(2):132-138. doi:10.1016/S1701-2163(16)34427-9