Startseite Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain
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Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain

  • Ida Katrina Flink EMAIL logo , Linnéa Engmana , Moniek M. Ter Kuile , Johanna Thomtén und Steven J. Linton
Veröffentlicht/Copyright: 1. Oktober 2017
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Scandinavian Journal of Pain
Aus der Zeitschrift Scandinavian Journal of Pain Band 17 Heft 1

Abstract

Background and aims

Chronic vulvovaginal pain is strikingly common and has a serious impact on women’s lives. Nevertheless, there are few longitudinal studies focusing on mechanisms involved in the pain development. One area of interest is how women cope with sexual activities and how this affects their pain. In this study, avoidance and endurance coping behaviors were explored as possible mediators of the relation between catastrophizing and pain, cross-sectionally and longitudinally.

Methods

251 women (18-35 years old) with vulvovaginal pain were recruited in university settings and filled out questionnaires about their pain, catastrophizing and coping behaviors at two occasions, with five months in between. Multiple mediation models were tested, exploring avoidance and endurance as mediators of the relation between catastrophizing and pain.

Results

The results showed that avoidance was an influential mediator of the link between catastro¬phizing and pain. Using multiple mediation models we found that although the indirect effects of both avoidance and endurance were significant cross-sectionally, only avoidance was a significant mediator in the combined model exploring associations over time.

Conclusions

This study indicates that the strategies women with vulvovaginal pain use for coping with sexual activities are important for the course of pain. Avoidance and, to a lesser degree, endurance strate¬gies were identified as important mediators of the effects of catastrophizing on pain. When exploring the links over time, only avoidance emerged as a significant mediator.

Implications

In this longitudinal study, catastrophizing was linked to vulvovaginal pain, via avoidance and endurance of sexual activities. Hence, targeting catastrophizing early on in treatment, as well as addressing coping, may be important in clinical interventions.

Keywords: Vulvovaginal pain; Sexual pain; Women; Coping; Avoidance-endurance

1 Introduction

Chronic vulvovaginal pain and othertypes of gynecological pain are widespread problems, reported by 8-21% of premenopausal women (e.g.[1,2]). The pain has a serious impact on women’s lives, affecting daily activities[3] and quality oflife [4] as well as sexual activities and satisfaction[5] since vaginal penetration often is very painful. Yet, there are few longitudinal studies focusing on this pain group.

One topic ofinterest is how these women cope with sexual activities. In other pain populations, fear-related avoidance has emerged as a central coping strategy[6], which may seem functional in the short run but is associated with worse outcome over time because of increased pain and disability. The fear-avoidance model of pain [7] was developed to illustrate this vicious circle, and has been endorsed by substantial empirical support, mainly in people suffering from musculoskeletal pain (see e.g.[6,8]). While fear-avoidance tendencies are acknowledged as maladaptive also in women with vulvovaginal pain (for a review, see [9]), there is limited support for the impact over time. To our knowledge, there is only one prospective study exploring this topic[10]. In that study, changes in fear-avoidance variables over a two-year period were not associated with outcomes. Endurance is another frequently used coping behavior in women with vulvovaginal pain (e.g.[11]), but longitudinal data of its influence is lacking.

In line with the fear-avoidance model of pain, avoidance behavior mediates the link between pain catastrophizing (i.e. exaggerated negative cognitions around pain) and pain-related outcomes[7]. An alternative possibility is that women with vulvovaginal pain instead of avoiding rather endure sexual activities, because they catastrophize around other topics than the pain itself (e.g. losing the partner). This hypothesis is supported by evidence that these women more often have intercourse because of mate guarding and duty or pressure motives than women without vulvovaginal pain [12,13]. Endurance behavior may however result in a lack of arousal, insufficient lubrication and an increase in nociceptor sensitization[14]. Hence, an alternative model is that endurance mediates the relationship between catastrophizing and pain-related outcomes. Consequently, there are two possible mediation models to be tested, cross-sectionally, of a descriptive purpose, and longitudinally. Examining mediation in this context is important, as it may help to understand the link between catastro- phizing and pain. It may also provide a direction for interventions early on in the pain development. The aim of this study is to explore whether avoidance and/or endurance of sexual activities, when triggered by catastrophizing, might influence vulvovaginal pain over time.

2 Methods

2.1 Design

This longitudinal study is based on a subsample from a larger data set (Sex and Pain, SAP) including women with and without vulvovaginal pain who filled out a number of self-report inventories and were followed over time, in order to study the development of vulvovaginal pain. The current study used data from the first and second measurement points, with five months in between.

2.2 Recruitment

Women between 18 and 35 years were recruited at two universities in two middle sized cities in Sweden. The university setting was chosen to maximize the chances of getting the women to respond on several occasions, which in turn enables analyses of how mechanisms influence vulvovaginal pain overtime.All women in 66 classes were invited to remain in the classroom after lectures to get information about the study. The purpose of the study was described as: “.. .to increase the understanding of sexual pain in women, with the main focus on psychological and relational factors linked to pain, but also to explore sexual habits more broadly.” If the women agreed to participate, they filled out informed consents, picked questionnaires from an open box in the classroom, completed the questionnaires, and put them in blank envelopes in a closed box in the classroom. If they preferred to fill out the questionnaires at home, they got the possibility to bring them and hand them in later, in a closed box at the research center. The participants were provided coffee coupons as incentives. Five months later, all participants were sent an identical questionnaire to their home address together with written information about the study and a pre-paid envelope. Non-responders were sent e-mail reminders after two and four weeks. After returning the questionnaire, responders were sent cinema tickets as incentives. The study was approved by the Regional Ethical Review Board in Uppsala, Sweden (D Number 2014-407).

2.3 Participants

Inclusion criteria were: (1) 18-35 years old, (2) vulvovaginal pain during the last 6 months (“Have you experienced recurrent pain during sexual intercourse/touch/contact with the vulva during the last 6 months?”) and (3) sexually active during the last month. 1034 women completed the questionnaire at the first occasion. 12 women were excluded because informed consents were lacking. Out of the remaining 1022 women, 296 (29%) reported vulvovaginal pain. Of these women 39 were excluded because they were not sexually active and additionally 6 women had too many missing values (>20% or more than 1 missing value/subscale) on the measures used in the analyses. The remaining 251 women constitute the sample of the current study. At the second measurement point, 140 of the 251 women (56%) filled out the questionnaire; of these 2 women had too many missing values on the variables used in the study, resulting in 138 women included in the analyses at time point 2. At the second measurement point, 100 women (72%) reported vulvovaginal pain. Table 1 displays baseline characteristics of the sample. As can be seen, the mean age was 23, nearly 80% were is a relationship and 10% had children. The mean level of pain intensity was 2.84 (out of 10). A non-response analysis between responders at time point 1 only (N=111) and responders answering the questionnaire at both time points (N = 138) was executed on the variables age, pain catastrophizing, avoidance, endurance and pain intensity, showing no significant differences between non-responders and responders on any of the variables (t(249) = .50, p = .62; t (249) = –.53, p = .60; t (249) = .62, p = .53; t(249) = –.50, p = .62; t(249) = –.78, p = .43).

Table 1

Demographic data forthe sample at baseline (N=251).

Age (years)
 Mean (SD) 23.08 (3.3)
Relationship
 Yes (n, %) 198 (79%)
 No (n, %) 47 (19%)
 Other (n, %) 6 (2%)
Relationship length (years)
 Mean (SD) 3.1 (2.7)
Gender of partner
 Male (n, %) 196 (96%)
 Female (n, %) 6 (3%)
 Other (n, %) 2 (1%)
Children
 Yes (n, %) 25 (10%)
 No (n, %) 223 (90%)
Pain subscale FSFI (1-6)
 Mean (SD) 2.84 (1.3)

2.4 Measures

Swedish versions of all measures were used.

2.4.1 Demographics

The women completed details about their age, health care consumption, relationship status, and children based on questions used in earlier studies on this population [15].

2.4.2 Avoidance and endurance coping behaviors

The CHAMP Sexual Pain Coping Scale (CSPCS) [16] was used to assess endurance and avoidance. This measure was recently developed to assess how women with vulvovaginal pain cope with sexual activities, and is divided into three subscales: avoidance (e.g. “When my sexual partnerwants to have intercourse, I make excuses to avoid it because it can be painful”, “Because of my pain, my motto is “sex isn’t for me”.), endurance (e.g. “During painful intercourse, I try to endure because I would feel like a failure if I didn’t keep going.”, “When intercourse is painful, I try to think of something else and ignore the pain.”) and alternative strategies (e.g. “When intercourse is painful, me and my sexual partner try to find other ways to have sex, so that we both can enjoy it.”). Responders rate how often they consider each statement being true for them on a seven-point Likert scale (1 = Never true; 7 = Always true). In the preliminary validation of the questionnaire, which was made on a Swedish sample, the psychometric properties of the avoidance and the endurance subscales turned out to be good, whereas the alternative subscale was only partly supported [16]. Consequently, the avoidance and the endurance subscales were used in the current study, and the internal consistency was good (Cronbach’s alpha = .77 vs. .86).

2.4.3 Pain

The pain subscale from the Female Sexual Function Index (FSFI) [17] was used to assess pain. This subscale consists of three items reflecting different aspects of pain in relation to vaginal penetration (frequency during intercourse, frequency after intercourse and pain intensity) (e.g. “Over the past 4 weeks, how would you rate your level (degree) of discomfort or pain during or following vaginal penetration?”). The responders rate their answers on a six-point Likert scale, ranging from 0 to 5. As an answer of 0 indicates no sexual activity, women who responded 0 at the first measurement point were excluded from the study. The total score on the subscale ranges from 1 to 6 at the first measurement point, and from 0 to 6 at the second measurement point. To facilitate the interpretation of the results, the total score was reversed, meaning that in our study 6 indicates high levels of pain. FSFI has shown adequate psychometric properties [17], and is validated in a Swedish sample [18]. Cronbach’s alpha on the pain subscale in our sample was excellent (Cronbach’s alpha = .96 at measurement point 1 and .97 at measurement point 2).

2.4.4 Pain catastrophizing

The Pain Catastrophizing Scale (PCS) [19] was used to assess pain-related catastrophizing as a general tendency, not specifically linked to pain during intercourse. The PCS consists of 13 thoughts and feelings that people may have when in pain, and is divided into three subscales: magnification (e.g. “I keep thinking of other painful events”), rumination (e.g. “I can’t seem to keep it out of my mind”), and helplessness (e.g. “I feel I can’t go on”). Respondents rate to what extent they experience each thought and feeling on a five- point scale (0 = Not at all; 4 = All the time). The PCS has shown good psychometric properties [19], and the Swedish version is widely used (e.g. [39]). In the present study, we used the total score on the PCS, and the internal consistencywas good (Cronbach’s alpha = .92).

2.5 Data analyses

IBM Statistical Package of Social Sciences (SPSS) 23.0 was used for the analyses. Missing values were replaced with the individual’s mean score of the subscale, allowing maximum one missing value/subscale, if the missing values did not exceed 20%.

First, the data were summarized and inspected through descriptive and correlational statistics. Next, the two proposed mediators (avoidance vs. endurance) of the relation between catastrophizing and pain were combined in a multiple mediation model, cross-sectionally and longitudinally, enabling the comparison of the independent effect of each mediator in relation to the other. Due to high intercorrelation between the two mediators, the pathway through both mediators combined was also accounted for in the model [20]. The PROCESS macro for SPSS [21] was used to establish the indirect effects of the putative mediators in the model, as recommended by Hayes and Rockwood [22]. To evaluate the significance of the indirect effects, the macro generates bootstrapped bias-corrected confidence intervals which indicates significant mediation when the bootstrapped confidence interval does not contain zero [20]. The number ofbootstraps (n = 5000 bootstrap resamples) were based on recommendations by Hayes [23]. Lastly, effect sizes of the indirect effects were calculated using k2 to estimate the strength of the indirect effects. k2 is the ratio of the observed indirect effect to the maximum possible indirect effect that could have occurred, and the recommendations used for determining the effect sizes were: small ~.01; medium ~.09; large ~.25 [24]. The level of significance was set at p< .05.

3 Results

First, the associations between the variables in the mediation models were examined. To enhance understanding and provide an overview of the sample characteristics on the variables used in the analyses, Table 2 displays descriptive statistics and correlations between the variables. There were significant positive correlations between all variables, varying between weak (r=.21, p<.05) and strong (r =.57, p<.001) [25].

Table 2

Descriptive statistics and correlations between the main variables of the study.

N Range M (SD) 2 3 4 5
1. Pain catastrophizing 251 0-52 18.28 .36*** .29*** .29*** .21*
(PCS, t1) (10.81)
2. Avoidance 251 4-28 9.18 - .50*** .57*** .41***
(CSPCS-A, t1) (5.04)
3. Endurance 251 4-28 13.78 - .49*** .33***
(CSPCS-E, t1) (6.16)
4. Pain 251 0-6a 2.84 - .37***
(FSFI-P, t1) (1.30)
5. Pain 138 0-6 2.00 -
(FSFI-P, t2) (1.43)

Notes.PCS, Pain Catastrophizing Scale; CSPCS-A, CHAMP Sexual Pain Coping Scale-Avoidance subscale; CSPCS-E, CHAMP Sexual Pain Coping Scale-Endurance subscale; FSFI-P, Female Sexual Function Index-Pain subscale. t1, time point 1; t2, time point 2

  1. a Women scoring 0 at time point 1were excluded from the analysis.

  2. * p<.05.

  3. *** p<.001.

Table 3 displays the results of the multiple mediation analysis where avoidance and endurance were proposed to mediate the relationship between catastrophizing and pain cross-sectionally. The multiple mediation model showed a decrease in the total effect (c, β = .28, p<.001) compared to the direct effect (c′,β = .06, NS) from significant to non-significant at time point 1 (see Fig. 1). Furthermore, there was a significant indirect effect, excluding zero in the bootstrapped confidence interval, through avoidance as a mediator (a1 × b1, β = .148,95% BCI [.090, .225]), through endurance as a mediator (a2 × b2, β = .032, 95% BCI [.006, .071]), as well as through both avoidance and endurance as combined mediators (a1 × a3 × b2, β = .042, 95% BCI [.021, .072]). When comparing the indirect effects of the mediators, the indirect effect through avoidance was significantly larger than both the indirect effect through endurance (a1 × b1 –a2 × b2, β = .116, 95% BCI [.045, .199]) and through both mediators (a1 × b1 – a1 × a3 × b2, β = .107, 95% BCI [.051, .183]). Zero was included in the bootstrapped confidence interval, indicating that there was no significant difference between the indirect effects of endurance as sole mediator and the combined mediators (a1 × a3 × b2 –a2 × b2, β = .009, 95% BCI [-.025, .053]).

Fig. 1 Multiple mediation model with avoidance and endurance as proposed mediators cross-sectionally. Standardized regression coefficients (ß) forthe relationship betweencatastrophizing and pain as mediated by avoidance and endurance, respectively and combined. *p<.05; **p<.01;***p<.001.
Fig. 1

Multiple mediation model with avoidance and endurance as proposed mediators cross-sectionally. Standardized regression coefficients (ß) forthe relationship betweencatastrophizing and pain as mediated by avoidance and endurance, respectively and combined. *p<.05; **p<.01;***p<.001.

Table 3

Multiple mediation model of catastrophizing on pain by avoidance and endurance coping, cross-sectionally (N=251).

Model R2 β SE p CI (95%)
Model without mediators
 Catastrophizing → Pain (c) .284 .059 <.001 .168-.401
 RY,X2 .09
Model with mediators
 Catastrophizing → Avoidance (a1 ) .326 .053 <.001 .222-.431
 Catastrophizing → Endurance (a2) .117 .054 <.05 .010-.224
 Avoidance → Endurance (a3 ) .462 .060 <.001 .344-.582
 Avoidance → Pain (b1 ) .454 .065 <.001 .863-1.074
 Endurance → Pain (b2) .275 .061 <.001 .154-.395
 Catastrophizing → Pain (c′) .063 .053 .233, NS –.041 to .167
 RM1,X2 .13
 RM2,M1,X2 .26
 RY,M1M2X2 .38
Indirect effects
 Through avoidance (a1 × b1 ) .148 .034 .090-.225
 Through endurance (a2 × b2) .032 .016 .006-.071
 Through both mediators (a1 × a3 × b2) .042 .013 .021-.072
 Total indirect effect .222 .042 .148-.311

Notes. RY,X2, proportion of the variance in the painvariable (Y) explained by catastrophizing (X); RM1,X2, proportion of the variance in the avoidance variable (M1 ) explained by catastrophizing (X); RM2,M1,X2, proportion of the variance in the endurance variable (M2 ) explained by the avoidance variable (M1 ) and catastrophizing (X); RY,M1M2X2, is the proportion of the variance in the painvariable (Y) explained by avoidance (M1 ), endurance (M2) and catastrophizing (Y). The 95% CIs for the indirect effects are obtained by the bias-corrected bootstrap with 5000 resamples. NS = non-significant

Table 4 displays the results of the multiple mediation analysis where avoidance and endurance were proposed to mediate the relationship between catastrophizing and pain over time. There was a change from significant to non-significant in the total effect (c, β = .22, p<.05) and the direct effect (c′, β = .06, NS) when avoidance and endurance were explored as mediators of the relationship between catastrophizing and pain after five months (seeFig. 2). The bootstrapped indirect effect was significant through avoidance as a mediator (a1 × b1, β = .124, 95% BCI [.046, .253]) and through both mediators in combination (a1 × a3 × b2, β = .030, 95% BCI [.005, .080]), excluding zero in the confidence interval. The indirect effect of endurance as a mediator was not significant (a2 × b2, β = .008, 95% BCI [-.020, .058]). However, the indirect effect through avoidance was significantly greater than through both mediators combined (a1 × b1 – a1 × a3 × b2, β = .095, 95% BCI [.008, .218]), when comparing their individual indirect effects.

Table 4

Multiple mediation model of catastrophizing on pain by avoidance and endurance coping, longitudinally (N=138).

Model R2 β SE P CI (95%)
Model without mediators
 Catastrophizing → Pain (c) .224 .091 <.05 .044, -.405
R Y , X 2 .04
Model with mediators
 Catastrophizing→Avoidance (a1 ) .307 .067 <.001 .174-.440
 Catastrophizing →Endurance (a2) .038 .082 .642, NS –.124 to .201
 Avoidance→Endurance (a3 ) .472 .098 <.001 .279-.666
 Avoidance→Pain (b1 ) .405 .116 <.001 .174-.635
 Endurance→Pain (b2 ) .204 .095 <.05 .016-.391
 Catastrophizing→Pain (c′) .063 .090 .489, NS -.116 to .242
R M 1 , X 2 .13
R M 2 , M 1 , X 2 .18
R Y , M 1 M 2 X 2 .20
Indirect effects
 Through avoidance (a1 × b1 ) .124 .050 .046-.253
 Through endurance (a2 × b2) .008 .018 -.020 to .058
 Through both mediators (a1 × a3 × b2) .030 .018 .005-.080
 Total indirect effect .162 .055 .070-.287

Notes. RY,X2, proportion of the variance in the pain variable (Y) explained bycatastrophizing (X); RM1,X2, proportion of the variance in the avoidance variable (M1 ) explained by catastrophizing (X); RM2,M1,X2, proportion of the variance in the endurance variable (M2) explained by the avoidance variable (M1) and catastrophizing (X); RY,M1M2X2, is the proportion of the variance in the pain variable (Y) explained by avoidance (M1 ), endurance (M2) and catastrophizing (Y). The 95% CIs for the indirect effects are obtained by the bias-corrected bootstrap with 5000 resamples. NS = non-significant

Fig. 2 Multiple mediation model with avoidance and endurance as proposed mediators longitudinally. Standardized regression coefficients (β) for the relationship between catastrophizing and painas mediated by avoidance and endurance, respectively and combined. T2 = time point 2. *p<.05; **p<.01; ***p<.001.
Fig. 2

Multiple mediation model with avoidance and endurance as proposed mediators longitudinally. Standardized regression coefficients (β) for the relationship between catastrophizing and painas mediated by avoidance and endurance, respectively and combined. T2 = time point 2. *p<.05; **p<.01; ***p<.001.

4 Discussion

This study suggests that avoidance is an influential mediator of the relationship between catastrophizing and vulvovaginal pain. Using multiple mediation models we found that although the indirect effects of both avoidance and endurance were significant cross-sectionally, the combined model exploring associations over time demonstrated that avoidance was the only influential mediator over time.

These findings are in line with the extensive support for avoidance as being a salient risk factor for persistent pain and disability [6,8]. In the area of vulvovaginal pain, fear-avoidance beliefs - the cognitive aspect of avoidance behaviors - have been linked to increased sexual dysfunction, negative emotional reactions to pain and higher pain ratings [9]. Likewise, pain catastrophizing has been identified as a critical component, both in other pain problems (e.g., [26,27]) and in vulvovaginal pain (e.g., [28,29]). Our findings verify and extend the support for catastrophizing as well as avoidance behavior as being central factors also in women with vulvovaginal pain. More specifically, when catastrophizing is associated with avoidance behavior, this may lead to an increase in pain over time.

Our results are in line with the fear-avoidance model[7], highlighting the similarities between vulvovaginal pain and other pain disorders. However, our findings contradict the results from an earlier study where changes in fear-avoidance variables over a 2-year time period did not predict pain outcomes[10]. One explanation of the conflicting results is that Davis and colleagues used an indirect measure of avoidance by asking participants to recall the frequency of attempted sexual intercourse. The number of attempts, successful or not, was taken as a measure of avoidance. As the authors themselves admit, their measure relied on recall, and consisted of a single item which did not take into account practical circumstances (e.g. the willingness of the partner). Our measure of avoidance was a more general one, including behavioral as well as cognitive aspects, which may have resulted in a more sensitive measure. Taken together, our findings suggest that the psychological mechanisms in vulvovaginal pain is fairly similar to in other pain conditions.

One aspect where vulvovaginal pain differs from other pain conditions is that the pain occurs in an intimate interpersonal context. The partners’ reaction to the pain (i.e. the coping strategies of the partner) has been shown to interact with the women’s reaction, and the dyadic adjustment influences on pain and relational outcomes (see e.g., [30]). In this, the fear-avoidance model may not fully explain coping in women with vulvovaginal pain, pointing at a dire need for an expanded version of the model, taking the interpersonal context into account [9]. Nevertheless, the impact of partner responses on the woman’s coping behavior goes beyond the scope of the current study.

Although endurance was a mediator between catastrophizing and pain cross-sectionally, it was not significant in the longitudinal analysis. There may be several reasons for this. First, earlier studies on the importance of endurance on outcomes in other pain populations have yielded mixed findings [31]. This indicates that although endurance may be maladaptive, it does not have the same impact on pain as avoidance. Secondly, in our study we only assessed pain- related catastrophizing, and not catastrophizing about other issues such as losing the relation or letting the partner down. It may be that endurance of vaginal intercourse is more closely linked to other types of catastrophizing, beyond the pain itself. Our measure of endurance does indeed involve interpersonal aspects which may influence the tendency to endure vaginal intercourse despite pain (e.g. “When I have intercourse and it’s painful, it’s more important that my sexual partner is satisfied than it is to take my pain into consideration”). In an earlier study, nearly half of the women who experienced pain during vaginal intercourse reported that they continued despite discomfort, often because they did not want to displease their partner[11].

According to the approach-avoidance motivational theory, women may engage in sexual activities despite pain if the goal of enhancing intimacy is viewed as more important than avoiding pain [32]. If so, there may be cases where endurance is linked to positive affect which in turn counteracts its maladaptive impact on outcomes. This would be in line with the Avoidance- Endurance Model (AEM) of pain [33], in which different enduring subgroups have been identified. Likewise, in women suffering vulvovaginal pain there may be subgroups in which endurance plays different roles, and earlier studies support this assumption. In women with provoked vestibulodynia, for instance, approach sexual goals which may be reflected in endurance, have been linked to higher sexual and relationship satisfaction [34]. This means that endurance may not be regarded as a purely maladaptive coping strategy - its influence rather depends on the woman’s goals.

From the current findings we cannot tell whether avoiding and enduring strategies are opposites or if they may be used in combination. One possibility is that there are women who both avoid and endure vaginal intercourse, depending on the different goals within that specific situation [35]. Although these strategies might seem to be antonyms, the intercorrelation between them in the current study was large (.5). Consequently, one suggestion for future research is to explore if avoidance and endurance are separate strategies or if they are used in combination.

The longitudinal design of this study is a clear strength considering that there have been few prospective studies focusing on this population. Yet, the time frame was fairly short (five months), risking an underestimation of the mediation effects. Also, we need to keep in mind that only two assessment points were used in the mediation analyses, which naturallythreatens the conclusions that can be drawn. We view this as a first study, and the results need to be replicated with three assessment points and a longer time between baseline and follow-up. An obvious shortcoming relates to the sample selection. As we do not have data of how many women were invited to participate, we cannot provide an exact response rate. Consequently, we miss information about whether women who agreed to participate in the study differed from the ones who did not. To maximize the chances of getting a fairly large sample in an age group important for sexual and relational development, the participants were recruited in a university setting where it was possible to track students overtime.Nevertheless, nearly 20% of the sample was lost at the follow up assessment, and although these women did not differ at the first assessment, we cannot exclude that this may have influenced the results. Although attrition is a well-known problem in longitudinal studies [36], it naturally limits the conclusions that can be drawn. Yet, our purpose was not to report on epidemiological outcomes such as prevalence, where it is crucial to have a representative sample, but instead to study psychological mechanisms. Therefore it should be less sensitive to the make-up of the sample. Another potential limitation is that women who totally avoided vaginal penetration were excluded from the analyses, as our pain measure (the FSFI) asks about pain specifically during intercourse. However, the FSFI is the most frequently used measure in this context, and also the coping measure requires some degree of sexual activity to be relevant. An additional potential drawback is the measure used for assessing avoidance and endurance.This measure has recentlybeen developed and validated [16] which may raise questions about its psychometric robustness. One shortcoming is that the measure includes both clear coping behaviors, as well as thoughts behind the coping behaviors. This means that it captures more aspects of coping than the pure behavior. Nevertheless, to our knowledge there are no other measures of coping in this group and we have used the subscales that were found to have sound psychometric properties[16].

In sum, this study indicates that the strategies women use for coping with sexual activities when suffering from vulvovaginal pain are important for the development of chronic pain. We have identified avoidance and, to a lesser degree, endurance strategies as important mediators of the effects of catastrophizing on pain. This has considerable clinical importance since these women are often given recommendations that involve avoidance or endurance. Both strategies may be helpful in certain contexts allowing women to accommodate to the circumstances, but our results indicate that avoidance may be a risk factor for prolonged pain problems in the long run. Graded exposure in vivo, which focuses on reducing excessive avoidance behavior through gradual confrontation to the feared (sexual) stimuli, may be a viable treatment strategy for women with high levels of avoidance. Indeed, exposure has shown to be successful in decreasing fear and negative penetration beliefs in women with lifelong vaginismus [37,38].The effect of exposure in women with other types of vulvovaginal pain is still to explore. Taken together, future research is direly needed to explore further the characteristics of adaptive coping in this group.

5 Conclusions

This study indicates that the strategies women with vulvovaginal pain use for coping with sexual activities are important for the course of pain. Avoidance and, to a lesser degree, endurance strategies were identified as important mediators of the effects of catastrophizing on pain. When exploring the links over time, only avoidance emerged as a significant mediator.

6 Implications

In this longitudinal study, catastrophizing was linked to vulvovaginal pain, via avoidance and endurance of sexual activities. Hence, targeting catastrophizing early on in treatment, as well as addressing coping, may be important in clinical interventions.

Highlights

  • There are few studies about the mechanisms involved in vulvovaginal pain.

  • This longitudinal study explored the links between catastrophizing, coping and pain.

  • Avoidance and endurance of sexual activities were explored as coping behaviors.

  • Avoidance emerged as a mediator of the link between catastrophizing and pain.

  • This indicates that reactions as well as coping are central for pain in this group.

School of Law, Psychology, and Social Work, 70182 Örebro, Sweden

  1. Funding sources: This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

  2. Ethical issues:The participants filled out informed consents and the study was approved by the Regional Ethical Review Board in Uppsala, Sweden (D Number 2014-407). The study protocol was not registered.

  3. Conflict of interest: The authors have no conflicts of interest in relation to this study.

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Received: 2017-03-06
Revised: 2017-08-17
Accepted: 2017-08-23
Published Online: 2017-10-01
Published in Print: 2017-10-01

© 2017 Scandinavian Association for the Study of Pain

Artikel in diesem Heft

  1. Observational study
  2. Perceived sleep deficit is a strong predictor of RLS in multisite pain – A population based study in middle aged females
  3. Clinical pain research
  4. Prospective, double blind, randomized, controlled trial comparing vapocoolant spray versus placebo spray in adults undergoing intravenous cannulation
  5. Clinical pain research
  6. The Functional Barometer — An analysis of a self-assessment questionnaire with ICF-coding regarding functional/activity limitations and quality of life due to pain — Differences in age gender and origin of pain
  7. Clinical pain research
  8. Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain
  9. Observational study
  10. Chronic disruptive pain in emerging adults with and without chronic health conditions and the moderating role of psychiatric disorders: Evidence from a population-based cross-sectional survey in Canada
  11. Educational case report
  12. Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study
  13. Clinical pain research
  14. Behavioral inhibition, maladaptive pain cognitions, and function in patients with chronic pain
  15. Observational study
  16. Comparison of patients diagnosed with “complex pain” and “somatoform pain”
  17. Original experimental
  18. Patient perspectives on wait times and the impact on their life: A waiting room survey in a chronic pain clinic
  19. Topical review
  20. New evidence for a pain personality? A critical review of the last 120 years of pain and personality
  21. Clinical pain research
  22. A multi-facet pain survey of psychosocial complaints among patients with long-standing non-malignant pain
  23. Clinical pain research
  24. Pain patients’ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity, and treatment outcome
  25. Observational study
  26. Long-term treatment in chronic noncancer pain: Results of an observational study comparing opioid and nonopioid therapy
  27. Clinical pain research
  28. COMBAT study – Computer based assessment and treatment – A clinical trial evaluating impact of a computerized clinical decision support tool on pain in cancer patients
  29. Original experimental
  30. Quantitative sensory tests fairly reflect immediate effects of oxycodone in chronic low-back pain
  31. Editorial comment
  32. Spatial summation of pain and its meaning to patients
  33. Original experimental
  34. Effects of validating communication on recall during a pain-task in healthy participants
  35. Original experimental
  36. Comparison of spatial summation properties at different body sites
  37. Editorial comment
  38. Behavioural inhibition in the context of pain: Measurement and conceptual issues
  39. Clinical pain research
  40. A randomized study to evaluate the analgesic efficacy of a single dose of the TRPV1 antagonist mavatrep in patients with osteoarthritis
  41. Editorial comment
  42. Quantitative sensory tests (QST) are promising tests for clinical relevance of anti–nociceptive effects of new analgesic treatments
  43. Educational case report
  44. Pregabalin as adjunct in a multimodal pain therapy after traumatic foot amputation — A case report of a 4-year-old girl
  45. Editorial comment
  46. Severe side effects from intrathecal morphine for chronic pain after repeated failed spinal operations
  47. Editorial comment
  48. Opioids in chronic pain – Primum non nocere
  49. Editorial comment
  50. Finally a promising analgesic signal in a long-awaited new class of drugs: TRPV1 antagonist mavatrep in patients with osteoarthritis (OA)
  51. Observational study
  52. The relationship between chronic musculoskeletal pain, anxiety and mindfulness: Adjustments to the Fear-Avoidance Model of Chronic Pain
  53. Clinical pain research
  54. Opioid tapering in patients with prescription opioid use disorder: A retrospective study
  55. Editorial comment
  56. Sleep, widespread pain and restless legs — What is the connection?
  57. Editorial comment
  58. Broadening the fear-avoidance model of chronic pain?
  59. Observational study
  60. Identifying characteristics of the most severely impaired chronic pain patients treated at a specialized inpatient pain clinic
  61. Editorial comment
  62. The burden of central anticholinergic drugs increases pain and cognitive dysfunction. More knowledge about drug-interactions needed
  63. Editorial comment
  64. A case-history illustrates importance of knowledge of drug-interactions when pain-patients are prescribed non-pain drugs for co-morbidities
  65. Editorial comment
  66. Why can multimodal, multidisciplinary pain clinics not help all chronic pain patients?
  67. Topical review
  68. Individual variability in clinical effect and tolerability of opioid analgesics – Importance of drug interactions and pharmacogenetics
  69. Editorial comment
  70. A new treatable chronic pain diagnosis? Flank pain caused by entrapment of posterior cutaneous branch of intercostal nerves, lateral ACNES coined LACNES
  71. Clinical pain research
  72. PhKv a toxin isolated from the spider venom induces antinociception by inhibition of cholinesterase activating cholinergic system
  73. Clinical pain research
  74. Lateral Cutaneous Nerve Entrapment Syndrome (LACNES): A previously unrecognized cause of intractable flank pain
  75. Editorial comment
  76. Towards a structured examination of contextual flexibility in persistent pain
  77. Clinical pain research
  78. Context sensitive regulation of pain and emotion: Development and initial validation of a scale for context insensitive avoidance
  79. Editorial comment
  80. Is the search for a “pain personality” of added value to the Fear-Avoidance-Model (FAM) of chronic pain?
  81. Editorial comment
  82. Importance for patients of feeling accepted and understood by physicians before and after multimodal pain rehabilitation
  83. Editorial comment
  84. A glimpse into a neglected population – Emerging adults
  85. Observational study
  86. Assessment and treatment at a pain clinic: A one-year follow-up of patients with chronic pain
  87. Clinical pain research
  88. Randomized, double-blind, placebo-controlled, dose-escalation study: Investigation of the safety, pharmacokinetics, and antihyperalgesic activity of L-4-chlorokynurenine in healthy volunteers
  89. Clinical pain research
  90. Prevalence and characteristics of chronic pain: Experience of Niger
  91. Observational study
  92. The use of rapid onset fentanyl in children and young people for breakthrough cancer pain
  93. Original experimental
  94. Acid-induced experimental muscle pain and hyperalgesia with single and repeated infusion in human forearm
  95. Original experimental
  96. Swearing as a response to pain: A cross-cultural comparison of British and Japanese participants
  97. Clinical pain research
  98. The cognitive impact of chronic low back pain: Positive effect of multidisciplinary pain therapy
  99. Clinical pain research
  100. Central sensitization associated with low fetal hemoglobin levels in adults with sickle cell anemia
  101. Topical review
  102. Targeting cytokines for treatment of neuropathic pain
  103. Original experimental
  104. What constitutes back pain flare? A cross sectional survey of individuals with low back pain
  105. Original experimental
  106. Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain
  107. Clinical pain research
  108. Chronic low back pain and the transdiagnostic process: How do cognitive and emotional dysregulations contribute to the intensity of risk factors and pain?
  109. Original experimental
  110. The impact of the Standard American Diet in rats: Effects on behavior, physiology and recovery from inflammatory injury
  111. Educational case report
  112. Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series
  113. Original experimental
  114. Hyperbaric oxygenation alleviates chronic constriction injury (CCI)-induced neuropathic pain and inhibits GABAergic neuron apoptosis in the spinal cord
  115. Observational study
  116. Predictors of chronic neuropathic pain after scoliosis surgery in children
  117. Clinical pain research
  118. Hospitalization due to acute exacerbation of chronic pain: An intervention study in a university hospital
  119. Clinical pain research
  120. A novel miniature, wireless neurostimulator in the management of chronic craniofacial pain: Preliminary results from a prospective pilot study
  121. Clinical pain research
  122. Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending
  123. Original experimental
  124. Unpredictable pain timings lead to greater pain when people are highly intolerant of uncertainty
  125. Original experimental
  126. Initial validation of the exercise chronic pain acceptance questionnaire
  127. Clinical pain research
  128. Exploring patient experiences of a pain management centre: A qualitative study
  129. Clinical pain research
  130. Narratives of life with long-term low back pain: A follow up interview study
  131. Observational study
  132. Pain catastrophizing, perceived injustice, and pain intensity impair life satisfaction through differential patterns of physical and psychological disruption
  133. Clinical pain research
  134. Chronic pain disrupts ability to work by interfering with social function: A cross-sectional study
  135. Original experimental
  136. Evaluation of external vibratory stimulation as a treatment for chronic scrotal pain in adult men: A single center open label pilot study
  137. Observational study
  138. Impact of analgesics on executive function and memory in the Alzheimer’s Disease Neuroimaging Initiative Database
  139. Clinical pain research
  140. Visualization of painful inflammation in patients with pain after traumatic ankle sprain using [11C]-D-deprenyl PET/CT
  141. Original experimental
  142. Developing a model for measuring fear of pain in Norwegian samples: The Fear of Pain Questionnaire Norway
  143. Topical review
  144. Psychoneuroimmunological approach to gastrointestinal related pain
  145. Letter to the Editor
  146. Do we need an updated definition of pain?
  147. Narrative review
  148. Is acetaminophen safe in pregnancy?
  149. Book Review
  150. Physical Diagnosis of Pain
  151. Book Review
  152. Advances in Anesthesia
  153. Book Review
  154. Atlas of Pain Management Injection Techniques
  155. Book Review
  156. Sedation: A Guide to Patient Management
  157. Book Review
  158. Basics of Anesthesia
https://doi.org/10.1016/j.sjpain.2017.08.007
Schlagwörter für diesen Artikel
Vulvovaginal pain; Sexual pain; Women; Coping; Avoidance-endurance

Artikel in diesem Heft

  1. Observational study
  2. Perceived sleep deficit is a strong predictor of RLS in multisite pain – A population based study in middle aged females
  3. Clinical pain research
  4. Prospective, double blind, randomized, controlled trial comparing vapocoolant spray versus placebo spray in adults undergoing intravenous cannulation
  5. Clinical pain research
  6. The Functional Barometer — An analysis of a self-assessment questionnaire with ICF-coding regarding functional/activity limitations and quality of life due to pain — Differences in age gender and origin of pain
  7. Clinical pain research
  8. Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain
  9. Observational study
  10. Chronic disruptive pain in emerging adults with and without chronic health conditions and the moderating role of psychiatric disorders: Evidence from a population-based cross-sectional survey in Canada
  11. Educational case report
  12. Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study
  13. Clinical pain research
  14. Behavioral inhibition, maladaptive pain cognitions, and function in patients with chronic pain
  15. Observational study
  16. Comparison of patients diagnosed with “complex pain” and “somatoform pain”
  17. Original experimental
  18. Patient perspectives on wait times and the impact on their life: A waiting room survey in a chronic pain clinic
  19. Topical review
  20. New evidence for a pain personality? A critical review of the last 120 years of pain and personality
  21. Clinical pain research
  22. A multi-facet pain survey of psychosocial complaints among patients with long-standing non-malignant pain
  23. Clinical pain research
  24. Pain patients’ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity, and treatment outcome
  25. Observational study
  26. Long-term treatment in chronic noncancer pain: Results of an observational study comparing opioid and nonopioid therapy
  27. Clinical pain research
  28. COMBAT study – Computer based assessment and treatment – A clinical trial evaluating impact of a computerized clinical decision support tool on pain in cancer patients
  29. Original experimental
  30. Quantitative sensory tests fairly reflect immediate effects of oxycodone in chronic low-back pain
  31. Editorial comment
  32. Spatial summation of pain and its meaning to patients
  33. Original experimental
  34. Effects of validating communication on recall during a pain-task in healthy participants
  35. Original experimental
  36. Comparison of spatial summation properties at different body sites
  37. Editorial comment
  38. Behavioural inhibition in the context of pain: Measurement and conceptual issues
  39. Clinical pain research
  40. A randomized study to evaluate the analgesic efficacy of a single dose of the TRPV1 antagonist mavatrep in patients with osteoarthritis
  41. Editorial comment
  42. Quantitative sensory tests (QST) are promising tests for clinical relevance of anti–nociceptive effects of new analgesic treatments
  43. Educational case report
  44. Pregabalin as adjunct in a multimodal pain therapy after traumatic foot amputation — A case report of a 4-year-old girl
  45. Editorial comment
  46. Severe side effects from intrathecal morphine for chronic pain after repeated failed spinal operations
  47. Editorial comment
  48. Opioids in chronic pain – Primum non nocere
  49. Editorial comment
  50. Finally a promising analgesic signal in a long-awaited new class of drugs: TRPV1 antagonist mavatrep in patients with osteoarthritis (OA)
  51. Observational study
  52. The relationship between chronic musculoskeletal pain, anxiety and mindfulness: Adjustments to the Fear-Avoidance Model of Chronic Pain
  53. Clinical pain research
  54. Opioid tapering in patients with prescription opioid use disorder: A retrospective study
  55. Editorial comment
  56. Sleep, widespread pain and restless legs — What is the connection?
  57. Editorial comment
  58. Broadening the fear-avoidance model of chronic pain?
  59. Observational study
  60. Identifying characteristics of the most severely impaired chronic pain patients treated at a specialized inpatient pain clinic
  61. Editorial comment
  62. The burden of central anticholinergic drugs increases pain and cognitive dysfunction. More knowledge about drug-interactions needed
  63. Editorial comment
  64. A case-history illustrates importance of knowledge of drug-interactions when pain-patients are prescribed non-pain drugs for co-morbidities
  65. Editorial comment
  66. Why can multimodal, multidisciplinary pain clinics not help all chronic pain patients?
  67. Topical review
  68. Individual variability in clinical effect and tolerability of opioid analgesics – Importance of drug interactions and pharmacogenetics
  69. Editorial comment
  70. A new treatable chronic pain diagnosis? Flank pain caused by entrapment of posterior cutaneous branch of intercostal nerves, lateral ACNES coined LACNES
  71. Clinical pain research
  72. PhKv a toxin isolated from the spider venom induces antinociception by inhibition of cholinesterase activating cholinergic system
  73. Clinical pain research
  74. Lateral Cutaneous Nerve Entrapment Syndrome (LACNES): A previously unrecognized cause of intractable flank pain
  75. Editorial comment
  76. Towards a structured examination of contextual flexibility in persistent pain
  77. Clinical pain research
  78. Context sensitive regulation of pain and emotion: Development and initial validation of a scale for context insensitive avoidance
  79. Editorial comment
  80. Is the search for a “pain personality” of added value to the Fear-Avoidance-Model (FAM) of chronic pain?
  81. Editorial comment
  82. Importance for patients of feeling accepted and understood by physicians before and after multimodal pain rehabilitation
  83. Editorial comment
  84. A glimpse into a neglected population – Emerging adults
  85. Observational study
  86. Assessment and treatment at a pain clinic: A one-year follow-up of patients with chronic pain
  87. Clinical pain research
  88. Randomized, double-blind, placebo-controlled, dose-escalation study: Investigation of the safety, pharmacokinetics, and antihyperalgesic activity of L-4-chlorokynurenine in healthy volunteers
  89. Clinical pain research
  90. Prevalence and characteristics of chronic pain: Experience of Niger
  91. Observational study
  92. The use of rapid onset fentanyl in children and young people for breakthrough cancer pain
  93. Original experimental
  94. Acid-induced experimental muscle pain and hyperalgesia with single and repeated infusion in human forearm
  95. Original experimental
  96. Swearing as a response to pain: A cross-cultural comparison of British and Japanese participants
  97. Clinical pain research
  98. The cognitive impact of chronic low back pain: Positive effect of multidisciplinary pain therapy
  99. Clinical pain research
  100. Central sensitization associated with low fetal hemoglobin levels in adults with sickle cell anemia
  101. Topical review
  102. Targeting cytokines for treatment of neuropathic pain
  103. Original experimental
  104. What constitutes back pain flare? A cross sectional survey of individuals with low back pain
  105. Original experimental
  106. Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain
  107. Clinical pain research
  108. Chronic low back pain and the transdiagnostic process: How do cognitive and emotional dysregulations contribute to the intensity of risk factors and pain?
  109. Original experimental
  110. The impact of the Standard American Diet in rats: Effects on behavior, physiology and recovery from inflammatory injury
  111. Educational case report
  112. Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series
  113. Original experimental
  114. Hyperbaric oxygenation alleviates chronic constriction injury (CCI)-induced neuropathic pain and inhibits GABAergic neuron apoptosis in the spinal cord
  115. Observational study
  116. Predictors of chronic neuropathic pain after scoliosis surgery in children
  117. Clinical pain research
  118. Hospitalization due to acute exacerbation of chronic pain: An intervention study in a university hospital
  119. Clinical pain research
  120. A novel miniature, wireless neurostimulator in the management of chronic craniofacial pain: Preliminary results from a prospective pilot study
  121. Clinical pain research
  122. Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending
  123. Original experimental
  124. Unpredictable pain timings lead to greater pain when people are highly intolerant of uncertainty
  125. Original experimental
  126. Initial validation of the exercise chronic pain acceptance questionnaire
  127. Clinical pain research
  128. Exploring patient experiences of a pain management centre: A qualitative study
  129. Clinical pain research
  130. Narratives of life with long-term low back pain: A follow up interview study
  131. Observational study
  132. Pain catastrophizing, perceived injustice, and pain intensity impair life satisfaction through differential patterns of physical and psychological disruption
  133. Clinical pain research
  134. Chronic pain disrupts ability to work by interfering with social function: A cross-sectional study
  135. Original experimental
  136. Evaluation of external vibratory stimulation as a treatment for chronic scrotal pain in adult men: A single center open label pilot study
  137. Observational study
  138. Impact of analgesics on executive function and memory in the Alzheimer’s Disease Neuroimaging Initiative Database
  139. Clinical pain research
  140. Visualization of painful inflammation in patients with pain after traumatic ankle sprain using [11C]-D-deprenyl PET/CT
  141. Original experimental
  142. Developing a model for measuring fear of pain in Norwegian samples: The Fear of Pain Questionnaire Norway
  143. Topical review
  144. Psychoneuroimmunological approach to gastrointestinal related pain
  145. Letter to the Editor
  146. Do we need an updated definition of pain?
  147. Narrative review
  148. Is acetaminophen safe in pregnancy?
  149. Book Review
  150. Physical Diagnosis of Pain
  151. Book Review
  152. Advances in Anesthesia
  153. Book Review
  154. Atlas of Pain Management Injection Techniques
  155. Book Review
  156. Sedation: A Guide to Patient Management
  157. Book Review
  158. Basics of Anesthesia
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