Impact of mindfulness versus supportive sex education on stress in women with sexual interest/arousal disorder.

Low desire in women is the most common sexual difficulty, and stress has been identified as a significant predictor of symptoms. We evaluated a mindfulness-based cognitive therapy (MBCT) group treatment versus a sex education comparison group treatment (STEP) on self-reported stress and on the physiological stress response measured via morning-to-evening cortisol slope in 148 women with a diagnosis of sexual interest/arousal disorder (SIAD). Perceived stress decreased following treatment in both groups, and significantly more after MBCT. The cortisol slope was steeper (indicative of better stress system regulation) from pre-treatment to 6-month follow-up, with no differences between the groups. As an exploratory analysis, we found that the reduction in perceived stress predicted increases in sexual desire and decreases in sex-related distress for participants after MBCT only. These findings suggest that group mindfulness targeting women with low sexual desire leads to improvements in self-reported and physiological stress, with improvements in self-reported stress partially accounting for improvements in sexual desire and distress.

A randomized trial comparing group mindfulness-based cognitive therapy with group supportive sex education and therapy for the treatment of female sexual interest/arousal disorder.

Objective: Sexual interest/arousal disorder (SIAD) is the most prevalent sexual dysfunction in women. Our goal was to compare (a) group mindfulness-based cognitive therapy (MBCT) plus sex education with (b) group supportive sex education and therapy (STEP) for women with SIAD. Method: Eight-session treatments were delivered weekly and participants completed the measures of sexual desire and arousal, sexual distress, relationship satisfaction, rumination, and global impressions of change, at baseline, immediately posttreatment, and at 6- and 12-month posttreatment. Of 148 women who consented, 70 were randomized to MBCT (mean age 39.3 ± 13.2 years) and 78 were randomized to STEP (mean age 37.9 ± 12.2 years). Results: Sexual desire and arousal significantly improved at each time point relative to baseline, with large effect sizes (d = -1.29 to -1.60), and similarly for MBCT and STEP. Sexual distress also improved at each time point with large effect sizes (d = 0.83-1.17), and more so for MBCT relative to STEP. Relationship satisfaction significantly improved (d = -0.17 to -0.20), and rumination about sex improved significantly in both arms, with medium effect sizes (d = 0.42-0.69), with both outcomes responding more to MBCT. About half the participants across both treatments reported moderate or great improvements in global indicators of desire and overall sexuality. Conclusions: Results support the efficacy of both group MBCT and group supportive sex education for improving symptoms of SIAD with 12-month retention of improvements. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Sexual Dysfunctions in Women: Are Androgens at Fault?

A critique of the literature that androgen deficit underlies women's sexual dysfunctions is provided. Although there is scant evidence that androgens are responsible, many aspects of androgen activity remain to be investigated. Research does link serum levels of dehydroepiandrosterone (DHEA) to women's sexual desire but apparently not via DHEA's androgenic activity. Current assessment and management of women's sexual dysfunction are summarized.

Moderators of Improvement From Mindfulness-Based vs Traditional Cognitive Behavioral Therapy for the Treatment of Provoked Vestibulodynia.

BACKGROUND AND AIM: The goal was to evaluate the moderators of mindfulness-based cognitive therapy (MBCT) and cognitive behavioral therapy (CBT) to improve dyspareunia, reduce pain catastrophizing, and improve overall sexual function in women with provoked vestibulodynia (PVD). Both treatments effectively reduced self-reported pain, sexual dysfunction, and pain catastrophizing in women with PVD. METHODS: A total of 130 women with PVD were assigned to CBT or MBCT. OUTCOMES: Potential moderators included (i) PVD subtype (primary or secondary), (ii) baseline pain intensity, (iii) trait mindfulness, (iv) treatment credibility, (v) relationship duration, and (vi) age. Outcomes were pain intensity, sexual function, and pain catastrophizing at 4 time points: before and after treatment and 6- and 12-month follow-up. Moderation was tested using multilevel models, nesting 4 time points within participants. The interaction of the moderator, time effect, and treatment group was evaluated for significance, and a simple slope analysis of significant interactions was performed. RESULTS: Pain reduction across 4 time points was the greatest in women who were younger, in relationships of shorter duration, and with greater baseline pain. Treatment credibility moderated pain intensity outcomes (B = 0.305, P < .01) where those with higher treatment credibility ratings (for that particular treatment) improved more in MBCT than CBT. PVD subtype moderated pain catastrophizing (B = 3.150, P < .05). Those with primary PVD improved more in the CBT condition, whereas women with secondary PVD improved more in the MBCT condition. Relationship length moderated sexual function (B = 0.195, P < .01). Women in shorter relationships improved more with MBCT, whereas women in longer relationships improved more on sexual function with CBT. No other tested variables moderated outcomes differentially across both treatment conditions. CLINICAL IMPLICATIONS: Women who present with high credibility about mindfulness, in shorter relationships, and with secondary PVD might respond better to MBCT whereas those with primary PVD and longer relationships might respond better to CBT. STRENGTHS & LIMITATIONS: Clinical sample. Half the women who were not sexually active were omitted from analyses of sexual function. CONCLUSION: Overall, treatment credibility, relationship length, and PVD subtype were found to moderate improvements differently in MBCT and CBT. These findings may assist clinicians in individualizing psychological treatment for women with PVD. CLINICAL TRIAL REGISTRATION: This clinical trial was registered with clinicaltrials.gov, NCT01704456. Brotto LA, Zdaniuk B, Rietchel L, et al. Moderators of Improvement From Mindfulness-Based vs Traditional Cognitive Behavioral Therapy for the Treatment of Provoked Vestibulodynia. J Sex Med 2020;17:2247-2259.

Primary Dysmenorrhea and Painful Sex: Canaries in the Coal Mine?

OBJECTIVE: Primary dysmenorrhea and provoked vestibulodynia (PVD) are common pain conditions in young women. The purpose of this study was to document the severity of dysmenorrhea in women with confirmed PVD to further clarify reports of comorbidity. Since central sensitisation (CS) of the nervous system is present in both conditions, diagnosis of either, but especially both conditions, may reflect past chronic stress. METHODS: We investigated this comorbidity in a sample of 63 women who met diagnostic criteria for PVD, and a comparison group of 89 women with low sexual desire and arousal but no pain during sex. All women completed questionnaires about the history and severity of their dysmenorrhea. RESULTS: Of the women with PVD, 28.6% recalled moderate and 34.9% severe dysmenorrhea. For women in the comparison group, these figures were 22.5% and 19.1%, respectively. Women with PVD reported that the periods they experienced as teenagers were more painful, longer, more debilitating, and persistently painful for more years than those recalled by women in the comparison group. CONCLUSIONS: Our findings suggest that the origins of the early-onset CS require serious investigation. Research into the potential to reduce future chronic pain conditions through early effective treatment of primary dysmenorrhea is also needed.

Mindfulness and cognitive behavior therapy for provoked vestibulodynia: Mediators of treatment outcome and long-term effects.

OBJECTIVE: Provoked vestibulodynia (PVD) is a chronic vulvo-vaginal pain condition affecting 8% of premenopausal women. Cognitive-behavioral therapy (CBT) is effective in managing pain and associated sexual and psychological symptoms, and a recent study found group mindfulness-based cognitive therapy (MBCT) to be equivalent. Our goal was to examine the long-term outcomes of these treatments and to explore mediators of change. METHOD: Participants were 130 women diagnosed with PVD who had participated in a clinical trial comparing 8 weeks of group CBT to 8 weeks of group MBCT. Data were collected at pretreatment, posttreatment, and at 6- and 12-month follow-up periods. Outcomes focused on (a) pain with vaginal penetration, (b) pain elicited with a vulvalgesiometer, and (c) sex-related distress. Mediators of interest included pain acceptance (both pain willingness and activities engagement), self-compassion, self-criticism, mindfulness, decentering, and pain catastrophizing. RESULTS: All improvements in the 3 outcomes were retained at 12-month follow-up, with no group differences. Pain catastrophizing, decentering, and chronic pain acceptance (both scales) were mediators of improvement common to both MBCT and CBT. Changes in mindfulness, self-criticism, and self-compassion mediated improvements only in the MBCT group. CONCLUSIONS: Both MBCT and CBT are effective for improving symptoms in women with PVD when assessed 12 months later. The findings have implications for understanding common and potentially distinct pathways by which CBT and MBCT improve pain and sex-related distress in women with PVD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A Comparison of Mindfulness-Based Cognitive Therapy Vs Cognitive Behavioral Therapy for the Treatment of Provoked Vestibulodynia in a Hospital Clinic Setting.

INTRODUCTION: Chronic and distressing genito-pelvic pain associated with vaginal penetration is most frequently due to provoked vestibulodynia (PVD). Cognitive behavioral therapy (CBT) significantly reduces genital pain intensity and improves psychological and sexual well-being. In general chronic pain populations, mindfulness-based approaches may be as effective for improving pain intensity as CBT. AIM: To compare mindfulness-based cognitive therapy (MBCT) with CBT in the treatment of PVD. METHODS: To ensure power of 0.95 to find medium effect size or larger in this longitudinal design, we enrolled 130 participants. Of these, 63 were assigned to CBT (mean age 31.2 years), and 67 to MBCT (mean age 33.7 years). Data from all participants who completed baseline measures were analyzed, with intent-to-treat analyses controlling for years since diagnosis. MAIN OUTCOME MEASURES: Our primary outcome was self-reported pain during vaginal penetration at immediate post-treatment and at 6 months' follow-up. Secondary endpoints included pain ratings with a vulvalgesiometer, pain catastrophizing, pain hypervigilance, pain acceptance, sexual function, and sexual distress. RESULTS: There was a significant interaction between group and time for self-reported pain, such that improvements with MBCT were greater than those with CBT. For all other endpoints, both groups led to similar significant improvements, and benefits were maintained at 6 months. CLINICAL IMPLICATIONS: Mindfulness is a promising approach to improving self-reported pain from vaginal penetration and is as effective as CBT for several psychological endpoints. STRENGTH & LIMITATIONS: A strength of the present study was the robust sample size (n = 130 women) who had received confirmed clinical diagnoses of PVD. CONCLUSION: The present study showed mindfulness to be as effective for most pain- and sexuality-related endpoints in the treatment of PVD. 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;16:909-923.

Dehydroepiandrosterone and cortisol as markers of HPA axis dysregulation in women with low sexual desire.

Previous research has found lower serum levels of dehydroepiandrosterone (DHEA) or its sulfated form, DHEA-S, in women diagnosed with Hypoactive Sexual Desire Disorder (HSDD). Given that DHEA and DHEA-S have multiple direct actions on the brain as well as anti-glucocorticoid properties, it is possible that lower levels of DHEA directly impact women's sexual functioning. To date, the significance of the lower DHEA levels remains unclear. To our knowledge, there has been no empirical study of stress hormones as markers of HPA dysregulation in women with HSDD. To attend to this gap, the present study utilized several measures of HPA axis function - morning and evening cortisol and DHEA, the cortisol awakening response (CAR), diurnal cortisol slope, and cortisol:DHEA ratio - and examined their relationship with sexual functioning in N = 275 women with (n = 137) and without (n = 138) HSDD. Results demonstrated multiple hormonal markers of HPA dysregulation in women diagnosed with HSDD compared to control participants, specifically, lower AM cortisol and AM DHEA levels, a flatter diurnal cortisol slope, and a lower CAR. Overall, results of the present study indicate that persistently low sexual desire in women is associated with HPA axis dysregulation, with both cortisol and DHEA alterations potentially detrimental to sexual desire.

Mindfulness-Based Group Therapy for Men With Situational Erectile Dysfunction: A Mixed-Methods Feasibility Analysis and Pilot Study.

INTRODUCTION: Recent advances in sexual health research support the benefits of mindfulness-based therapy (non-judgmental present-moment awareness) for the treatment of women's sexual dysfunction. AIM: To determine whether it is feasible to implement an adapted, empirically supported treatment protocol for female sexual dysfunction to the specific needs of men with situational erectile dysfunction (ED). METHODS: A mixed-methods approach was taken for this feasibility pilot study. A total of 10 men (Mage = 40.3, SD = 14.01, Range = 20-67) with a diagnosis of situational ED were recruited to participate in a 4-week mindfulness-based treatment group. The group was adapted from protocols shown to be effective for women with sexual dysfunction and edited to include content specific to situational ED. Sessions were 2.25 hours in length, included daily home-practice activities, and integrated elements of psychoeducation, sex therapy, and mindfulness skills. Men completed questionnaires (International Index of Erectile Functioning, Relationship Assessment Scale, Five Facets of Mindfulness Questionnaire, a treatment expectation questionnaire) at 3 time points (prior to treatment, immediately after treatment, and 6 months after treatment). 5 men (Mage = 44.4, SD = 15.76, Range = 30-67) participated in qualitative exit interviews. MAIN OUTCOME MEASURE: Findings support the feasibility of adapting a mindfulness-based group treatment for situational ED. RESULTS: With respect to feasibility, the dropout rate was 10%, with 1 participant who did not complete the treatment. Comparisons between Time 1 and Time 3 self-reports suggested that this treatment protocol holds promise as a novel means of impacting erectile functioning (Cohen's d = 0.63), overall sexual satisfaction (Cohen's d = 1.02), and non-judgmental observation of one's experience (Cohen's d = 0.52). Participants' expectations for the treatment were generally positive and correlated to self-reported outcomes (r = .68-.73). Qualitative analyses revealed 6 themes: normalization, group magic, identification of effective treatment targets, increased self-efficacy, relationship factors, and treatment barriers. CLINICAL IMPLICATIONS: In a shift toward a biopsychosocial framework for the treatment of men's sexual dysfunction, clinicians may consider incorporating mindfulness to address psychosocial and psychosexual components of dysfunction. STRENGTH & LIMITATIONS: This is the first study-to our knowledge-to adapt mindfulness protocols for use with men's sexual dysfunction. Because this is a pilot study aimed at feasibility, the sample size is small and no control group was included, thus conclusions about efficacy and generalizability cannot be made. CONCLUSION: The current study suggests that a mindfulness group therapy framework offers a feasible and potentially promising treatment avenue for men with situational ED. Bossio JA, Basson R, Driscoll M, et al. Mindfulness-based group therapy for men with situational erectile dysfunction: A mixed-methods feasibility analysis and pilot study. J Sex Med 2018;15:1478-1490.

Antenatal Vulvar Pain Management, Labour Management, and Postpartum Care of Women With Vulvodynia: A Survey of Physicians and Midwives.

OBJECTIVE: To examine maternity providers' recommendations for pregnant women with vulvodynia regarding management of vulvar pain and postpartum care, and to examine if, and how, a woman's chronic vulvar pain affects providers' examination and management during labour. METHODS: This research was part of a larger study that invited physicians and midwives to answer a questionnaire regarding pregnancy and childbirth care in women with vulvodynia. To achieve the current objectives, the questionnaire included both dichotomous (yes or no) and open-ended items. The current sample (n = 116) consisted of 75 physicians and 41 midwives. RESULTS: Over 60% of the sample reported making recommendations for vulvar pain management during pregnancy, and 32.8% of providers reported making special postpartum care recommendations for women with vulvodynia. Differences between physicians and midwives were noted for some of these recommendations. For example, to manage vulvar pain, only physicians recommended the use of/change in medications (P <0.001) and only midwives recommended complementary medicines (P = 0.02) and the use of lubricants (P = 0.006) and made recommendations for sexual well-being (P = 0.02). The majority of the sample (75%) reported that a woman having vulvodynia affected labour examination and management; providers most frequently reported minimizing exams and early use of epidural. Over 80% of midwives and 54% of physicians minimized exams during labour for women with vulvodynia (P= 0.01). CONCLUSION: Further research is needed to understand the optimal provision of care for pregnant and postpartum women with vulvodynia. We advocate for increased education of vulvodynia aimed at providers of antenatal, labour, and postnatal care.

Women's sexual dysfunction associated with psychiatric disorders and their treatment.

Impairment of mental health is the most important risk factor for female sexual dysfunction. Women living with psychiatric illness, despite their frequent sexual difficulties, consider sexuality to be an important aspect of their quality of life. Antidepressant and antipsychotic medication, the neurobiology and symptoms of the illness, past trauma, difficulties in establishing relationships and stigmatization can all contribute to sexual dysfunction. Low sexual desire is strongly linked to depression. Lack of subjective arousal and pleasure are linked to trait anxiety: the sensations of physical sexual arousal may lead to fear rather than to pleasure. The most common type of sexual pain is 10 times more common in women with previous diagnoses of anxiety disorder. Clinicians often do not routinely inquire about their patients' sexual concerns, particularly in the context of psychotic illness but careful assessment, diagnosis and explanation of their situation is necessary and in keeping with patients' wishes. Evidence-based pharmacological and non-pharmacological interventions are available but poorly researched in the context of psychotic illness.

Women With Hypoactive Sexual Desire Disorder Versus Sexual Interest/Arousal Disorder: An Empirical Test of Raising the Bar.

In 2013, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published with a major revision to the sexual dysfunction categories, and the diagnosis of female hypoactive sexual desire disorder (HSDD) was replaced with female sexual interest/arousal disorder (SIAD). Since being introduced, concern has been expressed that SIAD inappropriately "raises the bar" for diagnosis. To address these concerns, we sought to evaluate the number of women with a diagnosis of HSDD who also met criteria for SIAD. In a sample of 151 women, we found that 73.5% of women with a diagnosis of HSDD met criteria for SIAD. The two groups were compared on the Sexual Interest/Desire Inventory, and women who met criteria for both HSDD and SIAD consistently scored lower on sexual desire frequency and satisfaction, satisfaction with sex, receptivity, positive sexual thoughts, reactions to erotica, arousal frequency, ease, continuation, and orgasm ease/achievement, and higher on distress. In addition, women meeting criteria for HSDD only tended to have mild symptoms across the six SIAD criteria compared to those meeting criteria for both HSDD and SIAD. These findings suggest that the SIAD criteria does not unduly raise the bar for diagnosis.

Statistical and Epistemological Issues in the Evaluation of Treatment Efficacy of Pharmaceutical, Psychological, and Combination Treatments for Women's Sexual Desire Difficulties.

We were grateful to receive responses from Leonore Tiefer, Anita Clayton and Robert Pyke, and Richard Balon and Robert Segraves, to our commentary (Brotto et al., 2016 ) on Pyke and Clayton ( 2015 ). These commentaries raise a number of substantive statistical and epistemological issues relating to the evaluation of treatment efficacy in pharmaceutical, psychological, and combination treatments for sexual desire difficulties and caution researchers to remain mindful of sources of bias as we do the science. In what follows, we discuss each of these issues in turn in hopes of encouraging our field to adopt the highest possible standards when carrying out and interpreting treatment outcome research.

Clinicians' Perspectives and Experiences Regarding Maternity Care in Women With Vulvodynia.

OBJECTIVE: To assess clinicians' frequency of and comfort with provision of maternity care for women with vulvodynia, their beliefs and practices regarding delivery mode, and frequency of maternal requests for Caesarean section (CS). METHODS: We invited physicians and midwives to complete a questionnaire assessing their frequency of contact with pregnant women with vulvodynia; their level of comfort providing antenatal, intrapartum, and postpartum care for these women; whether they believed that vulvodynia is an indication for elective CS and the frequency of making this recommendation; and the number of patients with vulvodynia who strongly requested CS. RESULTS: Of the 140 participating clinicians, 91 were physicians and 49 were midwives. Most physicians (n = 64; 70.4%) saw patients with vulvodynia at least once per month. Clinicians who saw women with vulvodynia were most likely to see pregnant women with vulvodynia rarely (n = 54; 40.3%) or every six to 12 months (n = 29; 21.6%). Almost one third (n = 44; 31.4%) were not comfortable providing maternity care for these women, and 16.4% (n = 23) agreed that vulvodynia was an indication for elective CS. Of respondents who provided maternity care for women with vulvodynia, 15.4% (n = 18) had recommended CS; the most common reason for doing so was potential worsening of vulvar symptoms. The majority of clinicians who provided maternity care for women with vulvodynia (n = 73; 62.4%) indicated that maternal requests for CS were rare. CONCLUSION: Almost one third of participating clinicians (31.4%) were not comfortable providing maternity care for women with vulvodynia. Despite infrequent maternal requests, a minority of clinicians believed that vulvodynia is an indication for CS and/or made that recommendation. Additional research and education are needed to provide optimal obstetric care for women with vulvodynia.