Attachment and Childhood Maltreatment as Moderators of Treatment Outcome in a Randomized Clinical Trial for Provoked Vestibulodynia.

BACKGROUND: Although distal developmental factors, such as attachment and childhood maltreatment (CM), are associated with the occurrence, severity, and adjustment to provoked vestibulodynia (PVD)-the most prevalent form of vulvodynia-no studies to date have examined whether these variables are related to treatment efficacy in the context of PVD. Attachment and CM may act as moderating variables when examining different treatment modalities, whereby individuals with more insecure attachment orientations (anxiety/avoidance) or a history of CM may benefit less from treatments with higher interpersonal contexts, such as sex and couple therapy-a recommended treatment for PVD. AIM: The present randomized clinical trial (RCT) examined attachment and CM as predictors and moderators of sexual satisfaction, distress, and function at post-treatment and 6-month follow-up while comparing 2 treatments for PVD: Topical lidocaine, and a novel cognitive behavioral couple therapy focused on women's pain and partners' sexuality. METHODS: One hundred eight women with PVD were randomized to a 12-week treatment of either lidocaine or couple therapy. Women completed questionnaires at pretreatment, post-treatment, and at a 6-month follow-up. OUTCOMES: (1) Global Measure of Sexual Satisfaction; (2) Female Sexual Distress Scale-Revised; (3) Female Sexual Function Index. RESULTS: Both attachment and CM were significant moderators of treatment outcomes. At either post-treatment or 6-month follow-up, in the couple therapy condition, women with greater attachment avoidance had poorer outcomes on sexual distress, satisfaction and function, whereas women with higher levels of CM had poorer outcomes on sexual satisfaction and sexual function, compared to women in the lidocaine condition. CLINICAL IMPLICATIONS: Although these novel findings need further replication, they highlight the importance for clinicians to take into account distal factors, for instance, attachment and CM, when treating sexual difficulties such as PVD, as these variables may affect more interpersonal dimensions of treatment (eg, trust, compliance, etc.) and ultimately, treatment progress. STRENGTHS & LIMITATIONS: Using a rigorous RCT study design and statistical approach, this study is the first to examine attachment and CM as moderators in the treatment of sexual difficulties. It is however limited by the use of self-report measures, and further studies are necessary to validate the generalizability of current results to other sexual difficulties. CONCLUSION: Findings support the role of interpersonal factors in the treatment of PVD and indicate that short-term psychological interventions, such as couple therapy, may be less beneficial for women with antecedents of CM and attachment insecurity. V Charbonneau-Lefebvre, M-P Vaillancourt-Morel, NO Rosen, et al. Attachment and Childhood Maltreatment as Moderators of Treatment Outcome in a Randomized Clinical Trial for Provoked Vestibulodynia. J Sex Med 2022;19:479-495.

Pain Trajectories and Predictors: A 7-Year Longitudinal Study of Women With Vulvodynia.

INTRODUCTION: A significant proportion of women report a reduction of symptoms over time-even without treatment-yet the natural progression of vulvodynia and which factors may explain decrease vs persistence of pain remain unclear. AIM: To identify subgroups of pain trajectories in women with vulvodynia and to predict these different trajectories by treatments undertaken, pain characteristics, and psychosocial factors. METHODS: Data on pain intensity, treatments undertaken, pain characteristics, and psychosocial factors were collected 3 times over a 7-year period from 173 women who screened positive for vulvodynia. Latent class growth analysis was conducted to identify homogeneous subgroups with distinct pain trajectories. A multivariate binomial logistic regression was used to examine whether treatments, pain characteristics, and psychosocial factors predicted these trajectories. MAIN OUTCOME MEASURE: The main outcome was pain intensity (0-10), measured at 3 time points with the numerical rating scale. RESULTS: 2 pain trajectories were identified: 1 where pain persisted (28.9%), and 1 where pain decreased over time (71.1%). Whether a treatment had been undertaken was not predictive of the course of pain over time. Women who were older at first pain onset, had pain at another location than the entrance of the vagina, and reported more anxiety were more likely to have a persistent pain trajectory relative to the decreased pain trajectory. CLINICAL IMPLICATIONS: Findings suggest that the evolution of pain differs among women with vulvodynia depending on pain characteristics and anxiety. STRENGTHS & LIMITATIONS: Strengths of the study include the 7-year longitudinal design to examine the natural history of provoked vestibulodynia and the inclusion of biopsychosocial factors as predictors of pain trajectories. However, women with major medical and psychiatric illnesses or deep dyspareunia were not included, and, thus, these factors could not be examined as predictors. CONCLUSION: Assessing baseline characteristics associated with different pain trajectories during medical visits could have positive implications for the management of vulvodynia. Pâquet M, Vaillancourt-Morel M-P, Jodouin J-F, et al. Pain Trajectories and Predictors: A 7-Year Longitudinal Study of Women With Vulvodynia. J Sex Med 2019;16:1606-1614.

Self-Efficacy Mediates the Attachment-Pain Association in Couples with Provoked Vestibulodynia: A Prospective Study.

INTRODUCTION: Attachment influences the way individuals anticipate, react, and seek support when faced with chronic pain. Although cross-sectional research indicates that attachment insecurity and pain self-efficacy are associated with pain intensity in chronic pain populations, little is known about their long-term effects on pain, and about the directionality of associations between these constructs. Furthermore, whereas attachment is a relational concept, few studies on genito-pelvic pain have espoused a couples' perspective. AIM: Using a prospective dyadic design, the present study aimed to examine the directionality of the associations among attachment dimensions, pain self-efficacy, and pain intensity in couples coping with provoked vestibulodynia (PVD). A second aim was to test whether pain self-efficacy mediated the attachment-pain association. METHODS: 213 couples coping with PVD completed self-report questionnaires at baseline (T1) and at a 2-year follow-up (T2). MAIN OUTCOME MEASURE: (1) Experiences in Close Relationships - Revised; (2) Painful Intercourse Self-Efficacy Scale; and (3) 10-point Numerical Rating Scale for pain intensity. RESULTS: Autoregressive cross-lagged models revealed that women's greater attachment anxiety and avoidance at T1 predicted their greater pain intensity at T2. Women's greater attachment anxiety at T1 predicted their poorer pain self-efficacy at T2, and poorer pain self-efficacy in women at T1 predicted their higher pain intensity at T2. A mediation model showed that women's lower pain self-efficacy at T2 fully mediated the association between women's higher attachment anxiety at T1 and their higher pain intensity at T2. Partners' attachment dimensions did not predict their own or women's pain self-efficacy nor pain intensity. CLINICAL IMPLICATIONS: Results suggest that greater attachment anxiety may contribute to women with PVD's lower confidence that they can manage their pain, which leads to long-term persistent pain. This study highlights the importance of assessing attachment and pain self-efficacy in women with genito-pelvic pain and to consider interventions targeting these variables, as they have far-reaching consequences. STRENGTH & LIMITATIONS: The use of longitudinal and dyadic data inform interpersonal processes and the long-term implications of attachment and pain self-efficacy in PVD. The use of self-report measures may introduce a social desirability and recall bias. CONCLUSION: This prospective dyadic study adds to a body of literature on PVD and chronic pain by empirically supporting theoretical models on attachment, pain self-efficacy, and persistent pain, and supports the role of psychosocial factors in the adjustment to PVD. Charbonneau-Lefebvre V, Vaillancourt-Morel M-P, Brassard A, et al. Self-Efficacy Mediates the Attachment-Pain Association in Couples with Provoked Vestibulodynia: A Prospective Study. J Sex Med 2019;16:1803-1813.

HPV Screening and Vaccination Strategies in an Unscreened Population: A Mathematical Modeling Study.

Human papillomavirus (HPV), a sexually transmitted infection, is the necessary cause of cervical cancer, the third most common cancer affecting women worldwide. Prevention and control strategies include vaccination, screening, and treatment. While HPV prevention and control efforts are important worldwide, they are especially important in low-income areas with a high infection rate or high rate of cervical cancer. This study uses mathematical modeling to explore various vaccination and treatment strategies to control for HPV and cervical cancer while using Nepal as a case study. Two sets of deterministic models were created with the goal of understanding the impact of various prevention and control strategies. The first set of models examines the relative importance of screening and vaccination in an unscreened population, while the second set examines various screening scenarios. Partial rank correlation coefficients confirm the importance of screening and treatment in the reduction of HPV infections and cancer cases even when vaccination uptake is high. Results also indicate that less expensive screening technologies can achieve the same overall goal as more expensive screening technologies.

A National Survey of Canadian Physicians on HPV: Knowledge, Barriers, and Preventive Practices.

OBJECTIVE: Physicians are the sole prescribers of the human papillomavirus (HPV) vaccine for adults in Canada. This survey of Canadian physicians aimed to explore knowledge, barriers, and preventive practices regarding HPV vaccination. METHOD: A survey of general practitioners (GPs) (n = 337) and obstetrician/gynaecologists (OB/GYNs) (n = 81) was conducted in May and June 2016 using an online panel. Demographic data and information pertaining to HPV knowledge, attitudes, and vaccination practices were collected by using a 22-item questionnaire. RESULTS: A total of 83% of GPs recommended or administered HPV vaccine to adults. Among physicians, 99% to 100% strongly agreed that vaccination is an important aspect of disease prevention. Physicians were rarely concerned about vaccine safety (5%-11%). Cost was seen as the number one barrier by 92% to 95% of physicians. Physicians rated consumers' understanding of HPV to be low (11%-14%, very good; and 49%-56%, somewhat good knowledge). Among physicians, 60% to 66% of said they routinely discussed HPV vaccination with patients. Female physicians demonstrated greater knowledge of HPV than their male counterparts. CONCLUSION: GPs and obstetrician/gynaecologists routinely recommend and administer the HPV vaccine to patients. The majority of physicians showed high levels of knowledge regarding HPV vaccine and associated cancers; however, perceived barriers of cost may limit recommendations for vaccination, particularly among older women or men.

A National Survey of Canadian Adults on HPV: Knowledge, Attitudes, and Barriers to the HPV Vaccine.

OBJECTIVE: Identifying human papillomavirus (HPV) vaccination motivators and barriers among adults could lead to new approaches to improve HPV vaccination rates in non-pediatric populations. This Canadian survey aimed to assess current knowledge of, attitudes towards, and barriers to the HPV vaccine among the general public. METHODS: An online panel was used to survey HPV unvaccinated women (n = 802) and vaccinated women (n = 250) 18 to 45 years old, as well as 18- to 26-year-old men (n = 200), in May and June 2016. A 16-item questionnaire collected data on sociodemographic factors, health-seeking behaviours, knowledge of HPV infection and its consequences, and the HPV vaccine. Data were stratified by sex and by vaccination status among women. RESULTS: The majority of individuals somewhat or strongly agreed that vaccination is an important aspect of disease prevention (vaccinated women, 93%; unvaccinated women, 85%; and men, 59%). However, a high proportion of patients were concerned about vaccine safety (vaccinated women, 26%; unvaccinated women, 40%; and men, 36%). Moreover, 58% to 61% of participants were generally cautious about taking any vaccine. The number one reported barrier to vaccination was not having a recommendation from a doctor (38%). Cost was seen as a barrier by only 18% to 20% of participants. CONCLUSION: Canadian participants show a broad diversity in HPV knowledge and regarding barriers to vaccination. The youngest populations (vaccinated women and men) showed higher levels of knowledge regarding HPV.

The early impact of human papillomavirus vaccination on anogenital warts in Québec, Canada.

In Québec province in Canada, a public school-based and catch-up HPV vaccination programs with the quadrivalent vaccine have been introduced in September 2008 for girls aged 9-17 years. We assessed the early impact of the HPV vaccination program on the incidence of anogenital warts (AGW) in the Quebec general population. We used the provincial health administrative data of the Régie de l'assurance maladie du Québec (RAMQ). AGW were identified either through a prescription of podofilox, or a medical procedure code specific to AGW, or a diagnostic code for viral warts followed by a prescription of imiquimod or fluorouracil. Sex- and age-specific incidence rates were calculated for pre-vaccination (2004-2007) and vaccination (2009-2012) periods. We found a significant decline of 45% and 19% in the incidence of AGWs among females aged 15-19 and 20-24 years, respectively. A decline of 21% was also seen among males aged 15-19 years. The median age at an episode of AGW increased from 27 years in 2004 to 31 years in 2012 among females and remained stable in males. Our findings indicate that the HPV public vaccination program is associated with an important reduction in the incidence of AGW among young females and males. The benefit is more pronounced among females 15-19 years of age, who were eligible for the public vaccination program. The observed decline among young males could be due to herd immunity and/or privately paid vaccination.

A Review of the Impact and Effectiveness of the Quadrivalent Human Papillomavirus Vaccine: 10 Years of Clinical Experience in Canada.

Publicly funded administration of the quadrivalent HPV (qHPV) vaccine in school-aged girls was implemented for all Canadian provinces and territories between 2007 and 2009. However, the impact of female qHPV vaccination in Canada has yet to be evaluated. This systematic literature review of studies published between September 1, 2006 and September 1, 2016 looked at real-world evidence related to the effects of qHPV vaccination on prevalence of HPV infection and disease in Canada over the past decade. PubMed was searched for studies published between September 1, 2006 and September 1, 2016. Studies were eligible if one or more of the following outcomes were assessed in individuals receiving the qHPV vaccine though public immunization programs: HPV infection, anogenital warts (AGW), HPV-associated lesions of the anogenital tract. A "pre-public vaccination program" or "unvaccinated" reference group was required. Key HPV conference abstracts were also reviewed. We identified seven eligible studies representing five Canadian provinces. Results reported indicated that the prevalence of HPV types 6, 11, 16, and 18 was lower in qHPV-vaccinated than unvaccinated individuals (1.5% vs. 11.0%, respectively), whereas non-vaccine-covered genotypes were comparable across vaccination status. Risk of AGW incidence decreased by up to 45% in vaccinated cohorts; incidence of cervical intraepithelial neoplasia 2 + was significantly reduced by up to 86% in the post-vaccine era. On the basis of these findings, HPV vaccination programs constitute a successful and effective public health initiative.

Recurrence of Human Papillomavirus External Genital Wart Infection Among High-Risk Adults in Montréal, Canada.

OBJECTIVES: The incidence of recurrent genital warts is not well characterized; this is especially true in a post-human papillomavirus (HPV) vaccination era. The objectives of this study were to assess the incidence of subsequent HPV-related external genital warts (EGW) episodes in high-risk male and female adults, as well as ascertain patient profile and disease characteristics, in a real-world Canadian sexual health clinical setting. METHODS: Retrospective chart review study conducted at Clinique médicale l'Actuel, a sexual health clinic in Montréal, Québec, Canada. Eligible patients were 18 to 45 years of age with a first diagnosis of EGW associated with a HPV infection between July 1, 2006, and June 30, 2012. RESULTS: A total of 400 first-episode EGW cases were identified. Up to 6 subsequent episodes were documented, with 194 (48.5%) patients reporting at least 1 subsequent EGW episode. Median time to first subsequent EGW episode was 3.97 years, and the incidence density rate for all subsequent episodes was 0.18/100 patient-years. Over 90% of patients reported clearance of the first subsequent episode, with median time to clearance of 0.30 years. Regardless of subsequent episode number, greater than 95% of patients received treatment, primarily cryotherapy, with high-risk sexual behavior reducing as number of episodes increased. CONCLUSIONS: Overall, a high rate of subsequent EGW episodes was observed in this high-risk population, despite high treatment rates and improvement in high-risk sexual behavior. These data, assessed in a prevaccination Québec health care system, may be compared with future EGW rates to assess the impact of a governmentally-funded HPV vaccination program.

No. 207-Genital Herpes: Gynaecological Aspects.

OBJECTIVE: The purpose of this guideline is to provide recommendations to gynaecology health care providers on optimal management of genital herpes. OUTCOMES: More effective prevention of complications and transmission of genital herpes. EVIDENCE: Medline was searched for articles published in French and English related to genital herpes and gynaecology. Additional articles were identified through the references of these articles. All study types and recommendation reports were reviewed.

No. 208-Guidelines for the Management of Herpes Simplex Virus in Pregnancy.

OBJECTIVE: To provide recommendations for the management of genital herpes infection in women who want to get pregnant or are pregnant and for the management of genital herpes in pregnancy and strategies to prevent transmission to the infant. OUTCOMES: More effective management of complications of genital herpes in pregnancy and prevention of transmission of genital herpes from mother to infant. EVIDENCE: Medline was searched for articles published in French or English related to genital herpes and pregnancy. Additional articles were identified through the references of these articles. All study types and recommendation reports were reviewed. VALUES: Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care. RECOMMENDATIONS: VALIDATION: These guidelines have been reviewed and approved by the Infectious Diseases Committee of the SOGC. SPONSOR: The Society of Obstetricians and Gynaecologists of Canada.

Associations of Anogenital Low-Risk Human Papillomavirus Infection With Cancer and Acquisition of HIV.

α-Mucosal human papillomavirus (HPV) types are implicated in a range of clinical conditions and categorized as "low-risk" (LR) and "high-risk" (HR) types according to their degree of association with cervical cancers. The causative role of LR HPV infection in the development of anogenital warts and in low-grade squamous intraepithelial lesions is well established. In addition, there is a growing body of evidence that infection with LR HPV types may be associated with an elevated risk of cancers and potentiation of coinfections. Prospective and case-control studies consistently report a higher risk of anogenital cancers in men and women with a history of anogenital warts. Based on currently available evidence, this higher risk may be due to shared exposure to HR HPV types or an underlying immune impairment, rather than a direct role of LR HPV types in subsequent cancer risk. Data also suggest that infection with LR HPV, HR HPV, or both may increase the risk of HIV acquisition, although the relative contribution of different HPV types is not yet known. There is also evidence implicating HPV clearance, rather than HPV infection, in increased risk of HIV acquisition.

Are primary and secondary provoked vestibulodynia two different entities? A comparison of pain, psychosocial, and sexual characteristics.

INTRODUCTION: Provoked vestibulodynia (PVD) is suspected to be the most frequent cause of vulvodynia in premenopausal women. Based on the onset of PVD relative to the start of sexual experience, PVD can be divided into primary (PVD1) and secondary PVD (PVD2). Studies comparing these PVD subgroups are inconclusive as to whether differences exist in sexual and psychosocial functioning. AIM: The aim of this study was to compare the pain, sexual and psychosocial functioning of a large clinical and community-based sample of premenopausal women with PVD1 and PVD2. METHODS: A total of 269 women (n = 94 PVD1; n = 175 PVD2) completed measures on sociodemographics, pain, sexual, and psychosocial functioning. MAIN OUTCOME MEASURES: Dependent variables were the 0-10 pain numerical rating scale, McGill-Melzack Pain Questionnaire, Female Sexual Function Index, Global Measure of Sexual Satisfaction, Beck Depression Inventory-II, Painful Intercourse Self-Efficacy Scale, Pain Catastrophizing Scale, State-Trait Anxiety Inventory Trait Subscale, Ambivalence over Emotional Expression Questionnaire, Hurlbert Index of Sexual Assertiveness, Experiences in Close Relationships Scale--Revised, and Dyadic Adjustment Scale-Revised. RESULTS: At first sexual relationship, women with PVD2 were significantly younger than women with PVD1 (P < 0.01). The average relationship duration was significantly longer in women with PVD2 compared with women with PVD1 (P < 0.01). Although women with PVD1 described a significantly longer duration of pain compared with women with PVD2 (P < 0.01), no significant subtype differences were found in pain intensity during intercourse. When controlling for the sociodemographics mentioned earlier, no significant differences were found in sexual, psychological, and relational functioning between the PVD subgroups. Nevertheless, on average, both groups were in the clinical range of sexual dysfunction and reported impaired psychological functioning. CONCLUSIONS: The findings show that there are no significant differences in the sexual and psychosocial profiles of women with PVD1 and PVD2. Results suggest that similar psychosocial and sex therapy interventions should be offered to both subgroups of PVD.

Attachment, Sexual Assertiveness, and Sexual Outcomes in Women with Provoked Vestibulodynia and Their Partners: A Mediation Model.

Provoked vestibulodynia (PVD) is a prevalent women's sexual pain disorder, which is associated with sexual function difficulties. Attachment theory has been used to understand adult sexual outcomes, providing a useful framework for examining sexual adaptation in couples confronted with PVD. Research to date indicates that anxious and avoidant attachment dimensions correlate with worse sexual outcomes in community and clinical samples. The present study examined the association between attachment, pain, sexual function, and sexual satisfaction in a sample of 101 couples in which the women presented with PVD. The actor-partner interdependence model was used in order to investigate both actor and partner effects. This study also examined the role of sexual assertiveness as a mediator of these associations via structural equation modeling. Women completed measures of pain intensity and both members of the couple completed measures of romantic attachment, sexual assertiveness, sexual function, and satisfaction. Results indicated that attachment dimensions did not predict pain intensity. Both anxious and avoidant attachment were associated with lower sexual satisfaction. Only attachment avoidance predicted lower sexual function in women. Partner effects indicated that higher sexual assertiveness in women predicted higher sexual satisfaction in men. Finally, women's sexual assertiveness was found to be a significant mediator of the relationship between their attachment dimensions, sexual function, and satisfaction. Findings highlight the importance of examining how anxious and avoidant attachment may lead to difficulties in sexual assertiveness and to less satisfying sexual interactions in couples where women suffer from PVD.