Mediators of change in cognitive-behavioral couple therapy for genito-pelvic pain: Results of a randomized clinical trial.

OBJECTIVE: A novel cognitive-behavioral couple therapy (CBCT) has shown efficacy for treating provoked vestibulodynia (PVD), the most common type of genito-pelvic pain, in comparison to topical lidocaine. However, mechanisms of therapeutic change have not been determined. We examined women's and partners' pain self-efficacy and pain catastrophizing as mediators of change in CBCT, using topical lidocaine as a control group. METHOD: 108 couples coping with PVD were randomized to 12-week CBCT or topical lidocaine and assessed at pre-treatment, post-treatment, and six-month follow-up. Dyadic mediation analyses were conducted. RESULTS: CBCT was not more effective in increasing pain self-efficacy than topical lidocaine, so this mediator was discarded. In women, decreases in pain catastrophizing at post-treatment mediated improvement in pain intensity, sexual distress, and sexual function. In partners, decreases in pain catastrophizing at post-treatment mediated improvement in sexual function. Partners' decreases in pain catastrophizing also mediated reductions in women's sexual distress. CONCLUSIONS: Pain catastrophizing may be a mediator specific to CBCT for PVD, explaining improvements in pain and sexuality. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Ensuring a Successful Transition From Cytology to Human Papillomavirus-Based Primary Cervical Cancer Screening in Canada by Investigating the Psychosocial Correlates of Women's Intentions: Protocol for an Observational Study.

BACKGROUND: The human papillomavirus (HPV) test has emerged as a significant improvement over cytology for primary cervical cancer screening. In Canada, provinces and territories are moving toward implementing HPV testing in cervical cancer screening programs. Although an abundance of research exists on the benefits of HPV-based screening, there is a dearth of research examining women's understanding of HPV testing. In other countries, failure to adequately address women's concerns about changes has disrupted the implementation of HPV-based screening. OBJECTIVE: The aims of the multipart study described in this paper are to develop psychometrically valid measures of cervical cancer screening-related knowledge, attitudes, and beliefs; to examine the feasibility of a questionnaire examining psychosocial factors related to HPV-based screening; and to investigate psychosocial correlates of women's intentions to participate in HPV-based screening. METHODS: We conducted a web-based survey (study 1) of Canadian women to assess the acceptability and feasibility of a questionnaire, including the validation of scales examining cervical cancer knowledge, HPV testing knowledge, HPV testing attitudes and beliefs, and HPV test self-sampling attitudes and beliefs. Preferences for cervical cancer screening were assessed using the best-worst scaling methodology. A second web-based survey (study 2) will be administered to a national sample of Canadian women between June 2022 and July 2022 using the validated scales. Differences in the knowledge, attitudes, beliefs, and preferences of women who are currently either underscreened or adequately screened for cervical cancer will be examined through bivariate analyses. Multinomial logistic regression will be used to estimate the associations between psychosocial and sociodemographic factors and intentions to undergo HPV-based screening. RESULTS: Between October 2021 and November 2021, a total of 1230 participants completed the questionnaire in study 1, and 1027 (83.49%) responses were retained after data cleaning methods were applied. Feasibility was comparable with similar population-based surveys in terms of survey length, participant attrition, and the number of participants excluded after data cleaning. As of May 2022, analysis of study 1 is ongoing, and results are expected to be published in the summer of 2022. Data collection is expected to begin for study 2 in the summer of 2022. Results are expected to be published between late 2022 and early 2023. CONCLUSIONS: Findings will provide direction for Canadian public health authorities to align guidelines to address women's concerns and optimize the acceptability and uptake of HPV-based primary screening. Validated scales can be used by other researchers to improve and standardize the measurement of psychosocial factors affecting HPV test acceptability. Study results will be disseminated through peer-reviewed journal articles; conference presentations; and direct communication with researchers, clinicians, policy makers, media, and specialty organizations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/38917.

Human papillomavirus seroprevalence and seroconversion following baseline detection of nine human papillomavirus types in young women.

BACKGROUND: Estimates of the humoral immune response to incident human papillomavirus (HPV) infections are limited. METHODS: In this post hoc analysis of 3875 women aged 16-23 years from a 4-valent HPV vaccine trial (NCT00092482), HPV seroprevalence on day 1 was measured with a 9-valent HPV (HPV 6/11/16/18/31/33/45/52/58) competitive Luminex immunoassay and compared with cervical/external genital HPV detection by polymerase chain reaction. In the control group, among women who were HPV DNA‒negative on day 1, seroconversion following initial HPV detection was estimated using Kaplan-Meier methods. RESULTS: Type-specific HPV seropositivity among women with no day 1 cervical/external genital HPV detection was 0.6%-3.6%. Women with any 9-valent HPV (9vHPV) cervical/external genital detection (796/3875; 20.5%) had concordant seropositivity ranging from 13.4% (HPV 45) to 38.5% (HPV 6). Among women in the control group who were negative for all HPV types on day 1, seroconversion by month 30 after initial detection ranged from 29% (HPV 45) to 75% (HPV 16). CONCLUSIONS: Humoral immune response to HPV is variable and dynamic, depending on type-specific exposure. This longitudinal analysis provides insight into the relationship between incident infection and seropositivity. CLINICALTRIALS: gov; NCT00092482 https://clinicaltrials.gov/ct2/show/NCT00092482.

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.

Predictors and Moderators of Provoked Vestibulodynia Treatment Outcome Following a Randomized Trial Comparing Cognitive-Behavioral Couple Therapy to Overnight Lidocaine.

Provoked vestibulodynia is a vulvar pain condition causing sexual dysfunction, affecting 8% to 10% of women. Our recently published randomized clinical trial (N = 108 couples) found that cognitive behavioral couple therapy (CBCT) and topical lidocaine reduced women's pain and associated sexual symptoms, with CBCT showing more benefits. Little is known about pretreatment predictors of treatment outcomes in couples sex therapy. In the current study, we examined women and their partners' pretreatment demographic (age, relationship length), clinical (pain duration, anxiety) and interpersonal (partner responses to pain, sexual goals) predictors/moderators of women's pain intensity, pain unpleasantness, and sexual function at posttreatment and 6-month follow-up. Longer relationship duration, lower anxiety in women, partner higher solicitousness and partner higher approach sexual goals predicted better pain outcomes for women with PVD irrespective of treatment condition. CBCT was more effective than lidocaine for improving women's sexual function at posttreatment when, at pretreatment, women had partners with higher anxiety and women reported lower approach sexual goals, whereas lidocaine was more effective for improving women's sexual function at follow-up when partners had higher approach sexual goals. Findings can assist clinicians in determining what treatment will be most beneficial for whom.

A health economic model to estimate the costs and benefits of an mRNA vs DNA high-risk HPV assay in a hypothetical HPV primary screening algorithm in Ontario, Canada.

This study models the impact of using two different types of high-risk (HR) human papillomavirus (HPV) tests: mRNA (Aptima) and DNA (Hybrid Capture 2) as part of a hypothetical primary HPV screening program in Ontario, Canada. Outcomes were the costs of the screening program, and number of colposcopies, HPV tests and cytology tests. Results were estimated for one cohort going through the screening algorithm. A decision tree model was adapted from a published UK study, with inputs drawn from published Canadian data for the probabilities through the model, costs, demographic, and screening data from Ontario. Sensitivity and scenario analyses explored uncertainty in the model inputs and assumptions. Results indicated that screening using an mRNA test could yield cost savings of CAD $4,007,266 (95% credibility interval [CI]: -7,866,251 - 8,035) compared to using a DNA test, with 10,639 (95% CI: 10,170 - 11,094) fewer women undergoing unnecessary colposcopies, and reductions in unnecessary HR-HPV and cytology tests. The HR-HPV test comprised the largest percentage of the costs saved, and the probability of being HPV positive in the first year had the biggest impact on results. These results indicate that the choice of HR-HPV test is important when implementing a primary HPV screening program to avoid unnecessary resource use and cost, which will benefit both women and healthcare providers.

Cognitive-behavioral couple therapy versus lidocaine for provoked vestibulodynia: A randomized clinical trial.

OBJECTIVE: This randomized clinical trial compared a novel cognitive-behavioral couple therapy (CBCT) and topical lidocaine for provoked vestibulodynia. METHOD: Participants were 108 women (M age = 27.06) and their partners randomized to one of two treatments and assessed at pre- and post-treatment and 6-month follow-up via questionnaires pertaining to the primary outcomes of women's pain (numerical rating scales of pain intensity and unpleasantness), and secondary outcomes of pain anxiety (Pain Anxiety Symptoms Scale), both partners' sexual function (Female Sexual Function Index; International Index of Erectile Function), sexual distress (Female Sexual Distress Scale Revised), pain-related psychological distress (Pain Catastrophizing Scale), treatment satisfaction, and global ratings of improvements in pain and sexuality. RESULTS: Intent-to-treat multilevel analyses showed that for women, CBCT yielded significantly more improvements than lidocaine in pain unpleasantness at 6-month follow-up, pain anxiety and pain catastrophizing at post-treatment and 6-month follow-up, and sexual distress at post-treatment, and resulted in better treatment satisfaction and global sexuality improvements at both time points. Partners significantly improved in their sexual function, sexual distress, and pain catastrophizing from pre- to post-treatment and pre-treatment to 6-month follow-up, with no significant group differences. Partners in the CBCT condition reported significantly greater treatment satisfaction at both time points, and greater sexuality improvements at post-treatment. CONCLUSIONS: CBCT yielded better outcomes on more dimensions of provoked vestibulodynia than lidocaine. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Perceived partner responsiveness is associated with sexual well-being in couples with genito-pelvic pain.

Intimacy is vital to romantic relationships, yet is often thwarted by relational challenges, such as sexual difficulties. With prevalence estimates ranging from 10% to 28%, genito-pelvic pain/penetration disorder (GPPPD) is an important sexual problem resulting in negative consequences for affected women and their partners, including significant sexual dysfunction and dissatisfaction. Findings from cross-sectional studies indicate that higher levels of intimacy are associated with better sexuality outcomes in couples coping with GPPPD. However, single-occasion measurements may not capture the daily variations in intimacy that could have important implications for couples' sexual well-being. The present study focused on a key intimacy-building component-perceived partner responsiveness (PPR)-and its daily associations with women's pain and both partners' sexual function and satisfaction. Using daily diaries over an 8-week period, 160 women (Mage = 26.23, SD = 6.26) with GPPPD and their partners (Mage = 27.73, SD = 7.35) reported on PPR, sexual function and satisfaction, as well as women's pain, on days when sexual activity occurred (M = 8.87, SD = 5.87). Drawing on the Actor-Partner Interdependence Model, a multivariate multilevel modeling approach was adopted. Controlling for trait-level PPR, when women and partners reported greater PPR, women reported greater sexual function and satisfaction and partners reported greater sexual function. When partners reported greater PPR, they reported greater sexual satisfaction. No association was found between PPR and women's pain. PPR may facilitate better sexual function and satisfaction and could be an important target in sex and couple therapy for GPPPD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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.

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.