Interpretation
The observed prevalence of dyspareunia in this study is similar to established epidemiological data (3). In obstetrical cohorts, the prevalence of dyspareunia has varied from 0.06% (8) to more than 40% (11). An explanation for this discrepancy may be different study populations and methodologies: some studies identified subjects according to a specific diagnosis in the medical records, such as “vaginismus” or “provoked vestibulodynia (PVD)” (8,10), while others have relied on self-report by patients (11).
Our study indicates similar mode of delivery in women with and without dyspareunia, confirming previous findings (11) and conflicting with studies showing a higher likelihood of cesarean deliveries in women with dyspareunia (8). We observed no difference between groups in rate or severity of perineal lacerations. This contrasts with previous data indicating increased risk for perineal tears in women with dyspareunia (10) and showing a correlation between perineal lacerations and dyspareunia severity (11). This discrepancy may be attributed to a selection bias, as there were no perineal tears grade 3-4 in our cohort.
We found no difference in rate of ART between groups. Likewise, Nguyen et al. (9) reported similar rates of conception in women with PVD versus comparisons. Conversely, studies focusing on women with vaginismus (7,8) have reported a high rate of ART. This discrepancy may stem from different coping strategies in vaginismus versus PVD. Women with vaginismus tend to be “fear-avoidant” and refrain from intercourse, hindering their ability to conceive, while women with PVD are “task-persistent” and continue to have intercourse despite pain (26).
The relationship between dyspareunia and pre-term labour has not been previously described, however studies have pointed out a connection between chronic pelvic pain conditions and pre-term labour. A systematic review (27) has suggested a relationship between endometriosis (28) and preterm delivery, through hyper-expression of pro-inflammatory mediators involving changes in gene expression, oxidative stress, local estrogen production and progesterone resistance. When such changes occur earlier than at pregnancy term, the contractile activity of the myometrium is triggered, leading to preterm labour (29). Some studies have shown a heightened systemic inflammatory response in PVD (3,30) and we suggest that an inflammatory mechanism may be plausible in women with dyspareunia.
The literature regarding emotional strategies for approaching reproductive events in women with dyspareunia is scarce. A study (13) on the impact of vulvodynia on thoughts and feelings on reproduction identified some central themes: efforts to reach acceptable pain levels before pregnancy; disconnect between dyspareunia treatment and obstetric care, anxiety and hopefulness regarding pregnancy. Rather than on conception and pregnancy, in our study we focused on women’s perception and emotional adjustment to childbirth.
We observed that women with dyspareunia are discontent with obstetric care, confirming previous data showing greater negative affect, more interpersonal and social discomfort (31) and mistrustful attitudes of women with dyspareunia toward health care providers (13). A study (32) exploring personality traits of women with PVD found evidence of cautiousness, insecurity, pessimism, shyness in social situations, along with a tendency to be intolerant, impatient and critical of others. Another recent study (33) observed social anxiety and paranoid ideation in women with dyspareunia. The low level of sense of control experienced by our dyspareunia patients is aligned with previous data (32) indicating reports by women with dyspareunia that their attitudes, behaviours and choices were determined by influences outside their control or against their own will. Expert opinion on management of women with dyspareunia during labour and delivery has indeed emphasized the importance of practices that increase women’s sense of control (34).
We observed more perinatal dissociation in women with dyspareunia. A relationship between dissociative symptoms and chronic pelvic pain states has been previously suggested (35). Recently, Farina et al. (36) conceptualized dyspareunia as a somatoform dissociative symptom and found an odds ratio of 6.15 of psychoform dissociation in women with dyspareunia. Similarly, Özen et al. (37) found high rates of somatoform dissociation in dyspareunia patients. Our study corroborates these data and is, to our knowledge, the first study specifically assessing perinatal dissociation in women with dyspareunia.
Women with dyspareunia reported more ASD-related symptoms, depression, negative affect, lower maternal bonding and self-efficacy. Previous research has indicated depression (3,38–40), anxiety (31,38,40–42), obsessive-compulsive and phobic symptoms (42) are common co-morbidities in dyspareunia. Regardless whether these affective states represent a personality style predating pain onset, or are a product of the prolonged pain experience, they constitute potential risk factors for negative affective reactions to childbirth.
We observed less spontaneous labour onset, more cervical ripening, and higher negative affect in women experiencing pain during pelvic exams. The presence of high anxiety levels, known to be related to increased need for induction of labour (43,44), may explain this relationship. Pain during pelvic exams is often related to anxiety, which results in phasic activation of the perineal muscles as part of a guarding response (45).