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A Multidimensional, Case-control Study of Women with Self-identified Chronic Vulvar Pain

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A Multidimensional, Case-control Study of Women with Self-identified Chronic Vulvar Pain
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    © American Academy of Pain Medicine1526-2375/02/$15.00/253253–259  PAIN MEDICINE  Volume 3 •  Number 3 •  2002   A Multidimensional, Case-control Study of Women withSelf-identified Chronic Vulvar Pain   Robin M. Masheb, PhD,* Elizabeth Brondolo, PhD,  †   and Robert D. Kerns, PhD*  ‡   *Yale University School of Medicine, New Haven, Connecticut; †   St. John’s University, Department of Psychology, ABSTRACT   Jamaica, NY; and ‡   VA Connecticut Healthcare System, Psychology Service (116B), West Haven, Connecticut   Objective.    The purpose of the present study was to conduct a multidimensional evaluation of women with chronic vulvar pain.   Design.   Fifty-seven women with self-identified vulvar pain were contrasted with 74 healthy control women. Measures were selected based on a multidimensional perspective and included questionnairesrelated to the core aspects of chronic pain: Pain severity, physical disability, affective distress, andmarital satisfaction.    Results.   In comparison with controls, women with vulvar pain reported significantly greater physicaldisability and affective distress. In women with vulvar pain, pain severity was not related to physicaldisability and affective distress. While women with vulvar pain scored in the normal range for maritalsatisfaction, they reported significantly less marital satisfaction than controls.   Conclusions.   Findings suggest that the experience of persistent vulvar pain in general, rather than thelevel of intensity of the pain, accounts for disturbances in functioning and emotional well-being. Incomparison with their peers, but not with norms, women with vulvar pain reported less marital satis-faction. A multidimensional approach to the assessment of chronic vulvar pain will lead to a greaterunderstanding of the psychosocial functioning of women with this condition.    Key Words.    Vulvar pain; Vulvodynia; Chronic Pain; Multidimensional  Introduction    Vulvodynia is a chronic pain disorder characterizedby constant or recurring complaints of vulvar painor discomfort. McKay [1,2] has identified five sub-types of vulvodynia: Dermatoses, cyclic vulvovaginitis,human papillomavirus (HPV) infection, vulvar ves-tibulitis, and dysesthetic vulvodynia. However, con-tinued pain after standard treatment for dermatitis, vaginitis and infection, and the absence of physicalpathology indicative of vulvar vestibulitis and dys-esthetic vulvodynia have made these subtypes diffi-cult to delineate. In fact, the current classificationsystem [1,2] has not been validated nor subjected tostudies of reliability, and there are reports that di-agnostic criteria for the subtypes of vulvodynia areneither well defined nor consistently utilized [3,4]. Many attempts have been made to evaluate treat-ments for subtypes of vulvodynia despite the ab-sence of a reliable and valid classification system.Historically, the literature on vulvodynia hastaken a unidimensional, acute pain approach to as-sessing the condition [5] (i.e., the site of pain is di-rectly proportional to some underlying pathology).However, in an effort to explain the absence of physical findings in many of these patients, or theirnonresponse to treatment, there have been many references in the literature to putative psychologi-cal etiologies. In addition, since dyspareunia (i.e.,pain with intercourse) is a common complaint in women with chronic vulvar pain, vulvodynia hasalso been referred to as a sexual dysfunction. How-ever, research suggests that both dyspareunia and    Reprint requests to: Robin M. Masheb, PhD, Yale University School of Medicine, P.O. Box 208098, New Haven, CT06520-8098. Tel: (203) 785-7807; Fax (203) 785-7855; E-mail:Robin.Masheb@yale.edu.    254    Masheb et al.    vulvodynia are more appropriately considered neu-ropathic pain syndromes with psychosocial factors,rather than sexual dysfunctions involving sensory disturbances, such as neuropathic pain [6-8].Living with chronic pain, regardless of physicalpathology, has a broad impact on the individual’slife with regard to pain severity, functioning, mood,and relationships. Despite increasing attention inthe literature to treatment outcome studies for sub-types of vulvodynia, few investigations have exam-ined the broader impact on the live’s of women withchronic vulvar pain. Multidimensional conceptual-izations of pain have provided an important contri-bution to the assessment and treatment of other    chronic pain conditions [9,10], yet few studies haveempirically investigated the psychosocial function-ing of women with vulvodynia from an empirically based multidimensional perspective [11,12]. Theimportance of a multidimensional assessment of  vulvodynia has been put forth by Masheb et al. [5]and Bergeron et al. [13]. The purpose of the present study was to providean empirical understanding of the psychosocial fac-tors associated with chronic vulvar pain using a mul-tidimensional approach. This study sought to inves-tigate the three key chronic pain domains: Painseverity, physical disability, and affective distress, in women who self-identified as having chronic vulvarpain. We hypothesized that women with self-iden-tified chronic vulvar pain would report greater dif-ficulties in psychosocial functioning than healthy controls in the three key chronic pain domains, as well as in marital satisfaction.  Methods  Subjects   Subjects were 131 volunteers who agreed to partic-ipate in a study involving a one-time survey to as-sess the psychosocial functioning of women withchronic vulvar pain. Participants were aged 19 to 86 years (mean: 42.9    13.1 SD), 87.8% (N    115) were Caucasian, 57.3% (N    75) were married, and54.6% (N    71) had at least a four-year college de-gree. Vulvar pain participants were 57 women whoidentified themselves as having vulvar discomfort for a duration of six months or greater. The healthy controls were 74 women who denied having chronic vulvar discomfort or any other chronic pain disorder. Two subject recruitment strategies were em-ployed. First, questionnaires were mailed to New  York City, Washington, DC, and Boston vulvo-dynia support group leaders and distributed to women who self-identified as having vulvar painand who agreed to participate. Forty-nine subjects were recruited by this method and determined tohave chronic vulvar pain if in response to the ques-tion, “Do you suffer from chronic     vulvar pain, burn-ing or discomfort,” they answered yes and in re-sponse to “How long have you had this problem,”they answered six months or greater. Although adiagnosis (e.g., of vulvodynia) was not confirmed by a physician specific to this study, it was assumedthat women in the support groups attended thesegroups because they had chronic vulvar pain and/orhad been given a diagnosis of vulvodynia by ahealthcare professional. Vulvar pain subjects re-ceived a packet of questionnaires for themselves,and one to be given to a female friend who did not suffer from any   chronic pain disorder. Subjects (i.e.,female friends) who denied vulvar pain and any other chronic pain were placed in the healthy con-trol condition.In the second strategy, eight subjects were re-cruited from the waiting rooms of two obstetric/ gynecology practices in New York City, which spe-cialize in vulvar diseases. The first author (RMM)asked patients who had chronic vulvar pain to par-ticipate in the study. Patients were included in the vulvar pain condition if they also answered in theaffirmative to the two questions above. Patients who did not have present vulvar pain were asked toparticipate as control subjects. If these patients de-nied having present vulvar pain and denied havingany other chronic pain condition (e.g., headache orback pain), they were placed in the healthy controlcondition. A cover letter explaining the study was enclosedin each questionnaire packet. Informed consents werenot witnessed because of the mail survey format.Subjects were asked to sign and return the in-formed consent in an addressed, prepaid postageenvelope. Subjects were asked to complete thepacket of questionnaires and return the packet in aseparate addressed, prepaid postage envelope. Thepurpose of this procedure was to keep the names of participants and their data separate.   Measures   West Haven-Yale Multidimensional Pain Inven-tory (WHYMPI).    The WHYMPI [14] is a widely used multidimensional self-report instrument de-signed to assess individuals with chronic pain. The WHYMPI has demonstrated reliability and validity [11]. Two of the nine subscales were used for thisstudy. The 3-item Pain Severity subscale containsitems such as “Rate the level of your pain at the    Self-identified Vulvar Pain    255   present moment” on a scale of 0 (no pain) to 6 (very intense pain). The 3-item Negative Mood subscalecontains items such as “Rate your overall moodduring the past week” on a scale of 0 (extremely low mood) to 6 (extremely high mood). Scoring proce-dures result in higher scores reflecting greater painseverity and greater negative mood.   The MOS 36-item Short-form Health Survey(SF-36).    The SF-36 [15] is a self-report instru-ment to assess health-related quality of life. TheSF-36 has well-established reliability and validity [16,17]. Five of the eight subscales were used inthis study. The Physical Functioning subscale in-cludes 10 questions about daily activities such as,“Does your health now limit you in lifting or car-rying groceries,” and items are rated on a 3-point scale from 1 (yes, limited a lot) to 3 (no, not lim-ited at all). The Physical Role Limitation subscaleincludes four questions such as, “During the past month, have you cut down on the amount of time you spent on work or other activities as a result of  your physical health or pain?” Items are rated on a2-point yes or no scale. The Emotional Role Limi-tation subscale includes three questions such as,“During the past month, have you cut down on theamount of time you spent on work or other activi-ties as a result of any emotional problems,” anditems are rated on a 2-point yes or no scale. The Mental Health subscale includes five questions re-lated to negative mood states over the past month(e.g., Have you been a very nervous person?), anditems are rated on a 6-point scale from 1 (all of thetime) to 6 (none of the time). The Vitality subscaleincludes four questions related to energy level andfatigue over the past month (e.g., Did you have alot of energy?), and items are rated on a 6-point scale from 1 (all of the time) to 6 (none of thetime). SF-36 raw scale scores were transformed tot scores [18]. Scoring procedures result in higherscores reflecting better functioning for all sub-scales. Locke-Wallace Marital Adjustment Test (LW-MAT).    The LWMAT [19] is a 15-item, self-report scale that assesses global marital satisfaction. Sub- jects who were married or living with a partnercompleted the LWMAT. This measure has well-established reliability and validity and has beenused frequently in studies of chronic pain [14]. In-dividuals were asked to rate the extent of agreement or disagreement on items such as handling fi-nances, using a 6-point scale from 0 (always dis-agree) to 5 (always agree). Higher scores reflect greater marital satisfaction.  Results  Statistical Analyses   Prior to conducting the primary statistical analyses,descriptive statistics were generated in order to ex-amine the accuracy of data input. Missing data werechecked and corrected, and distributions of each variable were evaluated. To determine whether vari-ables were normally distributed, the estimates of skewness were divided by the standard error of skew [20]. Transformations were performed on skewed variables (Physical Functioning, Physical Role Lim-itation, Emotional Role Limitation, and MaritalSatisfaction). Analyses were run first with untrans-formed variables and then with square-root trans-formed variables. The pattern of findings was similarin both analyses, and results from the untrans-formed variables were reported. The internal consistencies of the main outcome variables were investigated to assess the reliability of these measures for the vulvar pain sample only. Ta-ble 1 includes Cronbach’s    , a measure of the over-all correlation between items within a scale, for eachmeasure. Each Cronbach’s    exceeded 0.70, the cut-off considered acceptable for group comparisons [21]. Means, standard deviations, frequencies, and per-centages were used to present the pain characteris-tics of the vulvar pain sample. Bivariate Pearsonproduct-moment correlation (PPMC) coefficients were used to denote associations among the mainoutcome variables for the vulvar pain condition. ANOVAs were performed with the two study con-ditions for age, socioeconomic status (SES), andeach outcome variable, and chi-square analysis wasperformed for race.  Demographics and Pain Characteristics    Vulvar pain subjects and controls did not differ inage (mean: 43.9    14.6 SD vs mean: 42.1    12.0   Table 1   Internal consistency for the vulvar pain condition   Number ofItemsInternal Consistency(Cronbach’s    )Pain Severity   a   30.78Physical DisabilityPhysical Functioning   b   100.92Physical Role Limitation   b   40.96Emotional Role Limitation   b   30.82Affective DistressNegative Mood   a   30.68Mental Health   b   50.82Vitality   b   40.72Marital Satisfaction150.83   a   West Haven-Yale Multidimensional Pain Inventory   b   MOS 36-item Short-form Health Survey    256    Masheb et al.   SD, respectively;  F    (1,128)    0.593,  P       0.443) orSES (mean: 52.1    10.0 SD vs mean: 52.9    7.8SD, respectively;  F    (1,123)    0.230,  P       0.633). The conditions were significantly different for race(      2   (1,131)    4.55,  P     0.05), such that there was agreater percentage of Caucasian women in the vul- var pain condition (94.7%; N    54) than in thehealthy control condition (82.4%; N    61). The age of onset of vulvar pain ranged from 16to 82 years, with a median age of onset of 34.5 years(interquartile range: 26.5-41.5 years). Vulvar painhad been present from six months to 26 years witha median duration of 5.5 years (interquartile range:4-8.5 years). Frequencies and percentages for average vulvar pain severity (0    ‘Not at all Severe’ to 6    ‘Extremely Severe’), worst vulvar pain intensity (0    ‘No Pain’ to 6    ‘Very Intense Pain’), andleast vulvar pain intensity (0    ‘No Pain’ to 6    ‘Very Intense Pain’ during the last week are shownin Table 2. Fifty-six percent (N    32) reportedgradual onset of pain. Eleven percent (N    6) re-ported that someone in their family had similarcomplaints. Ninety-six percent (N    55) of vulvar painsubjects reported some degree of limitation withsexual activity, compared with only 10% (N    7) of controls who reported some degree of limitation with sexual activity. In addition, 89% (N    51) re-ported some degree of pain with sexual intercourse,compared with 24% (N    18) of controls who re-ported some degree of pain with sexual intercourse.  Correlational Analysis   Intercorrelations among the main outcome vari-ables are presented in Table 3. Correlations are re-ported for the vulvar pain condition (N    57) onthe variables from the three key chronic pain do-mains. Correlations for Marital Satisfaction are re-ported on vulvar pain subjects who were married orcohabitating (N    42).Pain Severity was significantly correlated withonly one of the physical disability measures (i.e.,Physical Role Limitation,  R         0.48,  P     0.001).Pain Severity was not related to any of the affectivedistress measures or to Marital Satisfaction. Thethree physical disability measures were all signifi-cantly correlated with each other at least at the 0.05level. Only Emotional Role Limitation, from thephysical disability measures, was significantly cor-related with the affective distress measures and Marital Satisfaction. The affective distress mea-sures were significantly correlated with each otherand with Marital Satisfaction at the 0.001 level, with the exception of Vitality.   Analysis of Variance    Table 4 includes means, standard deviations, and ANOVA results for the two study conditions. Ef-fects were significant at the 0.05 level for PhysicalFunctioning, Physical Role Limitation, EmotionalRole Limitation, Negative Mood, Mental Health, Vitality, and Marital Satisfaction. Results were inthe expected direction, such that vulvar pain sub- jects reported worse functioning on all measures with the exception of Mental Health.  Discussion    The aim of this study was to understand the psy-chosocial functioning of women with vulvar painfrom a multidimensional chronic pain perspective[5,13]. Measures from the chronic pain literature were used to assess not only the subject’s subjectivepain severity, but also physical disability and affec-tive distress, constructs that have been establishedas core features of the chronic pain experience. Marital satisfaction was also measured in this study on the basis of anecdotal reports of negative effectsof chronic vulvar pain on marital functioning andbecause of demonstrations in the chronic pain liter-ature that interpersonal distress is a significant problem among a subgroup of individuals experi-encing chronic pain. Inspection of indices of internalconsistency for each of these measures confirmedtheir reliability and encourages their application infuture investigations of women with chronic vul- var pain.In contrast to studies of other chronic pain con-ditions, pain severity was not found to be associated with level of affective distress [9,22]. These dataseem to suggest that the experience of persistent  vulvar pain, in general, rather than the level of in-tensity of the pain, accounts for disturbances infunctioning and emotional well-being.Group analyses revealed that women with chronic vulvar pain had greater difficulty performing physi-cal activities including walking and dressing, had   Table 2   Ratings of vulvar pain for the past week (N    57)   AverageSeverityWorstIntensityLeastIntensityN%N%N%023.500.02543.911322.8712.31628.121424.6915.81221.131221.1915.823.541221.11628.111.8523.51017.511.8623.5610.500.0    Self-identified Vulvar Pain    257   greater problems with work and other daily activi-ties, reported feeling more tired and worn down, andexperienced more negative moods than women without vulvar pain. These findings were generally consistent with observations of individuals whoexperience other persistent pain conditions. Suchobservations have generally encouraged a multidi-mensional perspective of the chronic pain experience[23,24] and argue for the importance of the routineattention to functional limitations and affective dis-tress, in addition to complaints of pain, when as-sessing and treating these women. Among the affective distress measures used inthis study, women with vulvar pain reported greaterdistress than controls on measures of negative mood(e.g., During the past week how irritable have youbeen?) and vitality (e.g., Did you feel full of pep?). Van Lankveld et al. [25] and Reed et al. [12] foundno differences between women with vulvodynia andcontrols on measures of affective distress—findingsthat contradict this study and early anecdotal re-ports in the vulvodynia literature that suggestedthese women were emotionally distressed. In addi-tion, the finding that women with chronic vulvarpain, relative to women in the control condition,reported higher levels of mental health functioning(e.g., Have you felt downhearted and blue?) iscounterintuitive. These findings clearly deserve fu-ture investigation to help clarify their robustnessand to examine possible explanations. The finding that women with vulvar pain re-ported lower marital satisfaction than controls alsocontradicted findings by Van Lankveld et al. [25]and Reed et al. [12] but was consistent with anec-dotal reports. This discrepancy in findings may beattributed to a difference in sample selection (i.e.,participants from support groups in this study ver-sus medical clinics in the Van Lankveld et al. [25]and Reed et al. [12] studies). One interesting thingto note was that the women with vulvar pain in thisstudy scored above the normative cut point (i.e.,100) that is indicative of marital satisfaction [19].One hypothesis is that women with vulvar pain re-port marital dissatisfaction to their healthcare pro-   Table   3   Intercorrelations among outcome variables for the vulvar pain condition   (1)(2)(3)(4)(5)(6)(7)1. Pain Severity   a   Physical Disability2. Physical Functioning   b      0.203. Physical Role Limitation   b      0.48   e   0.58   e   4. Emotional Role Limitation   b      0.250.31   c   0.47   e   Affective Distress5. Negative Mood   a   0.20      0.16      0.24      0.38   d   6. Mental Health   b      0.070.120.210.47   e      0.47   e   7. Vitality   b      0.100.050.110.21      0.210.51   e   8. Marital Satisfaction0.070.280.180.43   d      0.50   e   0.59   e   0.23   a   West Haven-Yale Multidimensional Pain Inventory; lower scores reflect better functioning   b   MOS 36-item Short-form Health Survey; higher scores reflect better functioning   c   P       0.05   d   P       0.01   e   P       0.001   Table 4 Comparison of study conditions Vulvar PainMean (SD)ControlsMean (SD)df FP  Pain Severity a 2.7 (1.2)— —— ——Physical DisabilityPhysical Function b 76.0 (26.0)91.7 (17.1)(1,126)17.00.001Physical Role Limit b 50.5 (47.7)92.9 (21.7)(1,127)45.80.001Emotional Role Limit b 41.5 (41.9)83.8 (33.2)(1,129)41.50.001Affective DistressNegative Mood a 3.3 (1.2)2.2 (1.2)(1,128)26.50.001Mental Health b 49.9 (20.5)42.0 (23.6)(1,128)4.00.048Vitality b 40.8 (20.8)48.1 (17.3)(1,124)4.50.036Marital Satisfaction104.2 (33.6)116.6 (23.7)(1,88)4.20.044 a West Haven-Yale Multidimensional Pain Inventory; lower scores reflect better functioning; scores range from 0 to 6 b MOS 36-item Short-form Health Survey; higher scores reflect better functioning; scores range from 0 to 100
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