日本産科婦人科学会/日本産婦人科医会編：産婦人科診療ガイドライン 婦人科外来編2023. p210-211, p234-235. 2023.
Portman DJ, Gass ML; Vulvovaginal Atrophy Terminology Consensus Conference Panel.
Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society.
Maturitas. 2014 Nov;79(3):349-54. doi: 10.1016/j.maturitas.2014.07.013. Epub 2014 Aug 19.
Abstract/Text
BACKGROUND: In 2012, the Board of Directors of the International Society for the Study of Women's Sexual Health (ISSWSH) and the Board of Trustees of The North American Menopause Society (NAMS) acknowledged the need to review current terminology associated with genitourinary tract symptoms related to menopause.
METHODS: The 2 societies cosponsored a terminology consensus conference, which was held in May 2013.
RESULTS AND CONCLUSION: Members of the consensus conference agreed that the term genitourinary syndrome of menopause (GSM) is a medically more accurate, all-encompassing, and publicly acceptable term than vulvovaginal atrophy. GSM is defined as a collection of symptoms and signs associated with a decrease in estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra and bladder. The syndrome may include but is not limited to genital symptoms of dryness, burning, and irritation; sexual symptoms of lack of lubrication, discomfort or pain, and impaired function; and urinary symptoms of urgency, dysuria and recurrent urinary tract infections. Women may present with some or all of the signs and symptoms, which must be bothersome and should not be better accounted for by another diagnosis. The term was presented and discussed at the annual meeting of each society. The respective Boards of NAMS and ISSWSH formally endorsed the new terminology--genitourinary syndrome of menopause (GSM)--in 2014.
Copyright © 2014 D.J. Portman. Published by Elsevier Ireland Ltd.. All rights reserved.
日本産科婦人科学会・日本女性医学学会編：ホルモン補充療法ガイドライン 2017年度版. p103-104, p131-132. 2017.
Steege JF, Zolnoun DA.
Evaluation and treatment of dyspareunia.
Obstet Gynecol. 2009 May;113(5):1124-1136. doi: 10.1097/AOG.0b013e3181a1ba2a.
Abstract/Text
Dyspareunia affects 8-22% of women at some point during their lives, making it one of the most common pain problems in gynecologic practice. A mixture of anatomic, endocrine, pathologic, and emotional factors combine to challenge the diagnostic, therapeutic, and empathetic skills of the physician. New understandings of pain in general require new interpretations concerning the origins of pain during intercourse, but also provide new avenues of treatment. The outcomes of medical and surgical treatments for common gynecologic problems should routinely go beyond measures of coital possibility, to include assessment of coital comfort, pleasure, and facilitation of intimacy. This review will discuss aspects of dyspareunia, including anatomy and neurophysiology, sexual physiology, functional changes, pain in response to disease states, and pain after gynecologic surgical procedures.
Basson R, Berman J, Burnett A, Derogatis L, Ferguson D, Fourcroy J, Goldstein I, Graziottin A, Heiman J, Laan E, Leiblum S, Padma-Nathan H, Rosen R, Segraves K, Segraves RT, Shabsigh R, Sipski M, Wagner G, Whipple B.
Report of the international consensus development conference on female sexual dysfunction: definitions and classifications.
J Urol. 2000 Mar;163(3):888-93.
Abstract/Text
PURPOSE: Female sexual dysfunction is highly prevalent but not well defined or understood. We evaluated and revised existing definitions and classifications of female sexual dysfunction.
MATERIALS AND METHODS: An interdisciplinary consensus conference panel consisting of 19 experts in female sexual dysfunction selected from 5 countries was convened by the Sexual Function Health Council of the American Foundation for Urologic Disease. A modified Delphi method was used to develop consensus definitions and classifications, and build on the existing framework of the International Classification of Diseases-10 and DSM-IV: Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, which were limited to consideration of psychiatric disorders.
RESULTS: Classifications were expanded to include psychogenic and organic causes of desire, arousal, orgasm and sexual pain disorders. An essential element of the new diagnostic system is the "personal distress" criterion. In particular, new definitions of sexual arousal and hypoactive sexual desire disorders were developed, and a new category of noncoital sexual pain disorder was added. In addition, a new subtyping system for clinical diagnosis was devised. Guidelines for clinical end points and outcomes were proposed, and important research goals and priorities were identified.
CONCLUSIONS: We recommend use of the new female sexual dysfunction diagnostic and classification system based on physiological as well as psychological pathophysiologies, and a personal distress criterion for most diagnostic categories.
Nascu PC, Vilos GA, Ettler HC, Abu-Rafea B, Hollet-Caines J, Ahmad R.
Histopathologic findings on uterosacral ligaments in women with chronic pelvic pain and visually normal pelvis at laparoscopy.
J Minim Invasive Gynecol. 2006 May-Jun;13(3):201-4. doi: 10.1016/j.jmig.2006.02.002.
Abstract/Text
STUDY OBJECTIVE: To determine the prevalence and type of microscopic findings on laparoscopically resected uterosacral ligaments in women with chronic pelvic pain and no visible pelvic disease. The effect of this procedure on the patients' level of pain also was assessed as a secondary objective.
DESIGN: Prospective follow-up (Canadian Task Force classification II-2).
SETTING: University-affiliated hospital.
PATIENTS: Twenty-seven premenopausal women undergoing diagnostic laparoscopy for chronic pelvic pain had a normal pelvis on visual inspection. All patients underwent resection and histologic evaluation of the uterosacral ligaments. Pain relief was evaluated by use of a questionnaire administered before and at 3, 6, and 12 months after surgery.
MEASUREMENTS AND MAIN RESULTS: Microscopic examination identified endometriosis in 2 (7.4%), endosalpingiosis in 3 (11.1%), and inflammation in 14 (51.9%) patients. Laparoscopic uterosacral ligament resection was associated with a reduction in dysmenorrhea (p < or = .001), with 14 (52%) patients reporting improved or resolved symptoms. There was a statistically significant decrease in dyspareunia (p < or = .01) and in the severity of noncyclical pain (p < or = .002). Thirty-five percent of patients no longer required medication for pain control (p < or = .005). The number of days needed off work also decreased.
CONCLUSION: Despite normal laparoscopic appearance, microscopic endometriosis, endosalpingiosis, and inflammatory changes were found in uterosacral ligaments in 17 (63%) women with chronic pelvic pain. Laparoscopic resection of uterosacral ligaments improved dysmenorrhea, dyspareunia, and noncyclical pain and decreased the number of days lost from work, as well as the proportion of patients who required medication for pain control.
Copyright 2006 AAGL
Latthe P, Mignini L, Gray R, Hills R, Khan K.
Factors predisposing women to chronic pelvic pain: systematic review.
BMJ. 2006 Apr 1;332(7544):749-55. doi: 10.1136/bmj.38748.697465.55. Epub 2006 Feb 16.
Abstract/Text
OBJECTIVE: To evaluate factors predisposing women to chronic and recurrent pelvic pain. DESIGN, DATA SOURCES, AND METHODS: Systematic review of relevant studies without language restrictions identified through Medline, Embase, PsycINFO, Cochrane Library. SCISEARCH, conference papers, and bibliographies of retrieved primary and review articles. Two reviewers independently extracted data on study characteristics, quality, and results. Exposure to risk factors was compared between women with and without pelvic pain. Results were pooled within subgroups defined by type of pain and risk factors.
RESULTS: There were 122 studies (in 111 articles) of which 63 (in 64,286 women) evaluated 54 risk factors for dysmenorrhoea, 19 (in 18,601 women) evaluated 14 risk factors for dyspareunia, and 40 (in 12,040 women) evaluated 48 factors for non-cyclical pelvic pain. Age < 30 years, low body mass index, smoking, earlier menarche (< 12 years), longer cycles, heavy menstrual flow, nulliparity, premenstrual syndrome, sterilisation, clinically suspected pelvic inflammatory disease, sexual abuse, and psychological symptoms were associated with dysmenorrhoea. Younger age at first childbirth, exercise, and oral contraceptives were negatively associated with dysmenorrhoea. Menopause, pelvic inflammatory disease, sexual abuse, anxiety, and depression were associated with dyspareunia. Drug or alcohol abuse, miscarriage, heavy menstrual flow, pelvic inflammatory disease, previous caesarean section, pelvic pathology, abuse, and psychological comorbidity were associated with an increased risk of non-cyclical pelvic pain.
CONCLUSION: Several gynaecological and psychosocial factors are strongly associated with chronic pelvic pain. Randomised controlled trials of interventions targeting these potentially modifiable factors are needed to assess their clinical relevance in chronic pelvic pain.
Latthe P, Latthe M, Say L, Gülmezoglu M, Khan KS.
WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity.
BMC Public Health. 2006 Jul 6;6:177. doi: 10.1186/1471-2458-6-177. Epub 2006 Jul 6.
Abstract/Text
BACKGROUND: Health care planning for chronic pelvic pain (CPP), an important cause of morbidity amongst women is hampered due to lack of clear collated summaries of its basic epidemiological data. We systematically reviewed worldwide literature on the prevalence of different types of CPP to assess the geographical distribution of data, and to explore sources of variation in its estimates.
METHODS: We identified data available from Medline (1966 to 2004), Embase (1980 to 2004), PsycINFO (1887 to 2003), LILACS (1982 to 2004), Science Citation index, CINAHL (January 1980 to 2004) and hand searching of reference lists. Two reviewers extracted data independently, using a piloted form, on participants' characteristics, study quality and rates of CPP. We considered a study to be of high quality (valid) if had at least three of the following features: prospective design, validated measurement tool, adequate sampling method, sample size estimation and response rate >80%. We performed both univariate and multivariate meta-regression analysis to explore heterogeneity of results across studies.
RESULTS: There were 178 studies (459975 participants) in 148 articles. Of these, 106 studies were (124259 participants) on dysmenorrhoea, 54 (35973 participants) on dyspareunia and 18 (301756 participants) on noncyclical pain. There were only 19/95 (20%) less developed and 1/45 (2.2%) least developed countries with relevant data in contrast to 22/43 (51.2%) developed countries. Meta-regression analysis showed that rates of pain varied according to study quality features. There were 40 (22.5%) high quality studies with representative samples. Amongst them, the rate of dysmenorrhoea was 16.8 to 81%, that of dyspareunia was 8 to 21.8%, and that for noncyclical pain was 2.1 to 24%.
CONCLUSION: There were few valid population based estimates of disease burden due to CPP from less developed countries. The variation in rates of CPP worldwide was due to variable study quality. Where valid data were available, a high disease burden of all types of pelvic pain was found.
河端恵美子：更年期女性の性生活の現状と問題点‐女性外来の調査から‐．日本更年期医学会雑誌2005;13:111-120.
日本女性医学学会編：女性医学ガイドブック 更年期医療編 2019年度版 第2版. 金原出版. 2019. p148-153.
Suckling J, Lethaby A, Kennedy R.
Local oestrogen for vaginal atrophy in postmenopausal women.
Cochrane Database Syst Rev. 2006 Oct 18;(4):CD001500. doi: 10.1002/14651858.CD001500.pub2. Epub 2006 Oct 18.
Abstract/Text
BACKGROUND: Vaginal atrophy is a frequent complaint of postmenopausal women; symptoms include vaginal dryness, itching, discomfort and painful intercourse. Systemic treatment for these symptoms in the form of oral hormone replacement therapy is not always necessary. An alternative choice is oestrogenic preparations administered vaginally (in the form of creams, pessaries, tablets and the oestradiol-releasing ring).
OBJECTIVES: The objective of this review was to compare the effectiveness, safety and acceptability of oestrogenic preparations for women who suffer from vaginal atrophy.
SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group Register of trials (searched January 2006), The Cochrane Library (2006,Issue 2), MEDLINE (1966 to January 2006), EMBASE (1980 to January 2006), Current Contents (1993 to January 2006, Biological Abstracts (1969 to 2006), Social Sciences Index (1980 to January 2006), PsycINFO (1972 to February 2006), CINAHL (1982 to January 2006) and reference list of articles. We also contacted manufacturers and researchers in the field.
SELECTION CRITERIA: The inclusion criteria were randomised comparisons of oestrogenic preparations administered intravaginally in postmenopausal women for the treatment of symptoms resulting from vaginal atrophy or vaginitis.
DATA COLLECTION AND ANALYSIS: Thirty-seven trials were identified: of these 18 were excluded. Included trials were assessed for quality and two reviewer authors extracted data independently. The ratios for dichotomous outcomes and means for continuous outcomes were calculated. The outcomes analysed were categorised under the headings of: efficacy, safety and acceptability.
MAIN RESULTS: Nineteen trials with 4162 women were included in this review. The overall quality of the studies was good, although not all trials measured the same outcomes. All trials measured efficacy, with various outcome measures. When comparing the efficacy of different oestrogenic preparations (in the form of creams, pessaries, tablets and the oestradiol-releasing vaginal ring) in relieving the symptoms of vaginal atrophy, results indicated significant findings favouring the cream, ring, and tablets when compared to placebo and non-hormonal gel. Fourteen trials compared safety. Four looked at hyperplasia, four looked at endometrial overstimulation and seven looked at adverse effects. One trial showed significant adverse effects of the cream (conjugated equine oestrogen) when compared to tablets (oestradiol) which included uterine bleeding, breast pain and perineal pain (1 RCT; OR 0.18, 95% CI 0.07 to 0.50). Two trials showed significant endometrial overstimulation as evaluated by a progestagen challenge test with the cream (conjugated equine oestrogen) group when compared to the ring (OR 0.29, 95% CI 0.11 to 0.78). Although not statistically significant there was a 2% incidence of simple hyperplasia in the ring group when compared to the cream (conjugated equine oestrogen) and 4% incidence of hyperplasia (one simple, one complex) in the cream group (conjugated equine oestrogen) when compared to the tablet (oestradiol). Eleven studies compared acceptability to the participants by comparing: comfort of product use, ease of use, overall product rating, delivery system and satisfaction. Results showed a significant preference for the oestradiol-releasing vaginal ring.
AUTHORS' CONCLUSIONS: Creams, pessaries, tablets and the oestradiol vaginal ring appeared to be equally effective for the symptoms of vaginal atrophy. One trial found significant side effects following cream (conjugated equine oestrogen) administration when compared to tablets causing uterine bleeding, breast pain and perineal pain. Another trial found significant endometrial overstimulation following use of the cream (conjugated equine oestrogen) when compared to the ring. As a treatment choice women appeared to favour the oestradiol-releasing vaginal ring for ease of use, comfort of product and overall satisfaction.
Weijmar Schultz W, Basson R, Binik Y, Eschenbach D, Wesselmann U, Van Lankveld J.
Women's sexual pain and its management.
J Sex Med. 2005 May;2(3):301-16. doi: 10.1111/j.1743-6109.2005.20347.x.
Abstract/Text
INTRODUCTION: Approximately 15% of women have chronic dyspareunia that is poorly understood, infrequently cured, often highly problematic, and distressing. Chronic dyspareunia is an urgent health issue.
AIM: To provide recommendations/guidelines concerning state-of-the-art knowledge for the assessment and management of women's sexual pain disorders.
METHODS: An international consultation, in collaboration with the major sexual medicine associations, assembled over 200 multidisciplinary experts from 60 countries into 17 committees. One six-member committee focused on women's sexual pain disorders, developing recommendations over a 2-year period.
MAIN OUTCOME MEASURE: Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.
RESULTS: There is increasing evidence for the role of neuropathic pain mechanisms in the pathophysiology of sexual pain disorders. Empirical literature has demonstrated the comorbid presence of clinical psychopathology. With regard to the pathophysiologic role of the pelvic floor and sexual pain disorders, studies reveal that (i) differentiation between vaginismus and dyspareunia using clinical tools is difficult; (ii) vaginal spasms have not been identified; (iii) physical therapists can differentiate vaginismic women from matched controls based on muscle tone/strength differences; (iv) the traditional treatment of vaginismus with vaginal "dilatation" plus psycho-education, desensitization, and so forth is not evidence-based; (v) pelvic floor muscle tone/strength measures for women suffering from vulvar vestibulitis syndrome are intermediate between those of women with vaginismus and no-pain controls; and (vi) the pelvic floor musculature is indirectly innervated by the limbic system and highly reactive to emotional stimuli and states. Pelvic floor therapies for dyspareunia may be effective.
CONCLUSION: Recommendations include (i) revising the definitions of vaginismus and dyspareunia; (ii) integration of treatment approaches; (iii) validation of nonspecific treatment effects; (iv) controlled studies to test interventions; and (v) sexuality education to help prevent sexual pain.
日本産科婦人科学会/日本産婦人科医会編：産婦人科診療ガイドライン 婦人科外来編 2023. p86-87. 2023.
Ferrero S, Abbamonte LH, Giordano M, Ragni N, Remorgida V.
Deep dyspareunia and sex life after laparoscopic excision of endometriosis.
Hum Reprod. 2007 Apr;22(4):1142-8. doi: 10.1093/humrep/del465. Epub 2006 Dec 20.
Abstract/Text
BACKGROUND: Among subjects with endometriosis and deep dyspareunia (DD), those with endometriosis of the uterosacral ligament (USLE) have the most severe impairment of sexual function. This study examines the effect of laparoscopic excision of endometriosis on DD and quality of sex life.
METHODS: This observational cohort prospective study included 68 women with endometriosis suffering DD (intensity of pain >or= 6 on a 10-cm visual analogue scale). Patients underwent laparoscopic full excision of endometriosis. Following surgery, they were asked to use nonhormonal contraception devices. Before surgery, at 6- and at 12-month follow-up, patients answered a self-administered questionnaire based on the Sexual Satisfaction Subscale of the Derogatis Sexual Functioning Inventory.
RESULTS: At 6- and 12-month follow-up, women with and without USLE had significant improvement in DD. Subjects with USLE reported increased variety in sex life, increased frequency of intercourse, more satisfying orgasms with sex, relaxing more easily during sex and being more relaxed and fulfilled after sex. Similar improvements were observed among women without USLE; however, for some variables statistical significance was not reached.
CONCLUSIONS: Surgical excision of endometriosis improves not only DD but also the quality of sex life.
Cai T, Mondaini N, Migno S, Meacci F, Boddi V, Gontero P, Malossini G, Geppetti P, Mazzoli S, Bartoletti R.
Genital Chlamydia trachomatis infection is related to poor sexual quality of life in young sexually active women.
J Sex Med. 2011 Apr;8(4):1131-7. doi: 10.1111/j.1743-6109.2010.02194.x. Epub 2011 Jan 26.
Abstract/Text
INTRODUCTION: Chlamydia trachomatis (Ct) genital infection has been related to several diseases in young sexually active women. It could be related to their sexual quality of life.
AIM: To assess whether genital Ct infection can induce sexual function alterations in women.
METHODS: Nine hundred ninety-eight women (mean age 29.4, range 18-43) attending our Sexually Transmitted Disease Centre were enrolled in this observational case-control study. All participants were clinically and microbiologically investigated due to their sexual relationships with a subject affected by chronic bacterial prostatitis. All participants underwent microbiological cultures, DNA and antibodies evaluation for common bacteria and Ct on vaginal swab and urine samples. They completed the Female Sexual Function Index [FSFI] questionnaire. On the basis of microbiological investigation results, all patients were split into three groups: Group A-genital Ct infection, Group B-genital common bacteria/yeast infection, and Group C-negative for Ct and bacteria/yeast infection.
MAIN OUTCOME MEASURES: FSFI questionnaire.
RESULTS: Two hundred ninety-one women were classified in Group A, 276 in Group B, and 431 in Group C. Group A patients were statistically, significantly different from Group B and Group C patients in terms of pain during sexual intercourse and sexual satisfaction. Group C patients had significantly higher FSFI scores (27.1 ± 1.3) (P < 0.001) for both desire (4.9 ± 1.0) and lubrication domain (3.8 ± 1.1) (P < 0.001, P < 0.003, respectively) when compared with Group A patients. Multivariate analysis demonstrated that negative Ct infection marker in female patients must be considered as an independent prognostic factor in predicting a subsequent optimal FSFI questionnaire score (P = 0.002).
CONCLUSIONS: Positive values of Ct infection markers are associated with lower FSFI scores for sexual desire, lubrication, and overall sexual function. Genital Ct infection could induce pain during sexual intercourse, reducing sexual satisfaction and sexual quality of life in young sexually active women.
© 2011 International Society for Sexual Medicine.
McGuire H, Hawton K.
Interventions for vaginismus.
Cochrane Database Syst Rev. 2003;(1):CD001760. doi: 10.1002/14651858.CD001760.
Abstract/Text
BACKGROUND: Vaginismus is involuntary vaginal muscle contraction which makes sexual intercourse difficult or impossible. It is one of the more common female psychosexual problems. Various therapeutic strategies for vaginismus, such as sex therapy and desensitization, have been considered in uncontrolled studies.
OBJECTIVES: The aim of this review is to determine the clinical effectiveness of treatments for vaginismus and also to examine the role of partner participation in the effectiveness of the treatment.
SEARCH STRATEGY: The Cochrane Collaboration Depression, Anxiety & Neurosis Controlled Trials Register (Issue 3, 2000), the Cochrane Controlled Trials Register (Cochrane Library, Issue 2, 2002), MEDLINE (1966 to Nov 2002), EMBASE (1980 to Nov 2002), PsycINFO (1967 to Nov 2002) and CINAHL (1982 to Nov 2002) were searched. The Journal of Sex Research (1974 to 1999), Sexual & Marital Therapy (1986 to 1999), Sexual Dysfunction (1998 to 1999) and the Journal of Sex and Marital Therapy (1974 to 1999) were handsearched. Reference lists and conference abstracts were searched. Experts in the field were contacted regarding unpublished material.
SELECTION CRITERIA: Controlled trials comparing treatments for vaginismus with another treatment, a placebo treatment, treatment as usual or waiting list control.
DATA COLLECTION AND ANALYSIS: The reviewers extracted data which were verified with the trial investigator.
MAIN RESULTS: Two controlled trials were identified although data were only available from one trial. The second trial compared two forms of systematic desensitization and reported no discernible differences between them.
REVIEWER'S CONCLUSIONS: In spite of encouraging results reported from uncontrolled series of patients there is very limited evidence from controlled trials concerning the effectiveness treatments for vaginismus. Further trials are need to compare therapies with waiting list control and with other therapies.
