今日の臨床サポート

性交痛

著者: 倉林工 新潟市民病院 産科・婦人科

監修: 小林裕明 鹿児島大学大学院医歯学総合研究科生殖病態生理学

著者校正/監修レビュー済:2020/11/25
参考ガイドライン:
  1. 日本産科婦人科学会/日本産婦人科医会:産婦人科診療ガイドライン婦人科外来編2020
  1. 日本産科婦人科学会日本女性医学学会:ホルモン補充療法ガイドライン2017年版
患者向け説明資料

概要・推奨   

  1. 性交痛は、女性の8~22%が生涯のいずれかの時点で経験する症状である。
  1. 性交痛は、婦人科領域で最も多くみられる疼痛の1つであり、その診断や治療には解剖学的、内分泌的、病理的、情緒的などのさまざまな因子の理解が必要である。
  1. 子宮内膜症の疼痛に対する治療方法としては、アンドロゲン製剤・GnRHアゴニスト・プロゲステロン製剤・低用量経口避妊薬などがあるが、広く使用されているのはGnRHアゴニストと低用量経口避妊薬である。
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
倉林工 : 未申告[2021年]
監修:小林裕明 : 講演料(中外製薬株式会社,アストラゼネカ株式会社),奨学(奨励)寄付など(中外製薬株式会社)[2021年]

改訂のポイント:
  1. 産婦人科診療ガイドライン婦人科外来編2020に基づき一部改訂し、病態にVVA、GSMという概念を追加した。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 周閉経期から閉経後の女性では、エストロゲンの低下に伴い腟・外陰の乾燥、痒み、灼熱感、性交痛などの不快症状の訴えが多くなり、ときに性交痛などの性機能障害や排尿の障害を伴う。局所の所見としては外陰腟萎縮(vulvovaginal atrophy: VVA)、全身的な症状症候群としては閉経関連泌尿生殖器症候群(genitourinary syndrome of menopause: GSM)という概念が提唱されている[1][2]
  1. 原因によらず反復的に起こる性交時の疼痛が性交疼痛症dyspareuniaであり、臨床的に性交痛として問題となる。
  1. 性交痛は、それ自体苦痛であるばかりか性欲障害や性的興奮の障害など他の女性性機能障害female sexual dysfunction(FSD)の誘因となる。
  1. 性交痛は婦人科領域でよくみられる主訴の1つであるが、慢性骨盤痛とともに評価・治療が困難な疾患の1つである。
  1. 性交痛は、他の女性性機能障害に比べて器質的疾患が原因のものが多いが心因性や混合性も少なくない。
  1. 性交痛は、女性の8~22%が生涯のいずれかの時点で経験する症状である。
  1. 我が国の更年期女性の調査では、性交痛は40歳代、50歳代女性の約半数に認められ、更年期症状に悩む女性にとって、性交痛が配偶者との性交の継続に影響を与えている。
  1. 更年期には、腟の機能低下による血流低下により分泌物の減少、コラーゲンの硝子化、エラスチンの崩壊、腟結合組織の増殖、腟内環境の中性化といった変化が生じ、腟の乾燥や感染が起こりやすくなり、その結果、不快感・かゆみ・性交痛などの腟症状が生じる。
  1. 女性の性的反応(性機能)の生理学的変化は血管系と筋肉系の変化ならびにそれらをつなぐ神経系の反応と説明され、興奮期、高原期、オルガズム期、消退期という4つのプロセスをたどる。すなわち、性的興奮は骨盤内の血流増加(充血)と骨盤底や四肢伸展筋などの緊張で示され、その結果、女性では外陰部や腟が発赤・腫脹し、腟潤滑液が流出する。また、骨盤底筋群、特に腟の周囲の筋が緊張、伸展すると腟入口部は拡張する。ピークに達した筋緊張を収束させるオルガズムは交感神経の反射である。その後、骨盤底筋群はリズミカルな収縮を反復しながら弛緩し、骨盤内の充血が消退する。この一連の反応に動脈硬化や骨盤内血栓症といった加齢変化・疾患が影響すると、腟潤滑液の分泌不全を起こしうる[3]
 
  1. 性交痛は、婦人科領域で最も多くみられる疼痛の1つであり、その診断や治療には解剖学的、内分泌的、病理的、情緒的などのさまざまな因子の理解が必要であるS/CS
  1. その治療結果は、性交にともなう快感や満足度が得られるかによって評価されるべきものである。
  1. まとめ:本論文は性交痛の評価、治療に関するreviewであり、その原因である器質的疾患から精神的因子によるものまでそれぞれについて解説をされている[4]
 
  1. 女性の性交障害はよくみられるものの、その定義についてははっきりしていない。そのため国際的なコンセンサスカンファレンスが行われ、性交痛についてもその1つの項目として分類された(G)
  1. まとめ:性交障害の定義や分類に関する国際的コンセンサスの構築のために開かれ、1999年に行われた多分野にまたがるカンファレンスの報告である[5]。5つの国から19人のエキスパートにより、性的欲求、興奮、オルガスムス、性交疼痛障害について精神的や器質的原因について分類を行った。性交疼痛障害は、性交痛、ワギニスムス、その他の性交を伴わない疼痛に分けられ、更にABCのサブタイプに分類された。
  1. A: lifelong vs. acquired type
  1. B: generalized vs. situational type
  1. C: etiologic orgin
 
  1. 腹腔鏡で明らかな異常を認めない慢性骨盤痛の患者であっても、病理学的異常を認めることは多く、その切除によって性交痛も軽快する(O)
  1. まとめ:腹腔鏡で明らかな異常を認めない慢性骨盤痛の患者に対し、仙骨子宮靱帯の切除を行いその病理学的異常をみた論文である[6]。その結果7.4%に子宮内膜症、11.1%に卵管炎、51.9%に炎症を認めた。また術後に月経困難、性交痛、非周期的疼痛のすべての慢性骨盤痛が有意に軽快した。
  1. 結論:腹腔鏡で明らかな異常を認めない慢性骨盤痛の患者であっても、病理学的異常を認めることは多く、その切除によって性交痛も軽快する。
 
  1. 性交痛のリスクファクターとしては、閉経、骨盤炎症性疾患の既往、性的虐待、不安、うつが挙げられるS/CS
  1. まとめ:骨盤痛のリスクファクターに関するmeta-analysisの論文で、その1つである性交痛についても検討がなされている論文である[7]。性交痛のリスクファクターについては、19の研究で18,601人に対し14の因子に関しての検討がなされている。
  1. 結論:閉経、骨盤炎症性疾患の既往、性的虐待、不安、うつが有意なリスクファクターとして挙げられている。日本ではほとんどみられないが、割礼は有意ではないもののその可能性がある。
 
  1. 性交痛は、女性の8~22%が生涯のいずれかの時点で経験する症状であるS/CS
  1. まとめ:月経困難症、性交痛、非周期性疼痛の3つの慢性骨盤痛について、全世界的にどれくらいの女性が罹患しているかを調査したWHOのreviewである[8]。合計178の研究がメタアナリシスに用いられ、月経困難症は106編(対象者数:124259人)、性交痛は54編(対象者数:35973人)、非周期性疼痛は18編(対象者数:301756人)が質の高い論文として挙げられた。
  1. 結論:月経困難症は16.8~81%に、性交痛は8~21.8%に、非周期性疼痛は2.1~24%の女性が罹患していることが判明した。
 
  1. 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―(O)
  1. まとめ:女性専用外来を受診する更年期女性の調査[9]によると、性生活がなくなった理由として最も多かったのは性交痛であった。また性交痛は40歳代、50歳代の約半数に認められており、更年期症状に悩む女性にとって、性交痛が配偶者との性交の継続に影響を与えていることがうかがえる。
 
  1. 更年期の性交痛の機序(O)(参考文献:[10]
  1. まとめ:更年期には、腟の機能低下による血流低下により分泌物の減少、コラーゲンの硝子化、エラスチンの崩壊、腟結合組織の増殖、腟内環境の中性化といった変化が生じ、腟の乾燥や感染が起こりやすくなり、その結果、不快感・かゆみ・性交痛などの腟症状が生じる。
問診・診察のポイント  
 
  1. 性交痛については、多くの女性が医師などに話しづらいと感じており、十分な問診・相談ができるような環境整備が必要である。特にワギニスムス(腟痙)など心因性に由来する疾患の場合には重要である。

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文献 

著者: D J Portman, M L S Gass, Vulvovaginal Atrophy Terminology Consensus Conference Panel
雑誌名: 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.
PMID 25179577  Maturitas. 2014 Nov;79(3):349-54. doi: 10.1016/j.maturi・・・
著者: John F Steege, Denniz A Zolnoun
雑誌名: Obstet Gynecol. 2009 May;113(5):1124-36. 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.

PMID 19384129  Obstet Gynecol. 2009 May;113(5):1124-36. doi: 10.1097/A・・・
著者: R Basson, J Berman, A Burnett, L Derogatis, D Ferguson, J Fourcroy, I Goldstein, A Graziottin, J Heiman, E Laan, S Leiblum, H Padma-Nathan, R Rosen, K Segraves, R T Segraves, R Shabsigh, M Sipski, G Wagner, B Whipple
雑誌名: 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.

PMID 10688001  J Urol. 2000 Mar;163(3):888-93.
著者: Patricia C Nascu, George A Vilos, Hellen C Ettler, Basim Abu-Rafea, Jackie Hollet-Caines, Riad Ahmad
雑誌名: 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
PMID 16698525  J Minim Invasive Gynecol. 2006 May-Jun;13(3):201-4. doi・・・
著者: Pallavi Latthe, Luciano Mignini, Richard Gray, Robert Hills, Khalid Khan
雑誌名: 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.

PMID 16484239  BMJ. 2006 Apr 1;332(7544):749-55. doi: 10.1136/bmj.3874・・・
著者: Pallavi Latthe, Manish Latthe, Lale Say, Metin Gülmezoglu, Khalid S Khan
雑誌名: 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.

PMID 16824213  BMC Public Health. 2006 Jul 6;6:177. doi: 10.1186/1471-・・・
著者: J Suckling, A Lethaby, R Kennedy
雑誌名: 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.

PMID 17054136  Cochrane Database Syst Rev. 2006 Oct 18;(4):CD001500. d・・・
著者: Willibrord Weijmar Schultz, Rosemary Basson, Yitzchak Binik, David Eschenbach, Ursula Wesselmann, Jacques Van Lankveld
雑誌名: 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.

PMID 16422861  J Sex Med. 2005 May;2(3):301-16. doi: 10.1111/j.1743-61・・・
著者: Linda C Giudice, Lee C Kao
雑誌名: Lancet. 2004 Nov 13-19;364(9447):1789-99. doi: 10.1016/S0140-6736(04)17403-5.
Abstract/Text Endometriosis is an oestrogen-dependent disorder that can result in substantial morbidity, including pelvic pain, multiple operations, and infertility. New findings on the genetics, the possible roles of the environment and the immune system, and intrinsic abnormalities in the endometrium of affected women and secreted products of endometriotic lesions have given insight into the pathogenesis of this disorder and serve as the background for new treatments for disease-associated pain and infertility. Affected women are at higher risk than the general female population of developing ovarian cancer, and they also may be at increased risk of breast and other cancers as well as autoimmune and atopic disorders. Clinicians should assess and follow up affected women for these and other associated disorders. There will probably be a new repertoire of approaches for treatment and perhaps cure of this enigmatic disorder in the near future.

PMID 15541453  Lancet. 2004 Nov 13-19;364(9447):1789-99. doi: 10.1016/・・・
著者: S Ferrero, L H Abbamonte, M Giordano, N Ragni, V Remorgida
雑誌名: 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.

PMID 17182665  Hum Reprod. 2007 Apr;22(4):1142-8. doi: 10.1093/humrep/・・・
著者: Tommaso Cai, Nicola Mondaini, Serena Migno, Francesca Meacci, Vieri Boddi, Paolo Gontero, Gianni Malossini, Pierangelo Geppetti, Sandra Mazzoli, Riccardo Bartoletti
雑誌名: 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.
PMID 21269400  J Sex Med. 2011 Apr;8(4):1131-7. doi: 10.1111/j.1743-61・・・
著者: H McGuire, K Hawton
雑誌名: 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.

PMID 12535412  Cochrane Database Syst Rev. 2003;(1):CD001760. doi: 10.・・・

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