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Female infertility is a multifaceted issue that can arise from various underlying causes. The primary categories of female infertility include ovulatory disorders, tubal factors, endometriosis, and other medical conditions. Each of these categories encompasses specific conditions that can significantly impact a woman's ability to conceive.
Category | Description | Examples |
---|---|---|
Ovulatory Disorders | Conditions affecting the release of eggs from the ovaries, responsible for ~25-40% of infertility cases. |
- Polycystic Ovary Syndrome (PCOS) - Hypothalamic Dysfunction (due to stress, weight changes, etc.) - Premature Ovarian Insufficiency (POI) - Hyperprolactinemia (high prolactin levels) |
Tubal Factors | Blockage or damage to the fallopian tubes, preventing sperm and egg from meeting, accounts for ~15-20% of cases. |
- Pelvic Inflammatory Disease (PID) - Previous surgeries causing adhesions - Congenital tubal abnormalities |
Endometriosis | Growth of endometrial-like tissue outside the uterus, causing inflammation, adhesions, and anatomical distortions. |
- Pelvic adhesions - Tubal blockages - Ovulatory dysfunction due to endometrial lesions |
Uterine and Cervical Factors | Issues with the structure or function of the uterus or cervix that interfere with sperm passage or implantation. |
- Uterine fibroids - Congenital uterine anomalies (e.g., septate or bicornuate uterus) - Cervical stenosis - Poor cervical mucus quality |
Other Medical and Endocrine Conditions | Systemic conditions that disrupt reproductive hormones and cycles. |
- Thyroid disorders (e.g., hypothyroidism, hyperthyroidism) - Diabetes - Autoimmune disorders (e.g., lupus) |
Genetic or Chromosomal Abnormalities | Certain genetic conditions that impact egg production, hormone levels, or reproductive anatomy. |
- Turner Syndrome (45,X) - Fragile X Premutation - Kallmann Syndrome (a rare genetic condition causing hypothalamic dysfunction) |
Unexplained Infertility | Cases where no clear cause is identified after thorough evaluation, ~10-20% of infertility cases. | - May involve subtle issues such as mild hormonal imbalances or immune factors |
Lifestyle and Environmental Factors | External factors affecting fertility, often related to overall health and lifestyle. |
- Age (fertility declines after age 35) - Weight (significantly underweight or overweight) - Substance use (e.g., smoking, alcohol) - Exposure to environmental toxins |
Ovulatory disorders account for approximately 25% of infertility cases, with conditions such as Polycystic Ovary Syndrome (PCOS) being prevalent . Tubal factors, often resulting from pelvic inflammatory disease or previous surgeries, can also significantly impact fertility . Understanding these causes allows clinicians to tailor their approach to each patient effectively.
Thorough Evaluation is Key: A comprehensive assessment, including medical history, physical examination, and diagnostic tests, is essential for identifying the underlying causes of infertility. Hormonal assessments and imaging studies are critical components of this process.
Targeted Management Based on Cause: Management should be tailored to the specific diagnosis. Ovulatory disorders may benefit from lifestyle changes and medications, while tubal factor infertility may require surgical intervention or assisted reproductive technologies (ART).
Importance of Specialist Referral: Timely referral to a fertility specialist or reproductive endocrinologist is essential, especially for cases requiring advanced interventions. Collaboration with specialists ensures patients receive the most appropriate care for complex infertility issues.
Evidence-Based Approach: Staying updated on the latest evidence-based guidelines enables primary care clinicians to provide optimal initial care and recognize when specialist input is necessary.
1. **Abebe, M., Afework, M., & Abaynew, Y.** (2020). Primary and secondary infertility in Africa: systematic review with meta-analysis. *Fertility Research and Practice, 6*(1). [https://doi.org/10.1186/s40738-020-00090-3](https://doi.org/10.1186/s40738-020-00090-3)
2. **Abrão, M., Muzii, L., & Marana, R.** (2013). Anatomical causes of female infertility and their management. *International Journal of Gynecology & Obstetrics, 123*(S2). [https://doi.org/10.1016/j.ijgo.2013.09.008](https://doi.org/10.1016/j.ijgo.2013.09.008)
3. **Boltz, M., Sanders, J., Simonsen, S., & Stanford, J.** (2017). Fertility treatment, use of in vitro fertilization, and time to live birth based on initial provider type. *The Journal of the American Board of Family Medicine, 30*(2), 230-238. [https://doi.org/10.3122/jabfm.2017.02.160184](https://doi.org/10.3122/jabfm.2017.02.160184)
4. **Dhananjaya, S., Madhu, K., & Amiti, A.** (2014). Role of diagnostic hysterolaparoscopy in evaluation of primary and secondary infertility. *Journal of Evolution of Medical and Dental Sciences, 3*(9), 2194-2207. [https://doi.org/10.14260/jemds/2014/2126](https://doi.org/10.14260/jemds/2014/2126)
5. **Hinton, L., Kurinczuk, J., & Ziebland, S.** (2012). Reassured or fobbed off? Perspectives on infertility consultations in primary care: a qualitative study. *British Journal of General Practice, 62*(599), e438-e445. [https://doi.org/10.3399/bjgp12x649133](https://doi.org/10.3399/bjgp12x649133)
6. **Kabadi, Y., & Harsha, B.** (2016). Hysterolaparoscopy in the evaluation and management of female infertility. *The Journal of Obstetrics and Gynecology of India, 66*(S1), 478-481. [https://doi.org/10.1007/s13224-016-0863-5](https://doi.org/10.1007/s13224-016-0863-5)
7. **Khanuja, P., Sunny, J., & Pawar, S.** (2017). Study on infertility—etiology, medication therapy management, and outcomes at a tertiary care hospital. *International Journal of Infertility & Fetal Medicine, 8*(3), 106-112. [https://doi.org/10.5005/jp-journals-10016-1158](https://doi.org/10.5005/jp-journals-10016-1158)
8. **Madhuri, N., Rashmi, H., Sujatha, M., & Dhanyata, G.** (2019). Role of diagnostic hysterolaparoscopy in the evaluation of female infertility. *International Journal of Research in Medical Sciences, 7*(5), 1531. [https://doi.org/10.18203/2320-6012.ijrms20191630](https://doi.org/10.18203/2320-6012.ijrms20191630)
9. **Nida, .., Qureshi, M., Usman, H., Akram, A., Khan, S., Jawad, N., … & Bhutta, M.** (2022). A cross-sectional study on serum follicle stimulating hormone and luteinizing hormone in patients with anovulatory disorders with primary infertility. *PJMHS, 16*(12), 490-492. [https://doi.org/10.53350/pjmhs20221612490](https://doi.org/10.53350/pjmhs20221612490)
10. **Nour-Eldein, H.** (2013). Family physicians’ attitude and practice of infertility management at primary care - Suez Canal University, Egypt. *Pan African Medical Journal, 15*. [https://doi.org/10.11604/pamj.2013.15.106.1762](https://doi.org/10.11604/pamj.2013.15.106.1762)
11. **Palmer-Wackerly, A., Voorhees, H., D'Souza, S., & Weeks, E.** (2019). Infertility patient-provider communication and (dis)continuity of care: an exploration of illness identity transitions. *Patient Education and Counseling, 102*(4), 804-809. [https://doi.org/10.1016/j.pec.2018.12.003](https://doi.org/10.1016/j.pec.2018.12.003)
12. **Stanford, J., Carpentier, P., Meier, B., Rollo, M., & Tingey, B.** (2021). Restorative reproductive medicine for infertility in two family medicine clinics in New England, an observational study. *BMC Pregnancy and Childbirth, 21*(1). [https://doi.org/10.1186/s12884-021-03946-8](https://doi.org/10.1186/s12884-021-03946-8)
13. **Verma, K., & Baniya, G.** (2016). A comparative study of depression among infertile and fertile women. *International Journal of Research in Medical Sciences*, 3459-3465. [https://doi.org/10.18203/2320-6012.ijrms20162312](https://doi.org/10.18203/2320-6012.ijrms20162312)
Starting in September 2024, significant reforms to death certification laws in the UK will enhance the accuracy, quality, and scrutiny of mortality data. These updates aim to streamline the certification process while ensuring that key details about the cause of death are carefully reviewed and documented.
One of the central changes includes the addition of medical examiners who will independently review each Medical Certificate of Cause of Death (MCCD), adding a level of verification to support attending practitioners and improve public health insights. The new MCCD format now has more detailed sections to record the chain of events leading to death and includes specific fields for information on ethnicity, maternal status, and any medical devices or implants.
These updates will impact clinical practice by improving the precision of death reporting, providing crucial data for national and local health analysis, and ensuring a supportive process for families during bereavement. The following outlines the main changes and their implications for healthcare providers in the UK.
Aspect | Previous Practice | New Practice (from 2024) | Impact on Clinical Practice |
---|---|---|---|
Mandatory Independent Review | Only certain deaths required review by a Medical Examiner or Coroner | All deaths in England and Wales must be reviewed by either a Medical Examiner or Coroner | Ensures all deaths are independently reviewed, adding scrutiny and accuracy to the process |
Attending Practitioner Requirements | Practitioner must have seen the patient within 28 days before or after death | Practitioner only needs to have attended the patient at any point in their lifetime | Easier for practitioners to complete MCCD, removing the need for recent visits |
Issuing Medical Certificate of Cause of Death (MCCD) | GPs issued MCCDs independently | MCCD is sent to Medical Examiner, who reviews the cause and receives patient records | Practitioners must work with Medical Examiners and ensure patient records are accessible for review |
New MCCD Format | Limited lines for cause of death; no fields for ethnicity, pregnancy, or devices | Includes additional "line 1d" for cause of death, fields for ethnicity, pregnancy status, and medical devices | More detailed recording enhances public health data and aligns with international standards |
Medical Examiner Signature | Practitioner signs and sends MCCD directly to the registrar | Medical Examiner adds their declaration to the MCCD before registrar submission | Adds an extra layer of accountability and verification for causes of death |
Removal of 28-Day Rule | Referral to coroner needed if patient not seen recently by GP | Coroner referral no longer needed based on recent visits alone | Simplifies MCCD process, reducing unnecessary coroner referrals |
Registration Timelines | Death registration deadline was 5 days from the date of death | 5-day limit now starts when registrar receives MCCD from Medical Examiner | Aligns timelines with the review process, potentially allowing more time for accurate certification |
Exceptional Circumstances | Coroner involvement required if attending practitioner unavailable | Medical Examiner may issue MCCD if cause is known and natural; coroner issues form CN1B in these cases | Supports timely certification if the attending practitioner is unavailable |
Electronic Certification | Paper-based death certification | Mandatory electronic death certification | Streamlines the process, enabling faster data entry and reporting |
Cremation Form Changes | Cremation Form 4 required in most cases | Cremation Form 4 removed; new forms (1, 6, and 10) introduced | Simplifies paperwork for cremation, reducing administrative burden on clinicians and families |
Key Impact on GPs in the UK
Aspect | Change | Impact on GPs |
---|---|---|
Death Certificate Issuance | GPs will no longer issue death certificates independently | GPs must now work with Medical Examiners, who verify MCCDs before submission |
New Referral Process | GPs or duty clinicians must contact relatives to gather information for Medical Examiner referral | Adds a new step, requiring GPs to reach out to families, usually within 72 hours |
Sharing Information with Medical Examiners | GPs must share the MCCD with a Medical Examiner before it’s sent to the Registrar | Increases collaboration with Medical Examiners and introduces a step for verification |
Wider Pool of Practitioners for MCCDs | Removal of the requirement to have seen the deceased within a specific timeframe | More practitioners are eligible to complete MCCDs, easing issuance requirements |
Potential Increase in Administrative Work | GPs may need new processes for referrals and information sharing | Likely additional administrative tasks to handle referrals and coordinate with examiners |
Possible Delays in Death Registration | Medical Examiner involvement may extend certification and registration timelines | May result in longer processing times, especially during early stages of implementation |
Reduced Need for Coroner Referrals | Coroner referrals no longer needed solely based on recent patient contact | Streamlines process, reducing unnecessary referrals to the coroner |
The 2024 reforms to the UK death certification process, particularly the removal of Cremation Form 4, are expected to impact GP incomes due to the elimination of payments previously associated with the form.
Removal of Cremation Form 4:
Sharing Patient Records with Medical Examiners:
New Obligations without Payment:
Transition to Mandatory Medical Examiner Review:
No Requirement for Verbal Discussion:
Timeframe for Referral:
Support from Medical Examiners for Complex Cases:
Nationwide and Permanent Change:
References
1. https://www.parkmedical.org.uk/2024/10/02/sept-2024-new-medical-examiner-changes-for-death-certificates/
2. https://www.gov.uk/government/publications/changes-to-the-death-certification-process
3. https://www.kctrust.co.uk/blog/revolutionising-death-certificates
4. https://portcullis-surgery.co.uk/changes-to-the-death-certification-and-registration-process-effective-from-september-2024/
5. https://www.nafd.org.uk/2024/09/09/death-certification-reforms-in-england-and-wales-go-live-just-after-midnight/
6. https://www.gov.uk/government/publications/changes-to-the-death-certification-process/an-overview-of-the-death-certification-reforms
7. https://www.england.nhs.uk/long-read/national-medical-examiners-guidance-for-england-and-wales/
8. https://www.reddit.com/r/doctorsUK/comments/1fnlzwd/cremation_form_and_fee_removed_for_doctors/
9. https://www.gov.scot/publications/funeral-expense-assistance-scotland-amendment-regulations-2024-business-regulatory-impact-assessment/
10. https://www.gov.uk/government/collections/cremation-forms-and-guidance
11. https://www.gov.uk/government/publications/medical-practitioners-guidance-on-completing-cremation-forms
Vulvodynia is a complex and often misunderstood condition characterized by chronic vulvar pain without an identifiable cause. It can manifest as either provoked pain, which occurs upon touch or pressure, or unprovoked pain, which arises spontaneously. This condition significantly impacts the quality of life of affected individuals, leading to physical, psychological, and social challenges. The prevalence of vulvodynia is notable, with estimates suggesting that it affects approximately 8-12% of women, indicating a substantial public health concern that primary care clinicians must address (Cox & Neville, 2012; Kim et al., 2019).
Category | Details |
---|---|
Definition | Chronic vulvar pain lasting at least 3 months without an identifiable cause, potentially linked to multiple associated factors. |
Prevalence | Affects up to 16% of women across diverse age groups and ethnicities, highlighting its significant impact as a public health concern. |
Symptoms |
- Burning sensation (🔥) - Sharp, knife-like pain (🔪) - Stinging (🦂) - Rawness or soreness (🧠) - Aching or throbbing (🔄) |
Classification |
- Localized Vulvodynia (e.g., Vestibulodynia) - Generalized Vulvodynia |
Etiology |
- Genetic Susceptibility (🧬) - Inflammatory Processes (🦠) - Neurological Sensitization (🧠) - Pelvic Floor Muscle Dysfunction (💪) |
Diagnosis |
Diagnosis of Exclusion - Rule out: - Infections (e.g., candidiasis, herpes) - Inflammatory conditions (e.g., lichen sclerosus) - Neoplastic or Neurologic disorders |
Pain Types |
- Provoked Pain: Triggered by touch or pressure - Unprovoked Pain: Spontaneous without external stimulus |
Impact on Life | Affects physical, psychological, and social aspects of life, reducing quality of life for sufferers. |
Primary Care Role | Early recognition and intervention are essential for effective management. Primary care providers should initiate the diagnostic process and guide treatment pathways. |
Management Approaches |
- Multimodal Treatment (includes cognitive-behavioral therapy and physical therapy) - Education about the condition - Psychological Support - Physiotherapy for symptom relief |
Psychosocial Aspects |
- Psychological distress and chronic stress are associated with symptom onset and severity. - History of trauma or abuse may increase the risk, highlighting the need for mental health assessments. |
Comorbid Conditions | Conditions such as interstitial cystitis and fibromyalgia often coexist with vulvodynia, complicating the diagnosis and necessitating a comprehensive health evaluation. |
**Risk Factors for Vulvodynia:**
1. **Biological Factors**
- **Neurogenic Inflammation**: Increased nervous system sensitivity and hyperinnervation in the vulvar region, often due to chronic inflammation or injury, can lead to persistent pain【Barry et al., 2019; Tonc, 2023】.
- **Hormonal Influences**: Fluctuations in estrogen levels can affect vulvar tissue sensitivity and increase pain perception【Sacinti, 2023】.
- **Comorbid Conditions**: Disorders like interstitial cystitis, commonly seen alongside vulvodynia, can intensify symptoms and complicate diagnosis【Kahn et al., 2010; Reed et al., 2014】.
2. **Psychological Factors**
- **Mental Health History**: Anxiety, depression, or trauma, especially from sexual abuse, increases the risk for vulvodynia【Silva et al., 2023; Tribó et al., 2019】.
- **Pain-Psychology Connection**: Psychological distress can amplify pain, contributing to vulvodynia's persistence【Tribó et al., 2019; Bergeron et al., 2014】.
- **Comorbid Psychological Disorders**: High prevalence of anxiety and depression among vulvodynia patients complicates treatment【Thornton & Drummond, 2015; Sadownik, 2014】.
3. **Social Factors**
- **Adverse Experiences**: Childhood trauma and negative relationships increase susceptibility to chronic pain, potentially due to maladaptive coping【Sacinti, 2023; Bergeron et al., 2014】.
- **Societal Stigma**: Stigma around sexual health and pain can cause isolation and delay treatment-seeking, worsening outcomes【Bergeron et al., 2014; Sadownik, 2014】.
Understanding these multifactorial risk factors is crucial for effective management and patient support in cases of vulvodynia.
**References:**
1. Chisari, C., & Chilcot, J. (2017). The experience of pain severity and pain interference in vulvodynia patients: the role of cognitive-behavioural factors, psychological distress, and fatigue. *Journal of Psychosomatic Research, 93*, 83-89. https://doi.org/10.1016/j.jpsychores.2016.12.010
2. Cohen-Sacher, B., Haefner, H., Dalton, V., & Berger, M. (2015). History of abuse in women with vulvar pruritus, vulvodynia, and asymptomatic controls. *Journal of Lower Genital Tract Disease, 19*(3), 248-252. https://doi.org/10.1097/lgt.0000000000000075
3. Cox, K., & Neville, C. (2012). Assessment and management options for women with vulvodynia. *Journal of Midwifery & Women's Health, 57*(3), 231-240. https://doi.org/10.1111/j.1542-2011.2012.00162.x
4. Khandker, M., Brady, S., Vitonis, A., MacLehose, R., Stewart, E., & Harlow, B. (2011). The influence of depression and anxiety on the risk of adult-onset vulvodynia. *Journal of Women’s Health, 20*(10), 1445-1451. https://doi.org/10.1089/jwh.2010.2661
5. Kim, S., Kim, J., & Yoon, H. (2019). Sexual pain and IC/BPS in women. *BMC Urology, 19*(1). https://doi.org/10.1186/s12894-019-0478-0
6. Paszkowski, T., & Baszak-Radomańska, E. (2021). Vulvodynia in prepubertal girls: diagnosis. *Ginekologia Polska.* https://doi.org/10.5603/gp.a2021.0190
7. Patla, G., Mazur-Biały, A., Humaj-Grysztar, M., & Bonior, J. (2023). Chronic vulvar pain and health-related quality of life in women with vulvodynia. *Life, 13*(2), 328. https://doi.org/10.3390/life13020328
8. Reed, B., Harlow, S., Sen, A., Edwards, R., Chen, D., & Haefner, H. (2012). Relationship between vulvodynia and chronic comorbid pain conditions. *Obstetrics and Gynecology, 120*(1), 145-151. https://doi.org/10.1097/aog.0b013e31825957cf
9. Tersiguel, A., Bodéré, C., Schöllhammer, M., Postec, E., Quinio, B., Brenaut, E., & Miséry, L. (2015). Screening for neuropathic pain, anxiety, and other associated chronic pain conditions in vulvodynia: a pilot study. *Acta Dermato-Venereologica, 95*(6), 749-751. https://doi.org/10.2340/00015555-2053
10. Torres-Cueco, R., & Nohales-Alfonso, F. (2021). Vulvodynia—it is time to accept a new understanding from a neurobiological perspective. *International Journal of Environmental Research and Public Health, 18*(12), 6639. https://doi.org/10.3390/ijerph18126639
11. Barry, C., Matusica, D., & Haberberger, R. (2019). Emerging evidence of macrophage contribution to hyperinnervation and nociceptor sensitization in vulvodynia. *Frontiers in Molecular Neuroscience, 12.* https://doi.org/10.3389/fnmol.2019.00186
12. Bergeron, S., Likes, W., & Steben, M. (2014). Psychosexual aspects of vulvovaginal pain. *Best Practice & Research Clinical Obstetrics & Gynaecology, 28*(7), 991-999. https://doi.org/10.1016/j.bpobgyn.2014.07.007
13. Kahn, B., Tatro, C., Parsons, C., & Willems, J. (2010). Prevalence of interstitial cystitis in vulvodynia patients detected by bladder potassium sensitivity. *Journal of Sexual Medicine, 7*(2_Part_2), 996-1002. https://doi.org/10.1111/j.1743-6109.2009.01550.x
14. Reed, B., Legocki, L., Plegue, M., Sen, A., Haefner, H., & Harlow, S. (2014). Factors associated with vulvodynia incidence. *Obstetrics and Gynecology, 123*(2), 225-231. https://doi.org/10.1097/aog.0000000000000066
15. Sacinti, K. (2023). Is vulvodynia associated with an altered vaginal microbiota?: a systematic review. *Journal of Lower Genital Tract Disease, 28*(1), 64-72. https://doi.org/10.1097/lgt.0000000000000780
16. Sadownik, L. (2014). Etiology, diagnosis, and clinical management of vulvodynia. *International Journal of Women's Health, 437.* https://doi.org/10.2147/ijwh.s37660
17. Silva, V., Silva, G., Sousa, M., Pereira, R., Barbosa, A., & Lima, J. (2023). Physical and social repercussions generated in women with vulvodynia: a bibliographical review. *International Journal of Health Science, 3*(8), 2-5. https://doi.org/10.22533/at.ed.159382331016
18. Thornton, A., & Drummond, C. (2015). Current concepts in vulvodynia with a focus on pathogenesis and pain mechanisms. *Australasian Journal of Dermatology, 57*(4), 253-263. https://doi.org/10.1111/ajd.12365
19. Tonc, E. (2023). Immune mechanisms in vulvodynia: key roles for mast cells and fibroblasts. *Frontiers in Cellular and Infection Microbiology, 13.* https://doi.org/10.3389/fcimb.2023.1215380
20. Tribó, M., Canal, C., Baños, J., & Robleda, G. (2019). Pain, anxiety, depression, and quality of life in patients with vulvodynia. *Dermatology, 236*(3), 255-261. https://doi.org/10.1159/000503321
Vaginismus is a complex and often misunderstood condition characterized by involuntary contractions of the pelvic floor muscles, which can hinder vaginal penetration and cause significant distress for affected women.
The DSM-5 defines vaginismus as part of the broader category of Genito-Pelvic Pain/Penetration Disorder (GPPPD). This disorder encompasses difficulties with vaginal penetration, often accompanied by pain, fear, or marked tightening of the pelvic floor muscles.
Genito-Pelvic Pain/Penetration Disorder includes persistent or recurrent difficulties in one (or more) of the following areas:
Diagnostic Criteria:
Risk Factors
Category | Risk Factors |
---|---|
Psychological Factors |
- Anxiety or fear related to sexual activity - History of sexual abuse or trauma - Negative attitudes or beliefs towards sex |
Physical Factors |
- Previous painful sexual experiences - Pelvic floor muscle dysfunction - Medical conditions (e.g., endometriosis, vulvodynia, vestibulodynia) |
Cultural/Religious Factors | - Cultural or religious beliefs promoting negative views of sexuality |
Additional Organic Factors | - Conditions reducing arousal or lubrication (e.g., diabetes, spinal cord injury, multiple sclerosis) |
Congenital Factors | - Congenital genital malformations (e.g., paramesonephric duct abnormalities) |
Presentation
Category | Details |
---|---|
Clinical Presentation |
- Involuntary spasm of vaginal muscles during penetration attempts (e.g., intercourse, exams, tampon use) - May occur with sexual intercourse, gynecological exams, or tampon insertion |
Classification |
- Primary (Lifelong) Vaginismus: No prior painless penetration experience - Secondary (Acquired) Vaginismus: Develops after a period of normal sexual function |
Severity Grading |
- Grade 1: Mildest form; patient can control muscle contractions with suggestions - Grade 2: Persistent muscle contraction despite suggestions during examination - Grade 3: Patient attempts to avoid examination by lifting or moving hips - Grade 4: Patient prevents examination by lifting hips, pulling back, and closing legs - Grade 5: Severe reactions such as tremors, hyperventilation, palpitations, crying, nausea, or even attacking the examiner (defined by Pacik) |
Primary Symptoms |
- Involuntary tightening of vaginal muscles during attempted penetration - Pain or burning sensation with penetration attempts - Fear and anxiety about penetration |
Secondary Symptoms |
- Avoidance of sexual activity - Relationship stress - Difficulty with gynecological exams or tampon use |
Management requires a holistic, multidisciplinary approach targeting both psychological and physical factors. Clinicians must adopt a compassionate, sensitive method, recognizing the emotional and physiological aspects influencing patient comfort and cooperation in treatment.
Broad Principles of Management
Comprehensive Evaluation
Tailored, Multidisciplinary Approach
Patient Education & Communication
Partner Involvement & Sensate Focus
Pharmacological Interventions (if indicated)
Consideration for Pregnant Patients
Assisted Reproduction Options
Women with vaginismus generally have a favorable prognosis, especially with appropriate treatment, which often leads to significant symptom improvement and greater sexual satisfaction. Success can depend on factors such as the condition’s duration, any coexisting psychological issues, and support from partners and healthcare providers. GPs play a key role in creating a supportive environment for open discussions on sexual health, helping to ensure timely diagnosis and effective treatment.
**References:**
1. Eserdağ et al. "Insights into the Vaginismus Treatment by Cognitive Behavioral Therapies: Correlation with Sexual Dysfunction Identified in Male Spouses of the Patients." *Journal of Family & Reproductive Health* (2021). doi:10.18502/jfrh.v15i1.6079
2. Ferreira and Souza. "Botulinum Toxin for Vaginismus Treatment." *Pharmacology* (2012). doi:10.1159/000337383
3. Marthasari et al. "Vaginismus and Infertility." *Indonesian Andrology and Biomedical Journal* (2020). doi:10.20473/iabj.v1i2.33
4. Banaei et al. "Bio-Psychosocial Factor of Vaginismus in Iranian Women." *Reproductive Health* (2021). doi:10.1186/s12978-021-01260-2
5. Muammar et al. "Management of Vaginal Penetration Phobia in Arab Women: A Retrospective Study." *Annals of Saudi Medicine* (2015). doi:10.5144/0256-4947.2015.120
6. Ramanathan et al. "Common Pitfalls in the Management of Vaginismus in Couples With Subfertility in India." *Journal of Psychosexual Health* (2022). doi:10.1177/26318318221089600
7. Demirci and Kabukçuoğlu. "‘Being a Woman’ in the Shadow of Vaginismus: The Implications of Vaginismus for Women." *Current Psychiatry Research and Reviews* (2020). doi:10.2174/2666082215666190917153811
8. Çankaya and Aslantaş. "Determination of Sexual Attitude, Sexual Self-Consciousness, and Sociocultural Status in Women With and Without Lifelong Vaginismus: A Case-Control Study." *Clinical Nursing Research* (2022). doi:10.1177/10547738221103334
9. Pereira et al. "Physiotherapy Protocol with Interferential Current in the Treatment of Vaginismus."
10. Pacik et al. "Case Series: Redefining Severe Grade 5 Vaginismus." *Sexual Medicine* (2019). doi:10.1016/j.esxm.2019.07.006
11. Çankaya and Aslantaş. "Determination of Dyadic Adjustment, Marriage and Sexual Satisfaction as Risk Factors for Women with Lifelong Vaginismus: A Case Control Study." *Clinical Nursing Research* (2021). doi:10.1177/10547738211046136
12. Pacik and Geletta. "Vaginismus Treatment: Clinical Trials Follow-Up on 241 Patients." *Sexual Medicine* (2017). doi:10.1016/j.esxm.2017.02.002
13. Zarski et al. "Efficacy of Internet-Based Guided Treatment for Genito-Pelvic Pain/Penetration Disorder: Rationale, Treatment Protocol, and Design of a Randomized Controlled Trial." *Frontiers in Psychiatry* (2018). doi:10.3389/fpsyt.2017.00260
14. Pacik. "Vaginismus: Review of Current Concepts and Treatment Using Botox Injections, Bupivacaine Injections, and Progressive Dilation with the Patient Under Anesthesia." *Aesthetic Plastic Surgery* (2011). doi:10.1007/s00266-011-9737-5
15. Achour et al. "Vaginismus and Pregnancy: Epidemiological Profile and Management Difficulties." *Psychology Research and Behavior Management* (2019). doi:10.2147/prbm.s186950
Premature ejaculation (PE) is a prevalent male sexual dysfunction characterized by ejaculation that occurs before or shortly after vaginal penetration, leading to distress and dissatisfaction in sexual relationships. The condition affects approximately 20% to 30% of men at some point in their lives, making it a significant concern in primary care settings (Eid, 2023; Saitz & Şerefoğlu, 2016).
The causes of PE can be summarised as
Category | Cause | Description |
---|---|---|
Psychological Factors | Anxiety | Particularly about sexual performance, leading to a cycle of distress that impairs sexual function. |
Stress | General stress can exacerbate PE by affecting mental focus and physical responses. | |
Depression | Mood disorders influencing sexual desire and performance, contributing to PE. | |
Relationship Problems | Interpersonal issues increasing anxiety and reducing sexual satisfaction, leading to PE. | |
Early Sexual Experiences or Trauma Past experiences impacting current sexual function through psychological associations. | Past experiences impacting current sexual function through psychological associations. | |
Strict Upbringing Regarding Sex | May lead to guilt or anxiety during sexual activity, contributing to PE. | |
Biological Factors | Abnormal Hormone Levels ↑↓ | Imbalances in thyroid hormones, prolactin, or testosterone affecting sexual function. |
Neurotransmitter Imbalance Particularly serotonin levels affecting ejaculatory control. | Particularly serotonin levels affecting ejaculatory control. | |
Inflammation or Infection | Of the prostate or urethra causing increased sensitivity and PE. | |
Erectile Dysfunction | Fear of losing an erection may lead to rushing sexual activity, resulting in PE. | |
Genetic Predisposition | Family history indicating a genetic component to PE. | |
Certain Neurological Conditions | Conditions affecting the nervous system can impact ejaculatory control. | |
Hypersensitivity of the Glans Penis | Increased sensitivity leading to rapid ejaculation due to abnormal reflex pathways. | |
Other Factors | Substance Use | Use of certain drugs or alcohol affecting sexual performance and control. |
Age and Experience | Younger men or those with less sexual experience may be more prone to PE. | |
Type of PE | Lifelong (primary) or acquired (secondary); causes may differ between these types. |
Management - Quick summary
Management Approach | Details | Notes |
---|---|---|
Non-Pharmacological (First-line) |
Behavioral Therapies Techniques like the stop-start method and squeeze technique to enhance ejaculatory control. | Includes stop-start and squeeze techniques; can improve control and confidence. |
Psychosexual Counseling Therapy addressing psychological factors such as anxiety and relationship issues. | Helps reduce performance anxiety and improve communication between partners. | |
Pelvic Floor Muscle Training | Strengthening exercises to improve control over ejaculation. | |
Pharmacological (Second-line) |
Selective Serotonin Reuptake Inhibitors (SSRIs) Medications that increase serotonin levels to delay ejaculation. ↑ Serotonin |
- **Dapoxetine** (only SSRI licensed for PE) - Others (paroxetine, sertraline, fluoxetine) used off-label - Side effects: nausea, dizziness |
Topical Anesthetics |
- Lidocaine or prilocaine creams/sprays - Reduce penile sensitivity - Available over-the-counter |
|
Tricyclic Antidepressants |
- **Clomipramine** used off-label - Can delay ejaculation - Monitor for side effects |
|
Combined Therapy | Pharmacotherapy + Behavioral Techniques | Combining medications with behavioral therapy may enhance effectiveness. |
Adjunctive Therapies |
- Mindfulness therapy - Cognitive Behavioral Therapy (CBT) - Traditional Chinese Medicine |
|
Treat Underlying Conditions | Address Erectile Dysfunction | Treat ED first if PE is secondary to it. |
Patient Education | Communication Skills Improving dialogue with partner about needs and concerns. | Educate about normal sexual function; set realistic expectations. |
**References:**
1. **Asimakopoulos, A., Miano, R., Agrò, E., Vespasiani, G., & Spera, E.** (2012). Does current scientific and clinical evidence support the use of phosphodiesterase type 5 inhibitors for the treatment of premature ejaculation? A systematic review and meta-analysis. *Journal of Sexual Medicine*, **9**(9), 2404-2416. [https://doi.org/10.1111/j.1743-6109.2011.02628.x](https://doi.org/10.1111/j.1743-6109.2011.02628.x)
2. **Ayribas, B., & Toprak, T.** (2020). New approach to patients with premature ejaculation: Do social cognition and attachment profiles play a role in premature ejaculation? *Andrologia*, **53**(1), e13882. [https://doi.org/10.1111/and.13882](https://doi.org/10.1111/and.13882)
3. **Bagcioglu, E., Efe, E., Bahçeci, B., & Söylemez, H.** (2013). Prematür ejakülasyon hastalarında mizaç ve karakter farklılıkları. *Nöro Psikiyatri Arşivi*, **50**(4), 332-336. [https://doi.org/10.4274/npa.y6443](https://doi.org/10.4274/npa.y6443)
4. **Chen, Z., Yuan, M., Ma, Z., Wen, J., Wang, X., Zhao, M., ... & Guo, L.** (2020). Significance of piezo-type mechanosensitive ion channel component 2 in premature ejaculation: An animal study. *Andrology*, **8**(5), 1347-1359. [https://doi.org/10.1111/andr.12779](https://doi.org/10.1111/andr.12779)
5. **Cooper, K., James, M., Kaltenthaler, E., Dickinson, K., Cantrell, A., Wylie, K., ... & Hood, C.** (2015). Behavioral therapies for management of premature ejaculation: A systematic review. *Sexual Medicine*, **3**(3), 174-188. [https://doi.org/10.1002/sm2.65](https://doi.org/10.1002/sm2.65)
6. **Doğan, K.** (2023). The effects of behavioral therapy given to men with premature ejaculation on symptoms and their partners’ sexual functioning and sexual quality of life. *Journal of Health Sciences and Medicine*, **6**(5), 974-980. [https://doi.org/10.32322/jhsm.1341975](https://doi.org/10.32322/jhsm.1341975)
7. **Doğan, K., & Keçe, C.** (2023). Comparison of the results of stop-start technique with stop-start technique and sphincter control training applied in premature ejaculation treatment. *PLOS ONE*, **18**(8), e0283091. [https://doi.org/10.1371/journal.pone.0283091](https://doi.org/10.1371/journal.pone.0283091)
8. **Eid, A.** (2023). Evaluation of serum prolactin and testosterone in premature ejaculation patients. *Journal of Advances in Medicine and Medical Research*, **35**(20), 222-241. [https://doi.org/10.9734/jammr/2023/v35i205193](https://doi.org/10.9734/jammr/2023/v35i205193)
9. **Guo, J., Wang, F., Zhou, Q., Qian, G., Gao, Q., Zhang, R., ... & Jannini, E.** (2020). Safety and efficacy of traditional Chinese medicine, *Qiaoshao* formula, combined with dapoxetine in the treatment of premature ejaculation: An open-label, real-life, retrospective multicentre study in Chinese men. *Andrologia*, **53**(1), e13915. [https://doi.org/10.1111/and.13915](https://doi.org/10.1111/and.13915)
10. **Jiang, M., Yan, G., Deng, H., Liang, H., Lin, Y., & Zhang, X.** (2019). The efficacy of regular penis-root masturbation versus Kegel exercise in the treatment of primary premature ejaculation: A quasi-randomised controlled trial. *Andrologia*, **52**(1), e13473. [https://doi.org/10.1111/and.13473](https://doi.org/10.1111/and.13473)
11. **Li, Y., Duan, Y., Yu, X., Wang, J., Yao, Z., Gong, X., ... & Guo, J.** (2019). Traditional Chinese medicine on treating premature ejaculation. *Medicine*, **98**(18), e15379. [https://doi.org/10.1097/MD.0000000000015379](https://doi.org/10.1097/MD.0000000000015379)
12. **Nagabhairava, M.** (2024). Comparison of pain control between lidocaine and prilocaine spray (TEMPE) versus lidocaine gel in the treatment of premature ejaculation: A prospective randomized controlled trial in a tertiary care centre. *International Journal of Research in Medical Sciences*, **12**(5), 1601-1605. [https://doi.org/10.18203/2320-6012.ijrms20240944](https://doi.org/10.18203/2320-6012.ijrms20240944)
13. **Saitz, T., & Şerefoğlu, E.** (2016). The epidemiology of premature ejaculation. *Translational Andrology and Urology*, **5**(4), 409-415. [https://doi.org/10.21037/tau.2016.05.11](https://doi.org/10.21037/tau.2016.05.11)
14. **Santtila, P., Jern, P., Westberg, L., Walum, H., Pedersen, C., Eriksson, E., ... & Sandnabba, N.** (2010). The dopamine transporter gene (DAT1) polymorphism is associated with premature ejaculation. *Journal of Sexual Medicine*, **7**(4 Pt 1), 1538-1546. [https://doi.org/10.1111/j.1743-6109.2009.01696.x](https://doi.org/10.1111/j.1743-6109.2009.01696.x)
15. **Shindel, A., Althof, S., Carrier, S., Chou, R., McMahon, C., Mulhall, J., ... & Sharlip, I.** (2022). Disorders of ejaculation: An AUA/SMSNA guideline. *The Journal of Urology*, **207**(3), 504-512. [https://doi.org/10.1097/JU.0000000000002392](https://doi.org/10.1097/JU.0000000000002392)
16. **Waldinger, M.** (2014). Pharmacotherapy for premature ejaculation. *Current Opinion in Psychiatry*, **27**(6), 400-405. [https://doi.org/10.1097/YCO.0000000000000096](https://doi.org/10.1097/YCO.0000000000000096)
17. **Zadeh, S.** (2023). Effects of transcranial direct current stimulation and behavior therapy using the start-stop method on the treatment of men with sexual disorder premature ejaculation. *Journal of Clinical Research in Paramedical Sciences*, **12**(2). [https://doi.org/10.5812/jcrps-140182](https://doi.org/10.5812/jcrps-140182)
18. **Çayan, S., & Şerefoğlu, E.** (2014). Advances in treating premature ejaculation. *F1000Prime Reports*, **6**, 55. [https://doi.org/10.12703/P6-55](https://doi.org/10.12703/P6-55)
Dyspareunia, defined as persistent pain during or after sexual intercourse, is a multifactorial cpndition. The causes of dyspareunia can be broadly categorized into physical, psychological, and situational factors, each contributing to the patient's experience of pain.
Category | Cause | Description |
---|---|---|
Physical Causes | Endometriosis Growth of endometrial tissue outside the uterus | Growth of endometrial tissue outside the uterus causing pelvic pain, dysmenorrhea, and deep dyspareunia. |
Vulvodynia and Vestibulodynia Chronic pain conditions affecting the vulvar area | Chronic pain or discomfort of the vulvar area leading to superficial dyspareunia. | |
Vaginal Atrophy Thinning of the vaginal walls due to decreased estrogen levels | Thinning and drying of the vaginal walls due to decreased estrogen levels, common in postmenopausal women, causing pain during intercourse. | |
Infections | Includes vaginitis, urinary tract infections, yeast infections, and STIs like herpes, causing inflammation and pain during intercourse. | |
Pelvic Floor Dysfunction | Hypertonic pelvic floor muscles leading to pain during penetration due to muscle spasms or tightness. | |
Skin Disorders | Conditions such as lichen planus, lichen sclerosus, and psoriasis causing vulvar inflammation and discomfort during sex. | |
Pelvic Inflammatory Disease | Infection of the upper genital tract causing deep pelvic pain and dyspareunia. | |
Psychological Factors | Emotional Distress | Stress, anxiety, and depression increasing muscle tension and pain perception during intercourse. |
History of Trauma | Past sexual abuse or traumatic experiences contributing to pain due to psychological and physiological responses. | |
Situational Factors | Postpartum Changes | Perineal trauma or anatomical changes after childbirth leading to dyspareunia in the postpartum period. |
Surgical History | Previous pelvic surgeries like hysterectomy causing scar tissue or changes in anatomy resulting in painful intercourse. | |
Inadequate Lubrication | Often due to hormonal changes or insufficient arousal, leading to friction and discomfort during sex. |
**References:**
1. **Alimi, Y., Iwanaga, J., Oskouian, R., Loukas, M., & Tubbs, R.** (2018). The clinical anatomy of dyspareunia: a review. *Clinical Anatomy*, **31**(7), 1013-1017. [https://doi.org/10.1002/ca.23250](https://doi.org/10.1002/ca.23250)
2. **Corden, C.** (2013). Causes and management of dyspareunia. *InnovAiT: Education and Inspiration for General Practice*, **6**(2), 66-75. [https://doi.org/10.1177/1755738012470253](https://doi.org/10.1177/1755738012470253)
3. **Eisenberg, V., Weil, C., Chodick, G., & Shalev, V.** (2017). Epidemiology of endometriosis: a large population-based database study from a healthcare provider with 2 million members. *BJOG: An International Journal of Obstetrics & Gynaecology*, **125**(1), 55-62. [https://doi.org/10.1111/1471-0528.14711](https://doi.org/10.1111/1471-0528.14711)
4. **Farfaras, A., Pierrakos, G., Pateras, I., Skolarikos, P., Wen, S., & Sarris, M.** (2014). Endometriosis: does surgery offer long-term improvement in quality of life? *Journal of Endometriosis and Pelvic Pain Disorders*, **6**(2), 106-111. [https://doi.org/10.5301/je.5000187](https://doi.org/10.5301/je.5000187)
5. **Kj, W., S, I., Joseph, K., Kb, S., & Yong, P.** (2019). Dyspareunia in their own words: a comprehensive qualitative description of endometriosis-associated sexual pain. [https://doi.org/10.1101/19005793](https://doi.org/10.1101/19005793)
6. **Leeners, B., Hengartner, M., Ajdacic-Gross, V., Rössler, W., & Angst, J.** (2015). Dyspareunia in the context of psychopathology, personality traits, and coping resources: results from a prospective longitudinal cohort study from age 30 to 50. *Archives of Sexual Behavior*, **44**(6), 1551-1560. [https://doi.org/10.1007/s10508-014-0395-y](https://doi.org/10.1007/s10508-014-0395-y)
7. **Morris, C., Briggs, C., & Navani, M.** (2021). Dyspareunia. *InnovAiT: Education and Inspiration for General Practice*, **14**(10), 607-614. [https://doi.org/10.1177/17557380211030299](https://doi.org/10.1177/17557380211030299)
8. **Orr, N., Wahl, K., Joannou, A., Hartmann, D., Valle, L., Yong, P., & Renzelli-Cain, R.** (2019). Deep dyspareunia: review of pathophysiology and proposed future research priorities. *Sexual Medicine Reviews*, **8**(1), 3-17. [https://doi.org/10.1016/j.sxmr.2018.12.007](https://doi.org/10.1016/j.sxmr.2018.12.007)
9. **Schnittka, E., Lanpher, N., & Patel, P.** (2022). Postpartum dyspareunia following continuous versus interrupted perineal repair: a systematic review and meta-analysis. *Cureus*. [https://doi.org/10.7759/cureus.29070](https://doi.org/10.7759/cureus.29070)
10. **Streicher, L.** (2023). Diagnosis, causes, and treatment of dyspareunia in postmenopausal women. *Menopause: The Journal of the North American Menopause Society*, **30**(6), 635-649. [https://doi.org/10.1097/gme.0000000000002179](https://doi.org/10.1097/gme.0000000000002179)
11. **Yong, P., Mui, J., Allaire, C., & Williams, C.** (2014). Pelvic floor tenderness in the etiology of superficial dyspareunia. *Journal of Obstetrics and Gynaecology Canada*, **36**(11), 1002-1009. [https://doi.org/10.1016/s1701-2163(15)30414-x](https://doi.org/10.1016/s1701-2163(15)30414-x)
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