A Randomized Clinical Trial for Women With Vulvodynia: Cognitive-Behavioral Therapy vs. Supportive Psychotherapy

Abstract

Vulvodynia is a difficult-to-treat gynecological disorder that has received little mention in the medical literature. Major complaints by women with vulvodynia include chronic vulvar pain, sexual dysfunction, and emotional distress. Treatment of this disorder has been largely based on expert opinion. One psychological intervention, cognitive-behavioral therapy (CBT), emphasizes a self-management approach and has been associated with significant reductions in pain severity, disability, and affective distress in a few uncontrolled and randomized controlled clinical trials. In this randomized controlled trial, the investigators evaluated the efficacy of CBT for the treatment of vulvodynia in comparison to supportive psychotherapy (SPT), a less directive psychological intervention. Of the 50 participants randomized to a CBT group (n = 25) or a SPT group (n = 25), 42 (84%) completed the treatments, and 8 (16%) dropped out. Ninety-six percent of the remaining participants completed immediate posttreatment evaluation and 94% completed the 6- and 12-month follow-up evaluations. Women in the CBT group were taught self-management skills that alter thoughts, feelings, and behaviors, whereas those in the SPT group were treated by nondirective talk therapy lacking specific behavioral interventions. An equal number of treatments were administered in 10 weekly individual 60-minute sessions to each group. The pain outcome was assessed by physician ratings or self-reports of participants. Sexual and emotional function was assessed only by the participants. Mixed effects modeling was used to assess changes over time in outcomes. At the end of the treatment sessions, pain severity was significantly reduced on self-reports in both treatment groups and in physician ratings (P < 0.05 for all). Participants in the CBT group reported a greater improvement in overall sexual functioning than those in the SPT group (P < 0.017). Compared to baseline values, several parameters of emotional function were improved in both treatment groups (P < 0.05 for all). Among all participants, improvements in pain severity, sexual function, and emotional function were maintained or continued to improve to the 1-year follow up. Participants in the CBT group reported significantly greater satisfaction and more credibility for the treatment than those in SPT group (P < 0.05 for all). Although both CBT and SPT appear to be effective psychosocial treatments for vulvodynia, these findings indicate that CBT, a directed self-management behavioral approach, is associated with better pain and sexual function outcomes, and greater patient satisfaction than SPT, a less directed nonbehavioral approach.