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Abstract

We read with interest the comments by O’Connor et al in response to our article. In their cohort, sexual pain was associated with a higher likelihood of reporting somatic symptoms on the Patient Health Questionnaire-12 (PHQ-12). However, sexual pain was not associated with fecal calprotectin as a marker of inflammatory bowel disease (IBD) activity. The implication of their response is that women who report sexual pain are women who report more symptoms in general, and that vulvovaginal discomfort is not biologically associated with IBD. Their population of 777 women seen in a clinic had a similar mean age to our online cohort of 1250 (age, 43 y; range, 17–89 y vs 41 y; range, 18–90 y) and a similar proportion of women with Crohn’s disease (60% vs 64%).1Ona S. et al.Clin Gastroenterol Hepatol. 2020; 18: 604-611Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar However, they measured genital symptoms with a single question on the PHQ-12 that asks if women have “Pain or problems during sex.” In contrast, we used an extensive questionnaire about the presence and severity of multiple vulvovaginal symptoms including pain with vaginal penetration, itching, burning, discharge, and dryness. Our analysis examined the association between reporting at least 1 moderate–severe vulvovaginal symptom and IBD activity, in contrast to report of a single symptom of any severity. In addition, we controlled our analysis for menopausal status, which may be a driver of vulvovaginal symptoms that would be distinct from an association with IBD. Likely owing to their focus on a single symptom, O’Connor et al found a lower proportion of women in their symptomatic group (16% vs our 37% of premenopausal women). Given this low proportion of symptomatic women, and a higher prevalence of active disease in asymptomatic women, their analysis would be underpowered to show a similar size difference as seen in our analysis. The perception that women with vulvovaginal discomfort are more anxious, or are simply people with more somatic symptoms overall is common. However, we would argue that in a cross-sectional analysis it is not possible to say whether the somatic symptomatology is the driver of the genital discomfort or the result. In postmenopausal women, sexual dysfunction is associated with significantly lower quality-of-life scores in women.2Nazarpour S. et al.J Women Aging. 2018; 30: 299-309Crossref PubMed Scopus (22) Google Scholar In men, erectile dysfunction is associated with worse adaptation to other comorbid conditions, such as diabetes.3De Berardis G. et al.Diabetes Care. 2002; 25: 284-291Crossref PubMed Scopus (240) Google Scholar In fact, in the analysis by O’Connor et al, all domains of quality of life were lower in women who reported problems with sex. Neither our cross-sectional analysis nor the one presented by O’Connor et al can characterize an association as causal; it is just as plausible to hypothesize that sexual dysfunction leads to an overall decline in well-being and an increase in other symptoms. The most important point to both reports is that sexual pain and genital discomfort are associated with significant levels of distress for women with IBD. Addressing all components of discomfort is an important goal in patient-centered care in IBD. The authors would like the acknowledge the contributions of our co-authors, Dr Ashwin Ananthakrishnan and Dr. Kaitlyn James to the formulation of this response. Predictors of Dyspareunia Among Female Patients With Inflammatory Bowel DiseaseClinical Gastroenterology and HepatologyVol. 18Issue 4PreviewWe read the recent paper published in Clinical Gastroenterology and Hepatology by Ona et al1 with interest. Sexual dysfunction is a well-recognized complication of chronic illness. In inflammatory bowel disease (IBD), such factors as age of diagnosis, increased bowel frequency, abdominal pain, fatigue, incontinence, perianal fistulas, abscesses, or skin tags may lead to an accumulation of physical and psychosocial factors that can impair sexual function. The authors reported that vulvovaginal discomfort was significantly associated with IBD activity, measured using validated symptom-based questionnaires in an online survey of 1250 women in the United States. Full-Text PDF