In Favor of an Integrated Pain-Relief Treatment Approach for Vulvar Vestibuiitis Syndrome

In their commentary regarding the results of our vulvar vestibulitis randomized treatment outcome study', Weijmar Schultz and van de WieP raise a number of important clinical and scientific issues. We approve of most of their comments but would like to elaborate in an attempt to promote further discussion and research. Weijmar Schultz and van de Wiel suggest on page of this issue that the lowered efficacy of cognitive behavioral therapy in our study as compared to theirs resulted from our shorter duration of treatment (12 weeks versus 1-1.5 years). Although it makes sense that more therapy should result in better outcomes, to our knowledge, there are no data concerning the impact of length of treatment on outcome for pain or sexual dysfunction. How long should therapy last? A12-week duration, as found in our study1, is indeed short but was necessary for scientific and economic purposes. However, our recent two-year follow-up of the initial study participants revealed that although vestibulectomy remained superior to the other two conditions in its impact on vestibular pain (cotton-swab test), i t was equal to group cognitive-behavioral therapy in terms of self-reported pain during intercourse (Bergeron et al, unpublished data). This result corroborates that of Weijmar Schultz and colleagues2, who found no difference between cognitive-behavioral therapy and surgery at 2.5-3 year follow-ups. This suggests that the effects of cognitive-behavioral therapy may be slower to appear, and that if one is patient, surgerycan be avoided. Finally, it may be that the differences between our two studies are due more to the length of follow-up rather than to the length of treatment. Nonetheless, the impact of length of treatment and other relevant variables, such as patient degrees of self-efficacy, need to be further studied if we are to predict treatment outcome with greater accuracy. Weijmar Schultz and van de Wiel state that the positive results of the cognitivebehavioral therapy in their 1996 studyZ has lead them to favour this less invasive, albeit more time-consuming, intervention over surgery. The delivery of the cognitivebehavioral therapy in their study was in fact multidisciplinary and included physical therapy. Interestingly, despite the superior outcome results of the vestibulectomy condition in our randomized study', our overall clinical approach also begins by recommending cogni tive-behavioral therapy and physical therapy. Paradoxically, results of our study seem to have convinced participating gynecologists that cognitivebehavioral therapy and biofeedback were actually efficacious, and in turn convinced psychologists to overcome their biases against vestibulectomy. Overall, the gynecologists on our team report performing far fewer surgeries than they did five years ago. After diagnosing a woman with vulvar vestibulitis, the gynecologists typically recommend that she choose between cognitive-behavioral sex therapylpain management either given in group, couple or individual format, and physical therapy. If one or a combination of these treatments is not effective, i.e. to the satisfaction of the patient, the gynecologist will consider performing a vestibulectomy. The traditional medical approach postulates tha t we should always offer the more conservative treatment first. However, in the case of vulvar vestibulitis, conservative medical treatments such as corticosteroid 3. Bergeron, Department of Sexology, Universite du Quebec a Montreal, and Department of Psychology, McGill University Health Centre, Royal Victoria Hospital, Y. M. Binik, Department of Psychology, McGill University and Department of Psychology, McCill University Health Centre, Royal Victoria1 Hospital, and S. Khalife, Department of Obstetrics and Gynecology, McCill University, Jewish General Hospital, Montreal, Canada