Successful Treatment of Dyspareunia with an Integrative Medicine Approach: A Case Report

Abstract

A 50-year-old woman with a five-and-a-half-year history of dyspareunia was successfully treated with an integrative medicine approach, including Neural Therapy, osteopathic therapy, acupuncture, and trigger point therapy, resulting in complete resolution which has been maintained to the present day, nineteen years later. Further research is justified and recommended.

INTRODUCTION

Dyspareunia refers to painful sexual intercourse which can be intermittent or constant during or after intercourse. In women, dyspareunia can be superficial or deep. Superficial dyspareunia is localized to the vaginal opening while deep dyspareunia is felt inside the vagina or pelvis.¹ Dyspareunia can be of unknown etiology or a symptom associated with an underlying condition.² For example, females with dermatological diseases, perivaginal infections, and vaginitis may experience superficial dyspareunia. Females with visceral disorders like endometriosis, fibroids, interstitial cystitis, or vaginal atrophy can have a deep dyspareunia.¹

Vaginismus is a condition often used interchangeably with dyspareunia. This is defined as a vaginal muscle spasm that interferes with sexual intercourse.² While in theory vaginismus can exist without pain, it is often accompanied by pain.³ Together, dyspareunia and vaginismus are characterized as sexual pain disorders.⁴

Dyspareunia is reported more frequently in women.² It can be debilitating, negatively impacting the quality of life of a female and her partner.¹ Secondary to pain, women with dyspareunia often experience decreased sexual desire⁵ and function,¹ which can lead to significant relationship distress or other comorbidities like depression and anxiety.¹ Risk factors for dyspareunia include chronic health problems, sexual abuse, and caesarian section.^1,6,7,8,9,10

It is estimated that between 10 and 20% of women report recurrent or persistent pain during intercourse.^1,6 Dyspareunia is underreported and infrequently discussed with healthcare providers,^1,2,11 therefore it is likely that the prevalence of this condition is underestimated.

A clear standard of care is not identified to treat a patient with dyspareunia.¹ If the pain associated with intercourse is linked to a primary condition, the underlying cause should be treated first. Some of the current treatments for dyspareunia include patient education, distraction techniques, topical therapy, pelvic floor physical therapy, acupuncture,1 and cognitive behavior therapy.^2,5 These treatment modalities, however, are not well studied and often show varying results⁵ with high relapse rates.¹²

In 2009, the American College of Obstetrics and Gynecology published an article titled “Evaluation and Treatment of Dyspareunia.” In this article, treatment of scar pain is mentioned as a potential new treatment paradigm for gynecologists.¹² In 2013, Weinschenk reported successful use of Neural Therapy in a case of chronic pelvic pain,¹³ and in 2017, Bahat and Nazlikul reported promising results using Neural Therapy in endometriosis patients.¹⁴

We present a case of long-standing dyspareunia which was dramatically and quickly improved using a multimodal approach of Neural Therapy, osteopathic Jones Strain Counterstrain therapy, acupuncture, and manual trigger point therapy.

NEURAL THERAPY

As recently summarized in an Open Access article by Gurevich et al., “Neural therapy¹⁵ (NT) is a method that uses injections of local anesthetic into trigger points, scars, peripheral nerves, autonomic ganglia, tendon and ligament insertions, the epidural space, and tissues. The determination of injection site(s) depends on the findings of a conventional medical evaluation in the context of referred pain, dermatomes, regional influence of autonomic ganglia, and identified interference fields. Interference fields can be generated by any damaged tissue via chronic stimulation of afferent neurons in the autonomic nervous system resulting in chronic autonomic reflex activity such as nausea, vomiting, and pain. Scars are often sources of interference fields.” Local anesthetic injections, like procaine, have the capacity to repolarize the nerve cell membrane resulting in restoration of organ function.¹⁶ NT was developed in Germany and the former USSR. It is used in German- and Spanish–speaking countries for multiple medical conditions and pain.^{13,17,18,19,20,21,22,23,24,25,26,27}

CASE PRESENTATION

Context

The patient was in the office for a different medical condition when she discussed her dyspareunia for the first time. The patient mentioned her dyspareunia to the medical assistant towards the end of her visit after the physician left the room. After encouragement from the medical assistant, the patient spoke to her physician when he returned to the room.

HPI. This is the case of a 50-year-old female with a five-and-a-half-year history of dyspareunia. The patient delivered her only child vaginally at age 37. After this, she had a miscarriage and a life-threatening ectopic pregnancy when trying to have more children. At this point in her life, she did not experience dyspareunia. At age 42, the patient was diagnosed with breast cancer. She had a left sided mastectomy and a prophylactic hysterectomy, due to a family history of ovarian cancer. For the next year and a half, the patient had surgery every three to four months for her breast cancer. The patient noticed her dyspareunia around age 44 when she resumed being intimate with her husband.

The sexual pain that the patient was experiencing occurred shortly after entry by her husband. She described it as “devastating,” adding to her other significant life stressors and preventing her from having intercourse altogether. The patient did not mention this to her primary care physician or try anything for her pain. She just assumed it was another thing that she would have to live with.

PMH. Degenerative disc disease, herniated lumbar disc, spinal stenosis, sciatica, arthritis, right calf pain, acoustic neuroma, osteoporosis, tonsillectomy, facial surgery, and depression.

Medications. Tamoxifen, Clonazepam (Klonopin™), Tramadol (UltramTM), Ibuprofen (MotrinTM), Progesterone, Testosterone, Sumatriptan (ImitrexTM), Vitamin C.

SH. Patient was married and had one daughter that she delivered vaginally.

Allergies. Patient had no known drug allergies.

PE. On vaginal examination: the patient was found to have bilateral tender trigger points in the pubococcygeus muscle. Ischemic compression was applied to these trigger points.²⁸ On speculum examination the vaginal cuff was visible. A scar was present in the vaginal vault from the previous hysterectomy.

Assessment. It was decided that the surgical scar was likely to be a major factor contributing to the dyspareunia.

Treatment. The vaginal hysterectomy scar was injected with 4mL of 0.5% preservative free procaine solution.²⁹ The patient did not experience any side effects after this treatment.

First Follow-up Visit: 2 weeks after initial treatment.

The patient reported almost complete relief of her dyspareunia after her first treatment.

Pelvic exam again revealed tender trigger points palpable through the vaginal cuff. Trigger point release was performed with an osteopathic Jones Strain Counterstrain technique,³⁰ then the vaginal cuff scar and the vault were infiltrated with 2 x 6mL of 0.5% procaine.²⁹ Then, a Tai Yin/Yang Ming acupuncture circuit was administered at points large intestine 11, spleen 9, and spleen 6.³¹ The patient did not experience any side effects after this treatment

Follow-up Visit Two: 13 weeks after initial treatment

The patient had maintained improvement. The hysterectomy scar was infiltrated with 5mL of 0.5% procaine.²⁹ The patient did not experience any side effects after this treatment

Follow-up Visit Three: 6 months after initial treatment

The patient had maintained improvement. The osteopathic Jones Strain Counterstain maneuver³⁰ was performed again for the trigger points in the pubococcygeal muscle, and the vaginal cuff scar was injected with 5mL of 0.5% procaine.²⁹

Follow-up Visit Four: 7 months after initial treatment

Again, the patient had maintained improvement. A Jones Strain Counterstrain release was performed for the pubococcygeal trigger points.³⁰

First Telephone Contact: 19 years after initial treatment.

Patient recalled vividly what happened regarding her treatment for dyspareunia. She recalls today that in the past, she had developed severe pain on intercourse quickly after entrance by her husband. It made intercourse nearly impossible. After the first treatment, she remembers almost complete relief. After four more treatments over the course of seven months, the dyspareunia was completely resolved, and the patient had no further episodes of pain with intercourse over a nineteen year follow up period.

Second Telephone Contact: 19 years and 1 month after initial treatment.

Patient describes her treatment for her dyspareunia in her own words as “life changing.” At age 69, she has yet to flare up and experience dyspareunia again. Despite undergoing twenty-six different surgeries to date, she can maintain a passionate relationship with her husband, work full time, work out, and eat well.

DISCUSSION

A 50-year-old female with a five-and-a-half-year history of severe dyspareunia had total resolution of her chronic condition over the course of seven months. During this time period, the patient had five office visits and received an integrative medicine treatment approach consisting of Neural Therapy (NT) × 4, osteopathic Jones Strain Counterstain therapy × 3, manual trigger point therapy × 1, and one session of acupuncture. The patient experienced dramatic, nearly complete relief after the initial visit. Four more visits over a six-month period resulted in complete resolution that has been maintained for the past nineteen years.

The main limitation of this report is that it is a single retrospective case report. These reports are not generalizable. They sit at the bottom of the evidence hierarchy and contain confounding factors. It does, however, serve as a possible early detection signal for a significant therapeutic advance. Regarding confounders, we have four treatment variables: NT, acupuncture, osteopathic Jones Strain Counterstrain, and manual trigger point therapy. We cannot be certain which treatment modality or combination of modalities was responsible for the outcome. Also, we are unable to rule out a placebo response. Based on the timeline of this case and our clinical experience, we argue that the NT was the major contributor of the successful outcome seen in our patient with dyspareunia. The patient had almost complete relief after one NT treatment. This improvement was maintained. Acupuncture and the osteopathic Jones Strain-Counterstrain maneuver were done on the first follow-up visit. Acupuncture was not repeated, while the osteopathic Jones Strain-Counterstrain maneuver was not repeated until the last two follow-up visits which occurred six and seven months after initial treatment. The patient had maintained excellent improvement during this interval.

Many patients that experience dyspareunia after their hysterectomy, either have adhesions or recurrence of whatever prompted the hysterectomy in the first place (e.g., endometriosis).³² These issues often need to be addressed before resolution of the painful intercourse. This was not the case in our patient. The cause of her dyspareunia was seemingly unexplained. We have strong reason to believe that the patient’s vaginal hysterectomy scar was the cause of her chronic pain during intercourse, which is consistent with the nearly complete resolution of her symptoms and maintenance of that improvement after the first NT treatment.

CONCLUSION

Neural Therapy of vaginal hysterectomy scars may have a role in the treatment of dyspareunia. It behooves the research community to investigate this possibility.