New counseling model can help minimize vaginal pain in cancer survivors

The Minimizing Painful Vaginal Penetration (MPVP) model can help healthcare professionals educate and support cancer survivors with dyspareunia, according to an article published in Nursing2017. The model focuses on helping clinicians identify “causes and consequences” of dyspareunia and nonpharmacologic self-care interventions. It also links clinical concepts and treatments to quality-of-life outcomes, such as a linkage between the concept of vaginal pain and treatment with lubricants, which can lead to improvements in arousal and desire. 

Cancer treatments such as surgery, chemotherapy, and radiation are known to have a multifaceted impact on physical and psychological sexual health. Dyspareunia is the most common sexual difficulty reported by female cancer survivors. Despite how common sexual dysfunction is after cancer treatment, many healthcare professionals lack expertise or feel uncomfortable talking with patients about sexual issues. The authors noted that use of the PLISSIT Model is helpful in opening the discussion. In the context of dyspareunia, it would entail:

P=asking the patient for Permission to discuss dyspareunia

LI=asking for LimitedInformation on the problem, such as when it began

SS=providingSpecific Suggestions on interventions, such as vaginal lubricants and moisturizers

IT=offeringIntensive Treatment options, such as referral to a therapist

MPVP model

The MPVP Model focuses on pain with vaginal penetration, to which three clinical conditions can contribute: vaginal atrophy, loss of vaginal elasticity, and vaginal dryness. The latter is the most common cause of dyspareunia and may or may not be associated with vaginal atrophy. Vaginal dryness in cancer survivors can be related to hormonal changes induced by oophorectomy, radiation to the pelvic floor, or chemotherapy; direct effects of vaginal radiation and vaginal or pelvic surgery; and adverse effects of drugs such as aromatase inhibitors given to prevent recurrence. 

Clinicians can counsel women on use of vaginal lubricants and moisturizers as strategies for managing vaginal dryness and atrophy. The authors noted that many women do not know the difference between the two products, so it is helpful to explain that lubricants are used before intercourse to create a moisture barrier in the vagina that makes penetration more comfortable. In contrast, vaginal moisturizers are used every 3 to 4 days relieve dryness even if women do not plan to engage in sexual activity. The two products can be used together. Products that contain hyaluronic acid may actually improve vaginal pH and cellular maturation, reversing some of the physiologic effects of vaginal atrophy and thus leading to less vaginal dryness and dyspareunia, said the authors. 

Loss of vaginal elasticity, typically due to radiation to the pelvic floor, can be managed with dilator therapy and masturbation (either manually or with use of a vibrator applied to the vagina and/or clitoris). Dilator therapy can help women manage anticipatory anxiety about dyspareunia by allowing them to grow accustomed to penetration with vaginal dilators of different sizes. The authors noted that clinicians can teach patients how to use the dilators or refer them to a pelvic physical therapist for instruction. Self-stimulation can lead to improved blood flow and lubrication in the vagina, which can reduce dyspareunia. 

The authors concluded their paper by reporting on the link between dyspareunia and lessened desire and arousal. They wrote that “when vaginal pain with penetration is managed, patients are more likely to experience increased desire.”

They also noted that the literature shows patients want to talk about sexual health but are reluctant to bring up the topic themselves. The PLISSIT and MPVP models, therefore, can be useful in helping clinicians broach the subject.