Received: 17 November 2021 | Revised: 15 April 2022 | Accepted: 9 May 2022 | First published online: 12 July 2022

DOI: 10.1002/ijgo.14321

CLINICAL ARTICLE
Gynecology

Impact of a single-­session psychosocial counseling intervention

for women with vulvodynia

Molly B. Moravek1 | Laurie J. Legocki2 | Claudia Kraus Piper3 | Katie Bernard3 |

Barbara D. Reed2 | Hope K. Haefner1

1
University of Michigan Department of
Obstetrics and Gynecology, Ann Arbor,
MI, USA
2
University of Michigan Department of
Family Medicine, Ann Arbor, MI, USA
3
University of Michigan Department of
Social Work, Ann Arbor, MI, USA
Correspondence
Hope K. Haefner, Harold A. Furlong
Professor of Women's Health, Department
of Obstetrics and Gynecology, L4113 UH
South, 1500 E. Medical Center Dr. SPC
5276, Ann Arbor, MI 48109–­5276, USA.
Email: haefner@med.umich.edu
Funding information
Ansbacher Fund for Resident Education
and Research; The University of Michigan
Department of Family Medicine; The
University of Michigan Department of
Social Work
Abstract
Objective: To evaluate the impact of a single session of psychosocial counseling on
patients with vulvodynia.
Methods: Patients diagnosed with vulvodynia at a vulvovaginal specialty clinic were
randomly assigned to receive either a one-­on-­one 30-­to 45-­min psychosocial coun-
seling session with a psychosexual counselor plus written educational materials (in-
tervention group) or written materials alone (control group). They completed a survey
before and 6 weeks after randomization that included demographic information and
validated measures of sexual function and illness perception.
Results: Thirty-­one of 38 (81.6%) women approached chose to participate; 26 of
the 31 (83.9%) completed the 6-­week follow-­up survey. Only the intervention group
showed improvement in knowledge about vulvovaginal and sexual health, as well as in
most measures of improvement in illness perception, as measured by the Brief Illness
Perception Questionnaire (P < 0.05). When compared directly with those in the con-
trol group, patients in the intervention group reported increased understanding of
their vulvar symptoms (P < 0.005) and lessened emotional impact of these symptoms
(P = 0.035).
Conclusion: Patients receiving one session of the one-­on-­one psychosocial coun-
seling intervention reported improved understanding and lessened emotional impact
of their vulvar symptoms, compared with the control group. This study suggests that
improvement may occur following minimal intervention and supports the need for
further study.

KEYWORDS
counseling, pain, sexual health, vulvodynia

1 | I NTRO D U C TI O N condition can last for many years. The terminology of vulvar pain
was revised in 2015.1 It is categorized into two sets: (1) vulvar pain
Vulvar pain can occur in women of any age. It is defined as pain caused by a specific disorder, and (2) vulvodynia, consisting of vul-
located on the vulva for a minimum duration of 3 months. The var pain of at least 3 months duration without an identifiable cause.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction
in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology
and Obstetrics.

202 | 
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MORAVEK et al.
Vulvodynia has an estimated prevalence of 7%–­8.3% in women over
2,3
age 18 years. The incidence rate of vulvodynia is also substantial
(4.2 cases per 100 woman-­years).4
The specific cause of vulvodynia is unknown, and hence consid-
erable controversy exists about appropriate treatments. The major-
ity of treatments are used to diminish pain, restore activities of daily
living, and improve sexual function. Unfortunately, despite an in-
crease in the number of studies on vulvodynia, there is still a paucity
of literature comparing the effectiveness of different treatments,
including behavioral interventions.5 Despite the lack of knowledge
about its etiology, it is well known that the impact of vulvar disease
on the psychological well-­being, sexual functioning, and intimate
relationships of individuals is significant.6 Studies have shown a
positive effect of psychosocial therapy programs for women with
vulvodynia; however, no studies to date have investigated whether
benefit can be derived from a single psychosocial counseling session
at the time of the vulvodynia diagnosis.
The objective of this study was to prospectively assess the ef-
fect of adding a single session of psychosocial counseling to stan-
dard medical treatment compared with medical treatment alone in
women with vulvodynia. We hypothesized that the addition of a sin-
gle psychosocial counseling session would lead to improvements in
illness perception, sexual function, pain perception, and knowledge
of vulvar and sexual health at follow up 6 weeks later.
2 | M ATE R I A L S A N D M E TH O DS
This study was approved by the University of Michigan Medical
School institutional review board (HUM00041882) before the study
began. From February through July 2011, all new patients present-
ing to the Vulvovaginal Clinic at the University of Michigan Family
Practice Center in Chelsea, Michigan who were diagnosed with vul-
vodynia were invited to participate at the conclusion of their medical
visit. A research assistant approached interested patients to explain
the study and obtain written consent. Participants were randomized
to the intervention or control group based on the week of their ap-
pointment and were asked to complete a 48-­item questionnaire in
a secure location at the clinic immediately following their visit. At
the initial appointment, the intervention group received the stand-
ard evaluation and recommended medical treatment provided by
the physician (BDR), plus the psychosexual intervention—­a 45-­min
counseling session with a sexual health therapist (CKP). The control
group received the standard evaluation and recommended medical
treatment provided by the physician (BDR), without the psychosex-
ual intervention.
The questionnaire covered basic demographic information,
perceived knowledge about vulvar symptoms, a visual analog pain
scale (VAS), questions regarding counseling attitudes and history,
the Brief Illness Perception Questionnaire (BIPQ), and the Female
Sexual Function Index (FSFI) inventory. The BIPQ is a nine-­item scale
assessing cognitive and emotional experiences of illness through
various dimensions of the patient's perceptions of her illness.7
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203
These dimensions include consequences, timeline, personal control,
treatment control, identity, concern, understanding, and emotional
response. The FSFI is a 19-­item questionnaire measuring six do-
mains of female sexual functioning experienced during the previous
4 weeks.8 The domains include desire, arousal, lubrication, orgasm,
satisfaction, and pain, with a maximum score of 6 in each domain.
Higher scores indicate better sexual functioning.
Following completion of the questionnaires, patients in the con-
trol group were told their study participation was complete for the
day, whereas patients in the intervention group were led to a pri-
vate room for the counseling session. The intervention consisted of
a 30-­to 45-­min single psycho-­educational counseling session with
a psychosexual component, administered by a licensed clinical so-
cial worker certified in sex therapy (CKP). The session encompassed
general psychosocial and psychosexual information, education, and
sexual counseling focused on enhancing patient coping skills and ill-
ness perceptions.
The one-­on-­one psychosocial counseling intervention was per-
formed only on alternating weeks, with the participants enrolled on
“non-­intervention” weeks acting as controls.
All participants received a vulvodynia resource list that included
information on suggested vulvodynia publications and websites, as
well as information on lubricants, vaginal dilators, and condoms.
Participants in both the intervention and control groups were
contacted by mail 6 weeks after their initial appointment and asked
to complete the follow-­up survey, which repeated the inventories
asked on the initial survey, as well as follow-­up questions regarding
symptoms and changes that may have occurred. Data were entered
and analyzed using Predictive Analytics SoftWare (PASW) (IBM
PASW Statistics 20, Armonk, NY, USA).
Analysis included determination of frequencies of all variables,
transformations as indicated, and crosstabs and t tests as indi-
cated by variable type. Paired t tests were used to compare before
and after responses of individuals within their respective groups.
Regression analysis was then performed to directly compare the in-
tervention with the control groups within one model.
3 | R E S U LT S
Thirty-­one of the 38 women (81.6%) approached agreed to partici-
pate; 26 completed both the baseline and follow-­up surveys (26/31,
83.9% of total participants; 14/16, 87.5% of the intervention group;
and 12/15, 80.0% of the control group). Women who declined
participation cited time and other logistical interference. Women
who did not return the follow-­up survey were excluded from fur-
ther analysis. Baseline characteristics of the participants including
age, schooling, marital status, and worst pain level experienced
were analyzed (Table 1). The mean age of all of the participants was
40.7 ± 15.0 years (range 23–­81 years).
Most participants were college-­educated. There was a signifi-
cant difference between the two groups in marital status (or living
with a partner), with those in the intervention group less likely to be
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204
TA B L E 1 Baseline characteristics of participants included in the analysisa
Variable Intervention
Number of participants 14
Age, y 35.3 ± 10.7
College graduate 12 (85.7)
Married or living with partner 7 (50)
c
Worst pain ever experienced 9.2 ± 1.1
a
Values are presented as mean ± standard deviation or as number (percentage).
b
Fisher's exact test.
c
Scale: 1–­10, with 10 the most severe imaginable.
F I G U R E 1 Changes in pain scores using the visual analog scale at baseline and 6-­week follow up. *P = 0.022
in a stable relationship (P = 0.006) (Table 1). Women in both groups
reported similar worst lifetime pain scores, ranging from 6 to 10 on a
10-­point pain VAS (Table 1).
At the 6-­week follow up, both the intervention and control group
scores suggested improvement compared with baseline in VAS pain
scores in the previous week and with most recent intercourse, but
this reached statistical significance only during the most recent in-
tercourse among those in the control group (P = 0.022, Figure 1).
Although each group tended to report increased knowledge about
vulvar and sexual health, only the intervention group had a statisti-
cally significant increase in self-­reported knowledge of both vulvar
and sexual health (P = 0.003 and P = 0.025, respectively, Figure 2)
when comparing their baseline and 6-­week follow up.
Although none of the changes on the FSFI scores reached statis-
tical significance within either the intervention group or the control
group, the intervention group showed a trend toward improvement
over baseline in all six domains of the FSFI, whereas the control
group only showed a trend toward improvement in three (arousal,
orgasm, and pain) domains (Figure 3). Similarly, the intervention
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MORAVEK et al.
Control P value
12 —­
42.8 ± 18.5 0.236
7 (58.3) 0.190 b
12 (100) 0.006b
8.9 ± 1.6 0.577
group showed statistically significant improvement in all domains of
the BIPQ except impact of treatment, which showed no change. The
control group only showed statistically significant improvement in
the perception of control and illness severity domains when compar-
ing baseline to 6-­week follow up (Figure 4a,b).
Regression analysis was performed to assess whether the
changes noted at the 6-­week follow up in the intervention and
control groups differed from each other (assessed within one sta-
tistical model). Although the intervention group had improved sta-
tistically within their own group regarding domains on the BIPQ,
their improvement did not differ significantly when compared with
the change in the domain scores of the control group. Similarly, the
changes in domain scores on the FSFI were not significantly dif-
ferent between the intervention and control groups. There was no
statistical difference between the two groups of women regard-
ing worse vaginal/vulvar pain in the past week and worse vaginal/
vulvar pain with the most recent intercourse, estimated change in
vulvar pain, knowledge about vulvar health and sexual health, con-
trol over vulvar pain, estimated duration that the vulvar pain will
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MORAVEK et al. 205

F I G U R E 2 Self-­assessed knowledge at baseline and 6-­week follow up. *P = 0.003; **P = 0.025

F I G U R E 3 Mean scores on Female Sexual Function Index (FSFI) domains at baseline and 6-­week follow up. Higher scores indicate better
functioning. All differences were not significant at P < 0.05.

last or belief that treatment will help, severity of vulvar pain, and less emotional effect from their vulvar symptoms compared with
concern about the pain. However, the intervention group did differ the control group (P = 0.035). These changes remained even when
from the control group on the questions regarding better under- controlled for marital status—­a variable that differed between the
standing of their vulvar symptoms (P = 0.005) and experiencing two groups.

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206
F I G U R E 4 Mean scores on Brief Illness Perception Questionnaire (BIPQ) at baseline and 6-­week follow up. (a) Higher scores indicate
more favorable perceptions. (b) Lower scores indicate more favorable perceptions. *P < 0.05.
Women in both groups received the resource list. Of the women
who reported reading it (15/26, 57.7%), all (15/15, 100%) found it at
least somewhat helpful, and many (10/15, 66.7%) reported looking
up at least one of the provided references.
Of the 12 women in the intervention group who answered ques-
tions on the follow-­up questionnaire about their impression of the
counseling session, most (10/12, 83.3%) thought it taught them in-
formation about vulvodynia, and the majority (9/12, 75.0%) felt that
it gave them skills to better cope with vulvar pain and discomfort.
4 | DISCUSSION
This is the first study to report the effect of a single-­session psy-
chosocial counseling intervention on vulvodynia and associated
symptoms.
Although group support for vulvodynia patients has been re-
ported to be beneficial, no previous studies have evaluated the
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MORAVEK et al.
effect of a one-­time, individualized psychosocial intervention on
outcomes for vulvodynia patients.9,10 In one session, a therapist can
validate the patient's experience and address cognitive distortions.
Additionally, they can discuss coping mechanisms and address rela-
tionship and sexual dysfunction—­and empower patients to take an
active role in addressing these issues.
After just one counseling session, at the 6-­week follow-­up sur-
vey, patients reported improved understanding of vulvodynia and a
lessened emotional impact from their disease, as opposed to the con-
trol group, which did not demonstrate such changes. Interestingly,
although both groups demonstrated a trend toward improvement
in a number of items, such as lessened vulvar pain in the past week
and with most recent intercourse, there was no statistical difference
between the two groups of women on many of these measures.
Moreover, only 57.7% of patients reported reading the written
resource list provided to both groups, illustrating the importance
of an initial psychosocial session to present this material. An addi-
tional benefit of early contact with a psychosocial counselor may be

MORAVEK et al.
identification of patients who would benefit from more intensive or
long-­term behavioral health therapy.
The psychosocial needs of patients with vulvodynia and their
partners have been demonstrated in numerous reports. Multiple
studies suggest that there is a need to address the psychosocial as-
pects of living with vulvodynia in every treatment plan, as many of
these patients have depression, anxiety, emotional distress, somati-
zation, irritability, and anger.11–­14
Additionally, women with vulvodynia tend to have increased dif-
ficulty expressing feelings and communicating with their partners.
They report higher scores when evaluating negative impact on rela-
tionships, even when compared with women with other vulvar disor-
ders.15 Another study found detrimental effects on sexuality, chronic
pain, and individual and relational well-­being in women with superfi-
cial dyspareunia compared with controls.16 Decreased frequency and
satisfaction with intercourse, distress about sexuality, negative sexual
attitudes, and a more negative effect during their most recent sexual
15,16
encounter have been noted. Some women with vulvodynia find
that stress exacerbates their symptoms of pain, limiting their activities.
Psychosocial therapy may be beneficial in this population.
The relationship between the psychological characteristics of
women with vulvodynia and the pain they are experiencing is also
being assessed. It has been theorized that the psychosocial stresses
of vulvodynia trap many patients in a cycle of unhappiness, resulting
in changes in personality and relationship dynamics.11 Furthermore,
it has been reported that many women with vulvodynia have dys-
function in their relationships—­both sexual and nonsexual.15 It is
unclear whether these issues are considered to be part of the etiol-
ogy of vulvodynia, possible complications of vulvodynia, or comor-
bid conditions. The comorbid conditions are important to note, as
syndromes of chronic pain can be associated with one another and
affect adjacent anatomical areas.
Studies suggest that psychological interventions for vulvodynia
should focus on increasing couples' acceptance of vulvovaginal pain
in order to lessen women's pain and to improve the sexual and psy-
chological functioning of both members of the couple.17 Clinical tri-
als have found cognitive–­behavioral therapy (CBT) to be efficacious
in reducing vulvovaginal pain and improving associated psychosex-
ual outcomes. A positive effect of CBT group sessions and more
long-­term therapy in conjunction with medical interventions for the
treatment of vulvodynia has been investigated.16–­19 Mindfulness
(use of an acceptance-­based approach to treatment) has been used
alongside, or instead of, CBT in women with vulvodynia.11,12,18–­22
However, not all women are able or willing to commit to multiple
sessions with a therapist.
A one-­time psycho-­educational session would not be considered
to be as intensive as the CBT therapy described in those studies—­
suggesting that referral for further psychosexual treatment should
be considered for women reporting significant psychological, sex-
23
ual, and/or relationship distress —­distress that may be recognized
in the single-­session modeling in this study.
Limitations of the study include a small sample size, which lim-
ited the power of the study to detect differences between the two
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207
groups. With greater numbers of participants, additional differences
between the intervention and control groups may be recognized.
Additionally, there was a significant difference in marital status be-
tween the two groups, although controlling for this difference in the
final analysis comparing the two groups did not impact the findings.
It is also difficult to make any definitive statements on long-­term
benefit, given that patients were only evaluated at the 6-­week fol-
low up. The inability to detect other significant differences in pain
and other psychological and sexual estimates may be related to this
short follow-­up period; further study over a longer period of time
may be beneficial for clarifying this. Finally, the entire study was
performed at a single center; although this is a strength in that the
patients in both groups received consistent care, it may make the re-
sults less generalizable to the population as a whole. With this small
sample, there is the possibility that other factors may also be playing
a role. This can be further assessed in future studies.
As there is often a delay in a diagnosis of vulvodynia, with re-
sultant negative effects on relationships and sexual functioning,
psychosocial counseling sessions can restore hope to this vulnerable
population. A larger study to address the limitations of this study,
and to more thoroughly examine the role of a single-­session psy-
chosocial counseling intervention for patients with vulvodynia, is
needed.
In conclusion, a single one-­on-­one psychosocial counseling ses-
sion for patients with vulvodynia improved their understanding of
their vulvodynia and lessened the emotional impact of their illness
compared with the control group, which did not demonstrate such
changes. A written resource list provided to both groups was only
read by just over half of the patients, illustrating the importance of
an initial psychosocial session to present this material. Additionally, a
psychosocial counselor may assist in identifying patients who would
benefit from more intensive or long-­term behavioral health therapy.
AU T H O R C O N T R I B U T I O N S
MBM: design, planning, data analysis, and manuscript writing; LJL:
design, planning, data analysis, and manuscript writing; CKP: design,
conduct; KB: design, conduct; BDR: design, planning, data analysis,
and manuscript writing; HKH: design, planning, data analysis, and
manuscript writing.
AC K N OW L E D G M E N T S
Support for this study was provided in part by the Ansbacher Fund
for Resident Education and Research at The University of Michigan
Department of Obstetrics and Gynecology, The University of
Michigan Department of Family Medicine, and The University of
Michigan Department of Social Work.
C O N FL I C T O F I N T E R E S T
The authors have no conflicts of interest.
DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from
the corresponding author upon reasonable request.
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208
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How to cite this article: Moravek MB, Legocki LJ, Piper CK,
Bernard K, Reed BD, Haefner HK. Impact of a single-session
psychosocial counseling intervention for women with
vulvodynia. Int J Gynecol Obstet. 2023;160:202-208. doi:
10.1002/ijgo.14321