CHICAGO — Vulvodynia is best managed with a multidisciplinary approach utilizing a wide variety of therapeutic options, Dr. Hope K. Haefner said at a conference on vulvovaginal diseases sponsored by the American Society for Colposcopy and Cervical Pathology.
Vulvodynia is a complex pain disorder that can be challenging to treat. Although spontaneous remission of symptoms has occurred in some women, rapid resolution of symptomatic vulvar pain is unusual, even with appropriate therapy.
Pain can be continuous or intermittent, and is often aggravated by activities such as sitting, riding, or sexual intercourse. The treatment of vulvar pain is confounded by the fact that the etiology is unknown in the majority of cases.
“I don't think it's one disease, so I don't think there's going to be one cure,” said Dr. Haefner, a recognized expert on the subject, and professor of obstetrics and gynecology and codirector of the University of Michigan Center for Vulvar Diseases.
Vulvar care measures to review with patients include using mild soaps for bathing, avoiding soap on the vulva, keeping the vulva dry without the use of hair dryers, wearing white 100% cotton underwear during the day, and sleeping without underwear. Wicking briefs can be used if sweating is a problem.
If menstrual pads are irritating, 100% cotton pads may be helpful, but the drawback is that none are disposable. Dr. Haefner expressed concern about the use of Always brand sanitary pads, which was a common variable among patients with vulvodynia in a small Canadian case series (Can. Med. Assoc. J. 1996;154:1173–6).
Procter & Gamble, the manufacturer of Always, stated in a letter that its premarket clinical trials, which included over 1,500 women and specifically evaluated the genital area, did not detect “any increased risk (either in frequency or severity) of irritation as a result of Always products in comparison with other marketed products (Can. Med. Assoc. J. 1996;155:1036).”
Vaginal lubricants such as olive oil, Replens, Slippery Stuff, Astroglide, KY Liquid, and Probe are recommended to provide adequate lubrication for intercourse.
Topical 5% lidocaine may be useful in treating vestibulodynia, but “it's not the answer for most patients,” Dr. Haefner said. For point tenderness, she prefers 0.5 cc of topical amitriptyline 2% with baclofen 2% in a water-washable base squirted from a syringe onto the finger and applied to the affected area daily and titrated up to three times a day if needed.
Vagisil (benzocaine) is not recommended, as it is a sensitizing agent and can cause rebound vasodilation and pain. Estrogen vaginal rings help some patients, she said.
Recent studies have shown some benefit in vestibulodynia with capsaicin ointment, which contains the extract of red chili peppers. Research has also been done in botulinum toxin type A injections for vulvar pain, with some reported benefits.
Among oral medications, Dr. Haefner favors the tricyclic antidepressants, particularly amitriptyline, rather than SSRIs. She starts amitriptyline at a dose of 25 mg orally every night for 1 week, or 10 mg nightly in patients age 60 or older or in those who wish to avoid the associated drowsiness. Contraception should be discussed with patients who are prescribed antidepressants, she said.
If there is no response after 4 weeks of tricyclics, Dr. Haefner typically switches to anticonvulsants such as Neurontin (gabapentin) or rarely Tegretol (carbamazepine), which have a clearly demonstrated role in the treatment of neuropathic pain. Lyrica (pregabalin) is the newest addition to this family, said Dr. Haefner, who disclosed no relevant conflicts of interest.
Dr. Haefner occasionally uses bupivacaine (0.25% or 0.5%) and Kenalog (triamcinolone acetonide) injections for patients with localized vulvodynia. “But you've got to make sure you're not using too high a steroid dose,” she warned. “If you use 40 mg total on the perineum, it can cause entire erosion and loss of the perineum.”
Physical therapy and biofeedback are commonly used in the treatment of vulvar pain, with success rates reported in the 60%–80% range and are particularly helpful if there is concomitant vaginismus.
Surgical excision of the vulvar vestibule has met with success in up to 80% of reported cases, but should be reserved for women in whom other strategies have failed, Dr. Haefner said.