Chronic vulvar symptoms and dermatologic disruptions: How to make the correct diagnosis
When a patient reports chronic symptoms, it’s important to look beyond yeast infection and other common causes to accurately identify her condition and select the optimal treatment
Read Part 2: Chronic vulvar irritation, itching, and pain. What is the diagnosis? (June 2014)
Most postmenopausal women with lichen sclerosus also exhibit hypothyroidism, so they should be monitored for this. However, thyroid function testing in 18 children showed no evidence of hypothyroidism in that age group (L.E. unpublished data).
Estrogen replacement may be advised
Postmenopausal women who have prominent introital lichen sclerosus or dyspareunia should receive estrogen replacement of some type so that there is only one cause, rather than two, for their dyspareunia, thinning, fragility, and inelasticity.
Women with well-controlled lichen sclerosus should be followed twice a year to ensure that their disease remains suppressed with ongoing therapy, and to evaluate for active disease, adverse effects of therapy, and the appearance of dysplasia or squamous cell carcinoma.
Women with lichen sclerosus occasionally experience discomfort after their clinical skin disease has cleared. These women now have developed vulvodynia triggered by their lichen sclerosus.
Related series: Vulvar Pain Syndromes—A 3-part roundtable
Part 1. Making the correct diagnosis (September 2011)
Part 2. A bounty of treatments—but not all of them proven (October 2011)
Part 3. Causes and treatment of vestibulodynia (November 2011)
CASE 2. IS IT REALLY CHRONIC YEAST INFECTION?
A 36-year-old woman consults you about her history of chronic yeast infection that manifests as introital burning, discharge, and dyspareunia. She is otherwise healthy, except for irritable bowel syndrome and fibromyalgia.
Physical examination reveals a mild patchy redness of the vestibule and surrounding modified mucous membranes (FIGURE 2). Gentle probing with a cotton swab triggers exquisite pain in the vestibule, with slight extension to the labia minora. A wet mount shows no evidence of increased white blood cells, parabasal cells, clue cells, or yeast forms. Lactobacilli are abundant.
Diagnosis: Vulvodynia, with a nearly vestibulodynia pattern.
Treatment: Venlafaxine and pelvic floor physical therapy.
Vulvodynia is a genital pain syndrome defined as sensations of chronic burning, irritation, rawness, and soreness in the absence of objective disease and infection that could explain the discomfort. Vulvodynia occurs in approximately 7% to 8% of women.4
Vulvodynia generally is believed to be a multifactorial symptom, occurring as a result of pelvic floor dysfunction and neuropathic pain,5,6 with anxiety/depression issues exacerbating symptoms. Some recent studies have shown the presence of biochemical mediators of inflammation in the absence of clinical and histologic inflammation.7 Discomfort often is worsened by infections or the application of common irritants (creams, panty liners, soaps, some topical anesthetics). Estrogen deficiency is another common exacerbating factor.
Women tend to exhibit other pain syndromes such as chronic headaches, fibromyalgia, temperomandibular disorder, or premenstrual syndrome, as well as prominent anxiety, depression, sleep disorder, and so on.
Almost uniformly present are symptoms of pelvic floor dysfunction, such as constipation, irritable bowel syndrome, and interstitial cystitis or urinary symptoms in the absence of a urinary tract infection. These women also are frequently unusually intolerant of medications.
Classifying vulvodynia
There are two primary patterns of vulvodynia. The first and most common is vestibulodynia, formerly called vulvar vestibulitis. The term vestibulitis was eliminated to reflect the absence of clinical and histologic inflammation. Vestibulodynia refers to pain that is always limited to the vestibule. Generalized vulvodynia, however, extends beyond the vestibule, is migratory, or does not include the vestibule.
Several vulvologists have found that many patients exhibit features of both types of vulvodynia, and these patterns probably exist on a spectrum. The difference is probably unimportant in clinical practice, except that vestibulodynia can be treated with vestibulectomy.
How we manage vulvodynia
We focus on pelvic floor physical therapy and on the provision of medication for neuropathic pain, which is initiated at very small doses and gradually increased to active doses.8 The medications used and the ultimate doses often required include:
- amitriptyline or desipramine 150 mg
- gabapentin 600 to 1,200 mg three times daily
- venlafaxine XR 150 mg daily
- pregabalin 150 mg twice a day
- duloxetine 60 mg a day.
Compounded amitriptyline 2% with baclofen 2% cream applied three times daily is beneficial for many patients, and topical lidocaine jelly 2% or ointment 5% (which often burns) can help provide immediate temporary relief.
Most patients require sex therapy and counseling for maximal improvement. Women with vestibulodynia in whom these therapies fail are good candidates for vestibulectomy if their pain is strictly limited to the vestibule. Fortunately, most women do not require this aggressive therapy.
Related article: Successful treatment of chronic vaginitis Robert L. Barbieri, MD (Editorial; July 2013)
CASE 3. SEVERE ITCHING DISRUPTS SLEEP
A 34-year-old patient reports excruciating itching, with disruption of daily activities and sleep. She has been treated for candidiasis on multiple occasions, but in your office her wet mount and confirmatory culture are negative. Physical examination reveals a pink, lichenified plaque with excoriation (FIGURE 3).
