Vulvar pain syndromes: Causes and treatment of vestibulodynia
Although the origins of vestibulodynia are incompletely understood, this subset of vulvar pain is manageable and—good news—even curable in some cases
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Vulvodynia and depression often travel together. They are such common comorbidities, in fact, that some physicians theorize that vulvodynia may be a symptom of an underlying mood disorder, such as depression, or that depression may be one manifestation of chronic vulvar pain. Suffice it to say that chronic pain and depression are often associated, and it is frequently difficult to determine whether the relationship is one of cause and effect.
Comprehensive care of the patient who has vulvar pain, therefore, should include a thorough history, looking specifically for depression (including sleep disorders) and eliciting information on any suicidal thoughts or intentions.
Although many patients who have vulvodynia are treated with an antidepressant, the dose that relieves pain may not be high enough to attenuate an accompanying mood disorder. My approach is to team up with a psychiatrist or psychologist who is familiar with vulvar pain syndromes. Together, we monitor the patient and fine-tune the therapeutic response.
—Neal M. Lonky, MD, MPH
Do oral contraceptives contribute to vestibulodynia?
Dr. Lonky: Is PVD more prevalent among OC users?
Dr. Haefner: Controversy surrounds the question of whether vestibulodynia and OC use are linked. Some studies suggest no association12–14 and others suggest a possible effect of OCs on vulvodynia.15–17 A study by Reed and colleagues found no association between taking OCs or hormone therapy at enrollment and incident vulvodynia only in the univariable analysis, but not when controlling for age at enrollment.18 This reflects the finding that younger age was associated with incident disease; younger age and use of OCs are similarly associated.
Dr. Gunter: I am not a believer in a cause-and-effect relationship between OC use and vestibulodynia. I do not find the studies demonstrating an association convincing. Given the supraphysiologic levels of hormones during pregnancy, if high hormone levels played a role, we should also see a greater incidence of vestibulodynia among women who have several pregnancies at an early age.
Dr. Edwards: In my practice, stopping, starting, and changing OCs has made no difference for patients. Topical estrogen supplementation in the occasional OC user who has signs of low estrogen has been useful at times.
Do herpes or genital warts contribute to PVD?
Dr. Lonky: Does a history of vulvar herpes or genital warts have any impact on the incidence of PVD?
Dr. Edwards: No.
Dr. Gunter: I agree that it has no impact.
Dr. Haefner: Herpes is sometimes associated with vulvar pain. The lesions resolve, but pain may continue as post-herpetic neuralgia. As with shingles, a low threshold for starting a patient on gabapentin to control pain after herpes may be beneficial.
Genital warts rarely cause vulvar pain—but the treatment may. Patients sometimes feel pain following topical treatment, as well as pain from surgical wart treatment.
Effect of demographic variables
Dr. Lonky: Does race, skin type, or hair or eye color make a difference in the prevalence, manifestation of symptoms, or treatment of PVD?
Dr. Gunter: I am not aware of any studies that confirm an association between vulvodynia and those factors.
Dr. Edwards: I don’t know whether any of these variables make a difference. My own impression—confirmed by informal study in my office—is that vulvodynia patients weigh less than my general dermatology patients and are better educated. I sometimes get the sense that my vulvodynia patients are more likely to be fair.
Dr. Lonky: What age group is most commonly affected by PVD?
Dr. Edwards: In my experience the most common age group is women 25 to 45 years old, probably because they are the most sexually active group old enough and tough enough to pursue this issue.
Dr. Gunter: I believe it affects all women equally, although women in their reproductive years are more likely to visit a gynecologist and, therefore, probably more likely to be given this diagnosis.
Dr. Lonky: Do you believe that PVD and generalized vulvar dysesthesia are curable—or just treatable?
Dr. Gunter: That depends on many variables. It is far more challenging to cure a patient who has multiple pain syndromes (for example, fibromyalgia, migraines, and irritable bowel syndrome) than the woman who simply has vestibulodynia or generalized vulvar pain. In addition, stress, anxiety, coping skills, and depression all play a role. In my opinion, a woman without comorbidity has a good chance of having her symptoms well-controlled. Some will be cured (that is, able to discontinue medications), and others will need ongoing treatment but will not be bothered by their symptoms.
