Clinical Review

Vulvovaginal disorders: 4 challenging conditions

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References

Powerful corticosteroids are treatment of choice

Treatment can control lichen sclerosus, relieve symptoms, and prevent further anatomical changes. Potent or ultrapotent topical corticosteroids in an ointment base are preferred. These drugs are now widely recognized for their efficacy and minimal adverse effects, although no regimen is universally advocated.14 The patient applies ointment once daily for 1 to 3 months, depending on severity, and then once or twice a week.

Ointments are preferred over creams for vulvar treatment, because creams frequently contain allergens or irritants such as fragrance and propylene glycol preservative.

I continue once-weekly therapy indefinitely in postmenopausal women. If a premenopausal woman is not comfortable using the ointment indefinitely, I will allow her to discontinue treatment but follow her every 3 to 6 months.

Treatment also requires educating the patient about the disease, instructing her in gentle local care, and showing her exactly where to apply the ointment.

In all cases, lifelong follow-up is necessary. Hyperkeratosis, ecchymoses, fissuring, and erosions resolve, but atrophy and color change remain. Scarring usually remains unchanged, but may resolve if treated early in the course of the disease.15

Testosterone is not as effective as an ultrapotent steroid,16 and is no more effective than an emollient.17

Estrogen is valuable for skin integrity, but has no role in the treatment of lichen sclerosus.

Dilator work may be necessary for dyspareunia, once the disease is controlled.

Refer for help with depression and/or negative body image, if present.

4. VestibulodyniaEight treatment options to try

The prevalence of pain in an ethnically diverse population is 16%, and approximately half of this figure (8%) represents vulvodynia.18 The International Society for the Study of Vulvovaginal Disease now classifies vulvar pain in 3 categories:

  • vulvar pain with a known cause, including infection, trauma, and systemic disease (TABLE 2),
  • generalized vulvodynia, also known as dysesthetic vulvodynia, essential vulvodynia, or pudendal neuralgia, and
  • localized vulvodynia or vestibulodynia, formerly called vestibulitis, vulvar vestibulitis syndrome, and vestibular adenitis.

Terminology is likely to evolve with further study.

Vestibulodynia, the leading cause of dyspareunia in women under age 50,19 refers to pain on touch within the vestibule. It is primary pain if it has been present since the first tampon use or sexual experience, and it is secondary if it arises after a period of comfortable sexual function.

TABLE 2

Rule out these known causes of vulvar pain

INFECTIONS
  • Bartholin abscess
  • Candida albicans
  • Herpes
  • Molluscum
  • Trichomonas
TRAUMA
  • Sexual assault
  • Other physical injury
SYSTEMIC DISEASE
  • Behçet disease
  • Crohn disease
  • Sjögren syndrome
  • Systemic lupus erythematosus
CANCER AND PRE-CANCER
  • Vulvar cancer
  • Vulvar intraepithelial neoplasia (VIN)
IRRITANTS
  • Soaps
  • Sprays
  • Douches
  • Topical anesthetics
  • Antiseptics
  • Suppositories
  • Creams
  • HPV treatment
  • 5-FU
  • Laser treatment
SKIN CONDITIONS
  • Allergic or contact dermatitis
  • Eczema
  • Psoriasis
  • Hidradenitis suppurativa
  • Lichen planus
  • Lichen sclerosus
  • Pemphigoid and pemphigus
Source: Haefner and Pearlman27

Inflammation starts the cascade

Current theory suggests that inflammatory events such as yeast infection, seminal plasma allergy, and local chemical application release a cascade of cytokines that sensitizes nociceptors in the vestibular epithelium. Prolonged neural firing in turn alters neurons in the dorsal horn, allowing sensitization of mechanoreceptive fibers in the vestibule with sensory allodynia (pain on touch). The proliferation of introital nociceptive fibers is well documented.20

Diagnosis: Report of pain and a positive Q-tip test

When a woman reports superficial dyspareunia with introital contact and clinical examination reveals pain on touch in the vestibule (using a cotton swab), vestibulodynia is diagnosed, provided no other known causes of the vulvar pain are detected during a careful history and examination or after pH measurement, a wet mount, and any indicated cultures.

A careful psychosexual history can help the clinician identify current sexual practices, prior sexual issues, and the impact of the current sexual dysfunction with an eye toward guiding support and counseling.

Multifactorial treatment: 8 options

Because the cause of vestibulodynia is unclear, a multifactorial approach generally is accepted and involves the following:

  1. Patient education about the problem and instruction in gentle local care and the elimination of contactants.
  2. Referral for support, counseling, and treatment of depression, as indicated.
  3. Elimination of any known trigger such as C albicans, although this generally does not lead to remission unless the pain is also treated.
  4. Suppression of nociceptor afferent input using topical lidocaine hydrochloride, for which good results have been reported.21
  5. Systemic oral analgesia with a tricyclic antidepressant modulates the serotonin and epinephrine imbalance associated with persistent pain (TABLE 3).22
  6. Use of anticonvulsants such as gabapentin to increase the amount of stimuli needed for nerves to fire and elevate the central pain threshold.23
  7. Reduction of muscle tension and spasm in the pelvic floor, using physical therapy and biofeedback.24
  8. When medical management fails, vulvar vestibulectomy with vaginal advancement yields excellent long-term results,25 but should be a last resort.

TABLE 3

Tricyclic antidepressants modify chemical imbalance associated with persistent pain of vestibulodynia

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