- Part 1: Making the correct diagnosis
- Part 3: Vestibulodynia
As we discussed in the first installment of this three-part series in the September issue of OBG Management, the causes of vulvar pain are many, and the diagnosis of this common complaint can be difficult. Once the diagnosis of vulvodynia has been made, however, the challenge shifts to finding an effective treatment. Here, our expert panel discusses the many options available, the data (or lack of it) behind each therapy, and what to do in refractory cases.
In Part 3 of this series, in the November issue, the focus will be vestibulodynia.
The lower vagina and vulva are richly supplied with peripheral nerves and are, therefore, sensitive to pain, particularly the region of the hymeneal ring. Although the pudendal nerve (arrow) courses through the area, it is an uncommon source of vulvar pain.
Management of vulvar pain begins with simple measures
Dr. Lonky: How do you approach treatment of vulvar pain syndromes?
Dr. Haefner: I often advise the patient to begin with simple measures. For example, I recommend that she wear cotton underwear during the day, but no underwear at night. If she perspires with exercise, wicking underwear may be helpful. I also counsel the patient to avoid vulvar irritants, douches, and the application of soap of any kind to the vulva. Cool gel packs are sometimes helpful.
When it comes to intercourse, I recommend adequate lubrication using any of a number of effective products, such as olive oil, vitamin E oil, Replens, Slippery Stuff, Astroglide, KY Liquid, and others.
There is an extensive list of lubricants at http://www.med.umich.edu/sexualhealth/resources/guide.htm
Topical agents might offer relief—but so might placebo
Dr. Lonky: What is the role of topical medications, including anesthetics, for treating vulvar pain syndromes?
Dr. Edwards: I don’t find topical medications to be particularly useful in the treatment of vulvodynia, except for lidocaine 2% jelly, or lidocaine 5% ointment, which tends to burn with application—but I never start a patient on only one medication, so judging the effectiveness of a topical therapy is difficult in that context. Good studies of topical medications in the treatment of vulvar pain syndromes are lacking, other than the recent report on amitriptyline and baclofen.1
Dr. Haefner: For minor degrees of pain, consider lidocaine 5% ointment.
Lidocaine/prilocaine (eutectic mixture of local anesthesia or LMX) may be used but can be irritating.
Doxepin 5% cream can be applied to skin daily, gradually increasing the number of daily applications to as many as four.
Topical amitriptyline 2% with baclofen 2% in a water washable base has also been used for point tenderness (squirt 0.5 cc from a syringe onto the finger and apply it to the affected area three times a day).1
Dr. Gunter: Topical estrogen is prescribed by many providers, but we lack studies supporting its efficacy, except for reversing hypoestrogenic changes in postmenopausal women. Some providers use a high-dose, compounded topical estrogen with lidocaine for vestibulodynia. Certainly, local hypoestrogenic changes should be reversed in postmenopausal women before a diagnosis of vulvodynia or vestibulodynia is given.
As for other topical therapies, they are widely used. Some women report improvement with application of plain petrolatum.2 Response rates of 33% to 46% after use of a topical placebo for vestibulodynia are well described in the literature.3,4
Topical analgesics are used frequently, either sporadically (during pain flares) or regularly (daily application). One method of application for localized vestibulodynia involves liberally coating a cotton ball with lidocaine 5% and then applying it to the vestibule overnight (for at least 8 hours of exposure). In this study, after 7 weeks, 76% of women were able to be sexually active, compared with 36% before the start of treatment. However, a randomized, placebo-controlled trial that included lidocaine 5% cream in one arm identified only a 20% reduction in pain for women who had localized vestibulodynia—although, in this trial, the lidocaine was massaged into the vestibule four times daily.5 In this study, interestingly enough, topical lidocaine was less effective than topical placebo, which produced a 33% response rate.3
Lidocaine gel has also been used, although some women report more local irritation with gel than with ointment.
Dr. Lonky: Do we have any data on topical application of other drugs?
Dr. Gunter: Compounded adjuvant medications have been evaluated. In a retrospective study of topical gabapentin in a Lipoderm base, women who had generalized or localized vulvodynia applied a dose of 2%, 4%, or 6% three times daily. Of these women, 80% experienced a reduction of at least 50% in the pain score. In addition, 67% of patients who had localized vestibular pain were able to resume intercourse.6