Expert Commentary

VULVAR PAIN SYNDROMES A bounty of treatments—but not all of them are proven

OBG Manag. 2011 October;23(10):29-41

	Neal M. Lonky, MD, MPH, moderator of this discussion, is Clinical Professor of Obstetrics and Gynecology at the University of California–Irvine and a member of the Board of Directors of Southern California Permanente Medical Group. He serves as an OBG Management Contributing Editor.
	Libby Edwards, MD, is Adjunct Clinical Associate Professor of Dermatology at the University of North Carolina in Chapel Hill, NC, and Chief of Dermatology at Carolinas Medical Center in Charlotte, NC. Dr. Edwards is a Past President and Past Secretary General of the International Society for the Study of Vulvovaginal Disease.
	Jennifer Gunter, MD, is Director of Pelvic Pain and Vulvovaginal Disorders for Kaiser Permanente in San Francisco, Calif.
	Hope K. Haefner, MD, is Professor of Obstetrics and Gynecology at the University of Michigan Hospitals and Co-Director of the University of Michigan Center for Vulvar Diseases in Ann Arbor, Mich.
*The authors report no financial relationships relevant to this article.*

Treatments for vulvodynia and vestibulodynia range from lifestyle adjustments and application of topical agents to tricyclic antidepressants and nerve blocks—but the data on their efficacy are not as bountiful

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IN THIS ARTICLE

Therapies discussed by the panel
How to determine which treatments are best
Is physical therapy underrated?

References

1. Nyirjesy P, Lev-Sagie A, Mathew L, Culhane JF. Topical amitriptyline-baclofen cream for the treatment of provoked vestibulodynia. J Lower Genital Tract Dis. 2009;13(4):230-236.

2. Haefner HK, Collins ME, Davis GD, et al. The vulvodynia guideline. J Lower Genital Tract Dis. 2005;9(1):40-51.

3. Foster DC, Kotok MB, Huang L, et al. Oral desipramine and topical lidocaine for vulvodynia: a randomized controlled trial. Obstet Gynecol. 2010;116(3):583-593.

4. Nyirjesy P, Sobel JD, Weitz MV, Leaman DJ, Small MJ, Gelone SP. Cromolyn cream for recalcitrant idiopathic vulvar vestibulitis: results of a placebo-controlled trial. Sex Transm Infect. 2001;77(1):53-57.

5. Zolnoun DA, Hartmann KE, Steege JF. Overnight 5% lidocaine ointment for treatment of vulvar vestibulitis. Obstet Gynecol. 2003;102(1):84-87.

6. Boardman LA, Cooper AS, Blais LR, Raker CA. Topical gabapentin in the treatment of localized and generalized vulvodynia. Obstet Gynecol. 2008;112(3):579-585.

7. Reed BD, Haefner HK, Edwards L. A survey on diagnosis and treatment of vulvodynia researchers and members of the International Society for the Study of Vulvovaginal Disease. J Reprod Med. 2008;53(12):921-929.

8. Brown CS, Wan J, Bachmann G, Rosen R. Self-management amitriptyline, and amitriptyline plus triamcinolone in the management of vulvodynia. J Women Health (Larchmt). 2009;18(2):163-169.

9. Reed BD, Caron AM, Gorenflo DW, Haefner HK. Treatment of vulvodynia with tricyclic antidepressants: efficacy and associated factors. J Low Genit Tract Dis. 2006;10(4):245-251.

10. Munday PE. Response to treatment in dysaesthetic vulvodynia. J Obstet Gynecol. 2001;21(6):610-613.

11. McKay M. Dysesthetic (“essential”) vulvodynia: treatment with amitriptyline. J Reprod Med. 1993;38(1):9-13.

12. Dworkin RH, O’Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain. 2007;132(3):237-251.

13. Harris G, Horowitz B, Borgida A. Evaluation of gabapentin in the treatment of generalized vulvodynia unprovoked. J Reprod Med. 2007;52(2):103-106.

14. Ben-David B, Friedman M. Gabapentin therapy for vulvodynia. Anesth Analg. 1999;89(6):1459-1460.

15. Meltzer-Brody SE, Zolnoun D, Steege JF, Rinaldi KL, Leserman J. Open-label trial of lamotrigine focusing on efficacy in vulvodynia. J Reprod Med. 2009;54(3):171-178.

16. Jerome L. Pregabalin-induced remission in a 62-year-old woman with a 20-year history of vulvodynia. Pain Res Manag. 2007;12(3):212-214.

17. Steinberg AC, Oyama IA, Rejba AE, Kellogg-Spadt S, Whitmore KE. Capsaicin for the treatment of vulvar vestibulitis. Am J Obstet Gynecol. 2005;192(5):1549-1553.

18. Murina F, Radici G, Bianco V. Capsaicin and the treatment of vulvar vestibulitis syndrome: a valuable alternative? Med General Med. 2004;6(4):48.-

19. Park AJ, Paraiso MFR. Successful use of botulinum toxin type A in the treatment of refractory postoperative dyspareunia. Obstet Gynecol. 2009;114(2 pt 2):484-487.

20. Brown CS, Glazer HI, Vogt V, Menkes D, Bachmann G. Subjective and objective outcomes of botulinum toxin type A treatment in vestibulodynia: pilot data. J Reprod Med. 2006;51(8):635-641.

21. Dykstra DD, Presthus J. Botulinum toxin type A for the treatment of provoked vestibulodynia: an open-label pilot study. J Reprod Med. 2006;51(6):467-470.

22. Romito S, Bottanelli M, Pellegrini M, Vicentini S, Rizzuto N, Bertolasi L. Botulinum toxin for the treatment of genital pain syndromes. Gynecol Obstet Invest. 2004;58(3):164-167.

23. Bertolasi L, Frasson E, Cappelletti JY, Vicentini S, Bordignon M, Graziottin A. Botulinum neurotoxin type A injections for vaginismus secondary to vulvar vestibulitis syndrome. Obstet Gynecol. 2009;114(5):1008-1016.

24. Presthus JB, Dykstra DD. Botulinum toxin therapy for vulvodynia. NVA News. National Vulvodynia Association. 2007;12(3).

25. Peterson CD, Giraldi A, Lundvall L, Kristensen E. Botulinum toxin type A—a novel treatment for provoked vestibulodynia? Results from a randomized placebo-controlled, double-blinded study. J Sex Med. 2009;6(9):2523-2537.

26. Yoon H, Chung WS, Shim BS. Botulinum toxin A for the management of vulvodynia. Int J Impot Res. 2007;19(1):84-87.

27. Gunter J, Brewer A, Tawfik O. Botulinum toxin A for vulvodynia: a case report. J Pain. 2004;5(4):238-240.

28. Segal D, Tifheret H, Lazr S. Submucous infiltration of betamethasone and lidocaine in the treatment of vulvar vestibulitis. Eur J Obstet Gynecol Reprod Biol. 2003;107(1):105-106.

29. Murina F, Tassan P, Roberti P, Bianco V. Treatment of vulvar vestibulitis with submucous infiltrations of methylprednisolone and lidocaine. An alternative approach. J Reprod Med. 2001;46(8):713-716.

30. Dede M, Yenen MC, Yilmaz A, Baser I. Successful treatment of persistent vulvodynia with submucous infiltration of betamethasone and lidocaine. Eur J Obstet Gynecol Reprod Biol. 2006;124(2):258-259.

31. Dionisi B, Anglana F, Inghirami P, Lippa P, Senatori R. Use of transcutaneous electrical stimulation and biofeedback for the treatment of vulvodynia (vulvar vestibular syndrome): results of 3 years of experience [in Italian]. Minerva Ginecol. 2008;60(6):485-491.

READ THE SERIES

Part 1: Making the correct diagnosis
(September 2011)
Part 3: Vestibulodynia
(November 2011)

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