The guideline notes without judgment that many women use complementary and alternative therapies “before, during, and after seeking conventional medical diagnosis and treatment for their vulvar pain symptoms.” These include acupuncture, calcium citrate, low-oxalate diets, oatmeal water and saltwater baths, and, according to Dr. Haefner, hypnosis and botulinum toxin (Botox) injections.
“There are a lot of different things out there that need to be duplicated in different studies,” she said, describing low-oxalate diets, in particular, as controversial.
Finally, the guideline says vulvodynia is not a psychopathologic condition, but patients should receive emotional and psychological support during treatment.
For more information, contact the International Society for the Study of Vulvovaginal Disease by calling 704-814-9493 or go towww.issvd.org
Experts Dispute Psychosexual Factors
The new vulvodynia guideline rejects the assumption that vulvar pain without a clinically identifiable cause is all in a woman's head but notes that “sex therapy, couples counseling, psychotherapy, or a combination thereof” can be very helpful to patients.
“For years, there were people who thought it was a psychosomatic illness, and there are some people who still do believe that,” Dr. Haefner said. “I don't think it is. However, psychologically, many of our patients are depressed.”
The first description of vulvodynia in an 1880 medical textbook called the condition “hyperaesthesia of the vulva,” she said.
Although it has become more prevalent following recent media attention to women's accounts of the disorder, vulvodynia affects far more women and has been around far longer than has been recognized, she said.
Just what causes vulvodynia is still unclear. Dr. Haefner cited current thinking that the condition is neurologic or inflammatory in origin. (She leans toward neurologic but acknowledged it could be both.) Although she discounted sexual abuse as no more common in vulvodynia patients than in the general population, she said that it could be a factor in individual cases.
Elizabeth “Libby” Edwards, M.D., chief of dermatology of the Southeast Vulvar Clinic in Charlotte, N.C., said that many vulvodynia patients have psychosexual issues but also described them as a result of the illness.
“Depression, anxiety, psychosexual dysfunction is rarely, if ever, a cause of vulvodynia. I don't discount the possibility that it may occasionally happen,” said Dr. Edwards, also of the University of North Carolina at Chapel Hill.
Dr. Edwards, a dermatologist who specializes in vulvar disorders, said she encourages patients to go for counseling, but most won't go. She said her message is “not 'You're crazy, and that makes you hurt,' but 'You hurt, and that will make you crazy.'”
Sexual abuse is a major underlying factor for vulvodynia patients, according to Esperanza McKay, M.D., a biofeedback clinician at the Pain Management Center in Houston. That should not cause anyone to underestimate the women's suffering, she advised.
“Their pain is really very real,” she said. “The first thing I do is listen to them. You will be amazed at how many have been sexually abused.”
Dr. McKay recommended waiting 3 or 4 months until a treatment begins to succeed before bringing up counseling. Many patients do not trust psychiatry and need to develop trust in the clinician before they will agree to go for counseling, she said.
Peter J. Lynch, M.D., a professor emeritus at the University of California, Davis, also advocated psychiatric help, warning that extreme cases can be the result of severe sexual abuse. “I happen to believe that psychosexual issues are an important cause of vulvodynia,” he said.