SAN FRANCISCO — Vulvodynia so profoundly affects quality of life that management needs to address the physical, psychological, sexual, and relationship problems caused by the pain.
“Support, support, support” patients with vulvodynia by reassuring them that they're not crazy and validating the reality of their pain, Dr. Erika Klemperer said at a meeting sponsored by Skin Disease Education Foundation.
Refer women with vulvodynia for psychological counseling when appropriate, but be clear about why you're doing so. “It's not because we think they're crazy, but because pain makes people crazy,” often triggering depression, anxiety, or other problems, said Dr. Klemperer, a private-practice dermatologist in Santa Barbara, Calif.
Vulvodynia is a diagnosis of exclusion defined as vulvar discomfort—usually a “burning” pain—occurring without any relevant visible findings or a specific, clinically identifiable, neurologic disorder. Patients may have generalized vulvodynia or vestibulodynia. An estimated 3%–16% of women experience vulvodynia during their lifetimes.
Dr. Klemperer tells patients, “I know this pain isn't in your head. This is real, and I'm going to be here to get you through this.” Make an effort to understand clearly the patient's and her partner's goals for therapy so that you can guide them toward realistic expectations, because treatment may not cure the problem but should help control the pain. There are few randomized, controlled trials on treating vulvodynia, so therapy rests on expert opinion and few data.
Treatment starts with vulvar care measures, such as avoiding all irritants. Tell patients to wash the genital area using only their fingers and water, then pat dry (not blow dry). Bland emollients may help. For lubrication during intercourse, try olive oil to avoid the preservatives in commercial products.
First-line medication would be a topical anesthetic, especially for vestibulodynia. Other topical therapies tend to burn or are ineffective. Lidocaine 5% ointment or 2% gel may be used as needed or in twice- or thrice-daily regimens. Patients also can apply it 30 minutes before sexual activity but should wipe it off before sex so that it doesn't cause numbness in their partner. Dispense lidocaine gel in a 30-g tube and warn patients not to use more than 20 g per day to avoid side effects of erythema, edema, and purpura.
A 2003 study looked at women who placed a cotton ball coated with lidocaine 5% ointment on the vestibule and left it overnight, for at least 8 hours. About 75% of women were able to resume intercourse during the study, “which makes sense because we're trying to break that pain loop, break that feedback,” Dr. Klemperer said.
Off-label use of systemic therapies usually starts with tricyclic antidepressants, most often amitriptyline. Tricyclics improve vulvodynia by about 60% in around half of patients. Be specific in explaining to patients that you're using these medications to try to cool down nerve fibers, and that these regimens are used for other pain problems such as diabetic neuropathy or postherpetic neuralgias.
The key to systemic therapy is to start with a low dose and increase it slowly. Dr. Klemperer usually starts a tricyclic at 10 mg nightly, increasing by 5–25 mg/week to a maximum of 150 mg nightly. Amitriptyline is available in a syrup, “so you can titrate it down to a minuscule dose. The most important thing is that they tolerate it.”
Gabapentin, pregabalin, venlafaxine, and duloxetine have been used as second-line systemic therapies for vulvodynia. SSRIs have not been effective in these patients.
Chinese herbal remedies and acupuncture have benefited some of Dr. Klemperer's patients with vulvodynia, she said. She supports using complementary therapies such as hypnotherapy, meditation, and others if the patient is interested, though no clinical trials support their use. Strict dietary regimens probably are not wise in these already stressed-out patients, she added.
Injectable therapies have been tried, but the efficacy of interferon-α is questionable, so Dr. Klemperer doesn't use it. Trigger-point injections are difficult to tolerate. Pain specialists sometimes use nerve blocks for vulvodynia, and botulinum toxin has been mentioned in a few case reports.
Surgery should be reserved for patients with pure vestibulodynia with chronic, ongoing symptoms resistant to all other therapies. If vaginismus is present, treat that before sending the patient to vestibulectomy, which may alleviate symptoms in 60%–85% of cases.
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