HARVARD MEDICAL SCHOOL PRIMARY CARE REVIEW

Treatment of Vulvar Pain: A Worthwhile Clinical Challenge

July 7th, 2020

Many people experience sexual pain or dysfunction at various points throughout their lifetime, and women’s sexual pain conditions are often mis- or undiagnosed. A common pain disorder in women is vulvar pain, commonly referred to as vulvodynia or vestibulodynia, and it can have debilitating consequences for one’s sexual health and quality of life.

Vulvodynia (or vestibulodynia) is defined as vulvar pain lasting at least three months and without a clear identifiable cause. This condition affects up to 16% of women worldwide, translating into thousands of women searching for effective treatments, yet only 50% ever receive an accurate diagnosis. Inciting factors for persistent vulvar pain include genetic predisposition, altered hormonal status, inflammation, musculoskeletal dysfunction (i.e. hypertonic pelvic floor muscles), neurologic dysfunction (central or peripheral), psychosocial factors, and anatomical defects. Because multiple factors are often associated with the development and maintenance of vulvodynia, identification of the relevant factors in each individual has important treatment implications.

Treatment modalities

Current evidence and international consensus guidelines support psychological intervention and pelvic floor physical therapy as first-line treatments for the management of most chronic vulvar pain.

Cognitive behavioral therapy (CBT): CBT for vulvodynia aims to reduce pain and associated distress, improve sexual function and satisfaction, and strengthen one’s intimate relationships. CBT strategies target maladaptive thoughts, emotions, and behaviors that are associated with pain, improve communication skills, and seek to expand sexual behaviors beyond traditional intercourse. Research shows improvements in sexual pain with CBT, particularly when mindfulness training is included.

Pelvic floor physical therapy: Pelvic floor muscle dysfunction is a primary etiology for vulvar pain, which includes frequent pelvic floor muscle spasms, as well as decreased strength and coordination. Pelvic floor physical therapy includes stretching, dilation, massage, and myofascial trigger point release to facilitate muscle relaxation, improve circulation, and increase mobility. Research demonstrates that nearly 76% of women report improvement in pain with intercourse and gynecological exams, as well as increased sexual satisfaction.

Muscle relaxants: Various studies have shown potential improvement in vulvar pain with use of transvaginal diazepam, a benzodiazepine with muscle relaxing properties. Further, botulinum toxin (Botox) is a neurotoxin produced by Clostridium botulinum, and this neurotoxin induces localized muscle relaxation and pain relief. Various studies report significantly improved vulvar pain after the pelvic floor muscles are injected with botulinum toxin. Further clinical studies are underway to clarify findings from early studies.  

Hormonal mediation: Some research demonstrates increased incidence of vulvar pain among women using combined hormonal contraceptives, suggesting that relative estrogen or testosterone deficiency may contribute to vulvar pain. Application of topical estrogen to the vestibule, or combined estradiol and testosterone, may result in significant improvements in vulvodynia. Further clinical studies are needed to support this premise.

Anti-inflammatory treatment: Research has shown that inflammatory cytokines may be elevated in the vulvar tissue of women with vulvodynia, thereby supporting the use of anti-inflammatory agents. Potentially helpful medications with anti-inflammatory properties include enoxaparin (low-molecular-weight heparin with anti-heparinase activity) and meloxicam (COX-2 inhibitor). Further case reports utilizing local, subcutaneous lidocaine and methylprednisolone to the vestibule have shown some success. Anti-inflammatory interventions, though potentially beneficial, require further research.

Antinociceptive treatment: Topical capsaicin cream has demonstrated some improvement in vulvar pain in various clinical studies.

Surgical treatment: A vestibulectomy includes either partial or complete excision of the vestibular mucosa, which is an effective treatment for localized provoked vulvodynia. Vestibulectomy is nearly 90% effective in reducing chronic vulvar pain.

Though women’s sexual pain conditions are disproportionately mis- or undiagnosed, it doesn’t have to be that way. Vulvodynia affects thousands of women worldwide, and healthcare providers have numerous tools to address this common sexual pain disorder. A multidisciplinary model of care is optimal, which typically combines psychotherapy, physical therapy, and medical management. High-quality, biopsychosocial care improves patients’ sexual health and quality of life, and these benefits may also be experienced by their intimate partners.

**Feature photo by Ben Eaton on Unsplash

 

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HeadshotprofJpeg (1)Susan Kellogg-Spadt, PhD, CRNP, is the Director of Female Sexual Medicine at The Center for Pelvic Medicine in Bryn Mawr, Pennsylvania, Fellow of the International Society for the Study of Women’s Sexual Health, and serves on the Executive Board of the National Vulvodynia Association. She is also Professor of OB/GYN at Drexel University College of Medicine, Professor of Human Sexuality at Widener University, and Associate Professor at Rutgers Robert Wood Johnson School of Medicine.

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