By Rebecca Bowers

As you check the chart for the next patient, you note that she is complaining of burning, stinging, and irritation of the vulvar region. What possible diagnoses come to mind?

Consider vulvodynia, which is a chronic condition that causes pain and burning in the vulva in the absence of an infection or other known disease. The pain varies from mild to excruciating, and may be provoked, spontaneous, or both.1 Although the condition is common, it is rarely diagnosed. Vulvodynia is estimated to affect 8-15% of women, research suggests.2

A review of available evidence indicates that many vulvodynia interventions do not exhibit strong effectiveness in reducing pain associated with the condition. Also, while many vulvodynia treatments may lessen vulvovaginal pain and associated sexual impairments, they do not eliminate them.3

Gabapentin, a medication that is approved as a treatment for nerve-related pain and other conditions, is being studied for use in treatment of vulvodynia.4

Previous studies have suggested that gabapentin decreases pain from fibromyalgia, notes the study’s lead author, Gloria Bachmann, MD, MMS, director of the Women’s Health Institute at Rutgers Robert Wood Johnson Medical School. Researchers theorized that reducing pelvic floor muscle pain might reduce vulvodynia pain overall and, thus, improve sexual function, she says.

A total of 230 women, with an average age of 37, participated in study. Most of them had experienced vulvodynia for more than five years. Those who received the study medication experienced less pain and reported improved sexual desire, arousal, and satisfaction after using the oral medication. However, overall sexual function remained lower than for women without the pain disorder.4

“We found that women with greater muscle pain responded better in terms of pain and improved arousal than those with less pain, which suggests that gabapentin be considered for treatment in women who have significant muscle tightness and spasm in the pelvic region,” said Bachmann in a press statement.

Gabapentin’s potential for abuse has sparked regulatory review in jurisdictions experiencing high rates of opioid addiction, since some opioid users may seek alternatives to their chosen drug. Since 2016, 14 of 51 U.S. states and jurisdictions have implemented legislative mandates that require pharmacovigilance programs, have amended rules and regulations, or are pursuing further avenues for tracking gabapentin use.5

Examine the Options

Many women may suffer with vulvodynia without knowing that their symptoms have a name and that they can be treated. Research indicates that about 60% of affected women seek treatment, and about half overall receive a formal diagnosis.5

Medical options come in the form of pills, injections, and topical treatments. Use of local anesthetics prior to sexual intercourse may provide short-term pain relief.6 Antidepressants, such as amitriptyline, desipramine, or nortriptyline, may help with the symptoms of vulvodynia. Most women require starting at a low dose with slow titration over a time period of weeks to a higher dose.7 In some cases, application of estrogen cream to the vulva may help relieve vulvodynia symptoms, especially in perimenopausal women.

Physical therapy is another option for vulvodynia treatment. Physical therapy techniques can help relax tissues in the pelvic floor and relieve muscle and joint tension. Biofeedback also strengthens the pelvic floor muscles, which may help decrease pain.

To understand the pain experienced by women who present with vulvodynia, a comprehensive assessment is necessary, advised an expert committee convened at the Fourth International Consultation on Sexual Medicine in 2015.8 The committee suggested progressing from less invasive to more invasive treatments.

How can clinicians advise women about relief of chronic vulvar pain? Consider the following suggestions from the American College of Obstetricians and Gynecologists:

  • Wear underwear that is 100% cotton, and no underwear at night.
  • Avoid pantyhose and undergarments that are tight-fitting.
  • Avoid douching.
  • Use mild soaps when bathing, and clean the vulva with water only.
  • Do not use vaginal wipes or deodorants; avoid bubble bath.
  • Do not use pads or tampons with deodorants.
  • Use lubrication during intercourse.
  • Apply cool gel packs to the vulva area to decrease pain and itching.
  • Avoid exercises that put pressure directly on the vulva, such as bicycling.9 

REFERENCES

  1. Reed BD, Legocki LJ, Plegue MA, et al. Factors associated with vulvodynia incidence. Obstet Gynecol 2014;123(2 Pt 1):225-231.
  2. Phillips NA, Brown C, Foster D, et al. Presenting symptoms among premenopausal and postmenopausal women with vulvodynia: A case series. Menopause 2015;22:1296-1300.
  3. Goldstein AT, Pukall CF, Brown C, et al. Vulvodynia: Assessment and treatment. J Sex Med 2016;13:572-590.
  4. Bachmann GA, Brown CS, Phillips NA, et al. Effect of gabapentin on sexual function in vulvodynia: A randomized, placebo-controlled trial. Am J Obstet Gynecol 2019;220:89.e1-89.e8.
  5. Harlow BL, Kunitz CG, Nguyen RH, et al. Prevalence of symptoms consistent with a diagnosis of vulvodynia: Population-based estimates from 2 geographic regions. Am J Obstet Gynecol 2014;210:40.e1-e8.
  6. Sadownik LA. Etiology, diagnosis, and clinical management of vulvodynia. Int J Womens Health 2014;6:437-449.
  7. Leo RJ, Dewani S. A systematic review of the utility of antidepressant pharmacotherapy in the treatment of vulvodynia pain. J Sex Med 2013;10:2497-2505.
  8. Goldstein AT, Pukall CF, Brown C, et al. Vulvodynia: Assessment and treatment. J Sex Med 2016;13:572-590.
  9. American College of Obstetricians and Gynecologists. Vulvodynia. April 2017. Available at: https://bit.ly/2smykd9. Accessed Jan. 18, 2019.