Vulvodynia is chronic, unexplained vulvar pain or discomfort, characterized by burning, stinging, irritation, or rawness in the area around the opening of the vagina (i.e., the vulva). This is a poorly understood and under-researched pain syndrome for which optimal treatment remains unclear. The pain, burning or irritation associated with vulvodynia can make women so uncomfortable that sitting for long periods of time is tortuous and sexual intimacy becomes unthinkable. The condition can go on for months or years.
Susan Hoffstetter, PhD, associate professor in the Department of Obstetrics, Gynecology, and Women’s Health at the Saint Louis University School of Medicine, told Medscape: “The prevalence is anywhere from 3% to 18% of women of reproductive age, with onset most commonly between the ages of 18 and 25. Sadly, 60% of symptomatic women take an average of 3 different providers to receive the diagnosis of vulvodynia, and 40% of symptomatic women remain undiagnosed.”
Some women experience pain in only one area of the vulva or genitalia, while others experience pain in multiple areas. There are two main subtypes of vulvodynia, which sometimes co-exist:
• Vulvar Vestibulitis Syndrome (aka Provoked Vestibulodynia) is characterized by pain limited to the vestibule (the area surrounding the opening of the vagina). Pain occurs during or after pressure is applied to the vestibule, e.g., with sexual intercourse, tampon insertion, a gynecologic examination, prolonged sitting and/or wearing fitted pants.
• Generalized Vulvodynia occurs spontaneously and pain is relatively constant, although there can be some periods of symptom relief. Activities that apply pressure to the vulva, such as prolonged sitting or simply wearing pants, typically exacerbate symptoms.
If you have vulvodynia, don’t let the absence of visible signs or embarrassment about discussing the symptoms of vulvodynia keep you from seeking help. Treatment options are available to lessen the pain and discomfort of vulvodynia, ranging from topical therapies to oral medications, physical therapy and biofeedback. A physical therapist trained in treating pelvic floor muscle dysfunction can provide strengthening exercises that can be very helpful.
Blocking Pain Signals – The goal of drug treatment is to desensitize or block pain signals. Medications can be applied topically, directly on the vulva, taken orally or injected. Here are a few options:
• Topical anesthetics that contain lidocaine or capsaicin can be applied 30 minutes prior to the problematic activity to numb the affected area (avoid cortisone topical steroids). Local irritation from topical capsaicin has limited its use.
• Estradiol cream
• Antidepressant and anti-seizure medications that are known to have pain-reducing qualities
• Trigger-point injections of steroids or Botox
Oral gabapentin has been used to successfully manage neuropathic pain syndromes including vulvodynia. The clinical efficacy and tolerability of topical gabapentin 6% cream was evaluated. Patients were instructed to apply a small amount of cream (approximately 0.5 mL, equivalent to the size of a pea) three times daily. The researchers found that after a minimum of 8 weeks of therapy, pain was significantly reduced and sexual function improved. Common adverse effects of oral gabapentin – including dizziness, somnolence, and peripheral edema – were not reported with topical therapy because the amount of active drug in topical preparations is significantly less than that administered orally, and the topical route of delivery reduces systemic absorption of the medication. The conclusion: “Topical gabapentin seems to be well-tolerated and associated with significant pain relief in women with vulvodynia.”
Topical amitriptyline cream can be considered for first-line treatment of women with provoked vestibulodynia that causes painful intercourse. One study reported a response rate of 56%, and it eliminates drowsiness associated with oral administration.
A study of 34 women at UCLA Medical Center utilized a compounded low dose of topical nitroglycerin 0.2% and concluded “Topical nitroglycerin is safe and effective in providing temporary relief of [painful intercourse] and vulvar pain in women with vulvodynia.” Side effects associated with commercially-available higher strength nitroglycerin ointment, such as headache, are much less common with the lower dose.
Other causes of pelvic pain can include interstitial cystitis, endometriosis and urethral syndrome. It is important to work with health care providers who are experienced in the treatment of vulvodynia. Ask our compounding pharmacist how customized medications can help.