New guideline details care of vulvodynia
As you flip through the next patient’s chart, you review notes from several past visits, and all detail pain and burning on or around the vulva. According to the chart documentation, the patient states the vulvar area hurts most of the time, even when nothing is touching it.
If you already have ruled out infection, inflammation, neoplasia, and neurologic disorder, you may well be dealing with vulvodynia. Also known as vulvar vestibulitis syndrome or vulvar dysesthesia, vulvodynia now is defined by the Waxhaw, NC-based International Society for the Study of Vulvovaginal Disease as "vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable neurologic disorder."
A new vulvodynia diagnosis and treatment guideline has just been published by the Hagerstown, MD-based American Society for Colposcopy and Cervical Pathology.1 It covers general vulvar care, topical medications, oral medications, injectables, biofeedback and physical therapy, as well as dietary changes with supplementations, acupuncture, hypnotherapy, and surgery.
There is no one specific approach to treatment of vulvodynia, which can be very frustrating for the patient and the provider, says the guideline’s lead author, Hope Haefner, MD. Haefner, who is an associate professor of obstetrics and gynecology at the Ann Arbor-based University of Michigan and director of its Center for Vulvar Diseases, worked in concert with a broad cross-section of medical disciplines in developing the new guideline.
"The key is to start treatment early," she suggests. "The longer these patients have pain, the harder the condition is to treat."
How prevalent is it?
Chronic unexplained vulvar pain is a highly prevalent disorder that often is misdiagnosed, according to a 2003 study.2 In that analysis, researchers found that approximately 16% of respondents to a Boston-based population survey reported histories of chronic vulvar pain for at least three months or longer, with nearly 7% of respondents experiencing the pain at the time of the survey. The analysis showed that Caucasian and African American women reported similar incidence rates; Hispanic women were 80% more likely to experience symptoms compared to Caucasian and African American women; researchers do not yet understand the variations in prevalence.2 Based on survey data, the researchers conservatively estimate that approximately 5% of all women will experience chronic vulvar pain before age 25.2
In a 2004 study based on the results of an Internet survey of 994 women, researchers found 27.9% of women had experienced pain at the vulvar vestibule (the opening to the vulva) and 3% reported chronic pain.3 Researchers found that African American women had symptoms in the same numbers as did Caucasian women.3
"At the time, the prevalence of vulvodynia still was thought to be quite low and was estimated to be very rare in black women," says Barbara Reed, MD, MSPH, professor of family medicine at the University of Michigan’s School of Family Medicine, lead author of the article."The web survey allowed us to survey a larger number of women who were not necessarily being seen in a doctor’s office to get a better idea of the prevalence of symptoms suggesting the presence of vulvodynia."
Where does it hurt?
When making a diagnosis of vulvodynia, the guideline suggests using a diagram of the pain location. Using a cotton swab to test for pain locations on the vulva, start at the thighs and move medially to the vestibule. The vestibule is tested at the two o’clock, four o’clock, six o’clock, eight o’clock, and 10 o’clock positions; each time the vestibule is touched, if pain is present, ask the patient to quantify the pain as mild, moderate, or severe.1 Be sure to perform vaginal cultures to rule out conditions such as yeast infection.
Offer the following self-care tips:
- Wear cotton underwear during the day and none at bedtime.
- Avoid vulvar irritants such as perfumes, dyed toilet articles, shampoos, detergents, and douches.
- Use mild, nonirritating soap for the body, but none on the vulva. The vulva can be cleaned gently with water and patted dry. After cleansing, an emollient without preservatives (vegetable oil or plain petrolatum) helps to hold moisture in the skin.2
Topical therapies and oral medications may provide relief; be sure to check the patient’s medical history for any possible interaction. (Read the listing of drug therapies in the guideline, published in the January 2005 issue of the Journal of Lower Genital Tract Disease. See the resource listing, below, on how to access it, as well as review a number of provider resources.)
Vulvodynia has many possible treatments, but very few controlled trials have been performed to verify their efficacy, says Haefner. The National Institutes of Health has sponsored two national conferences on the subject, but more work is needed, she states.
Vulvodynia can take time to treat; improvement may take weeks to months, according to Haefner.
"No one single treatment is successful in all women," she notes. "It can be a difficult process to treat."
References
- Haefner HK, Collins ME, Davis GD, et al. The Vulvodynia Guideline. J Lower Gen Tract Dis 2005; 9:40-51.
- Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pain: Have we underestimated the prevalence of vulvodynia? J Am Med Womens Assoc 2003; 58:82-88.
- Reed B, Crawford S, Couper M, et al. Vulvar pain is more common than thought, not rare in African Americans. J Lower Gen Tract Dis 2004; 8:48-57.
Resources
- The American Society for Colposcopy and Cervical Pathology is a professional organization aimed at the study, prevention, diagnosis, and management of lower genital tract disorders. Its official publication, Journal of Lower Genital Tract Disease, contains "The Vulvodynia Guideline" in its January 2005 issue. The article may be accessed free of charge through the Society’s web site, www.asccp. org. Click on "Journal." For additional information, contact: American Society for Colposcopy and Cervical Pathology, 20 W. Washington St., Suite 1, Hagerstown, MD 21740. Telephone: (301) 733-3640. Fax: (301) 733-5775. Web: www.asccp.org.
- The International Society for the Study of Vulvovaginal Disease is a professional organization focused on care of vulvar diseases. The organization offers a patient education material section on its web site, with freely reproducible handouts on such topics as vulvar pain. Contact: International Society for the Study of Vulvovaginal Disease, 8814 Peppergrass Lane, Waxhaw, NC 28173. Telephone: (704) 814-9493. Fax: (704) 814-9571. E-mail: [email protected]. Web: www.issvd.org.
- The National Vulvodynia Association is a nonprofit organization created in 1994 to improve the lives of individuals affected by vulvodynia. It has produced a 24-page patient guide titled "I Have Vulvodynia . . . What Do I Need to Know?" that provides an overview of vulvodynia from gynecological and chronic pain perspectives. The brochure includes treatment information, self-help tips and coping strategies for vulvodynia patients, as well as information on general gynecological health. Health care providers may request a complimentary copy of the guide prior to purchase by contacting Gigi Brecheen at (301) 649-2236 or e-mailing [email protected]. Bulk order costs (which include shipping fees) are as follows: 25 guides, $40 members, $50 nonmembers; 50 guides, $75 members, $95 nonmembers; and 100 guides, $125 members, $160 nonmembers. Health care providers may join the association for an annual dues fee of $60, which includes the cost of subscriptions to its print newsletter and quarterly electronic research newsletter. Contact: National Vulvodynia Association, P.O. Box 4491, Silver Spring, MD 20914-4491. Telephone: (301) 299-0775. Fax: (301) 299-3999. Web: www.nva.org.
- The University of Michigan Center for Vulvar Diseases web site has a number of links on vulvar diseases. Read on-line its patient education booklet, "Vulvar Conditions & Management," which contains information on medications, diets, and treatment strategies for vulvar pain. Web: www.med.umich.edu/obgyn/vulva/links.htm.
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