Vulvar Pain Syndromes a Bounty of Treatments— but Not All of Them Are Proven

second of 3 parTs VulVar paIn syndroMes a bounty of treatments— but not all of them are proven Treatments for vulvodynia and vestibulodynia range from lifestyle adjustments and application of topical agents to tricyclic antidepressants and nerve blocks— but the data on their efficacy are not as bountiful neal M. lonky, Md, MpH, moderator; libby edwards, Md, Jennifer Gunter, Md, and Hope K. Haefner, Md, panelists s we discussed in the first installment vulva. Cool gel packs are sometimes helpful. of this three-part series in the Sep- In thIs When it comes to intercourse, I recom- Article A tember issue of OBG Management, mend adequate lubrication using any of a the causes of vulvar pain are many, and the number of effective products, such as olive Therapies discussed diagnosis of this common complaint can be oil, vitamin E oil, Replens, Slippery Stuff, As- by the panel difficult. Once the diagnosis of vulvodynia troglide, KY Liquid, and others. page 34 has been made, however, the challenge shifts There is an extensive list of lubricants at to finding an effective treatment. Here, our http://www.med.umich.edu/sexualhealth/ How to determine expert panel discusses the many options resources/guide.htm which treatments available, the data (or lack of it) behind each are best therapy, and what to do in refractory cases. In Part 3 of this series, in the November Topical agents might offer relief page 35 issue, the focus will be vestibulodynia. —but so might placebo Dr. Lonky: What is the role of topical medi- Is physical therapy cations, including anesthetics, for treating underrated? Management of vulvar pain vulvar pain syndromes? page 38 begins with simple measures Dr. Edwards: I don’t find topical medica- Dr. Lonky: How do you approach treatment tions to be particularly useful in the treat- of vulvar pain syndromes? ment of vulvodynia, except for lidocaine 2% Dr. Haefner: I often advise the patient to jelly, or lidocaine 5% ointment, which tends begin with simple measures. For example, I to burn with application—but I never start a recommend that she wear cotton underwear patient on only one medication, so judging during the day, but no underwear at night. If the effectiveness of a topical therapy is diffi- she perspires with exercise, wicking under- cult in that context. Good studies of topical wear may be helpful. I also counsel the pa- medications in the treatment of vulvar pain tient to avoid vulvar irritants, douches, and syndromes are lacking, other than the recent the application of soap of any kind to the report on amitriptyline and baclofen.1 continued on pAge 30 obgmanagement.com Vol. 23 No. 10 | October 2011 | OBG Management 29 Vulvar pain syndromes hypoestrogenic changes in postmenopausal The OBG ManaGeMent expert panel women. Some providers use a high-dose, compounded topical estrogen with lido- Neal M. lonky, Md, MpH, moderator of this discussion, caine for vestibulodynia. Certainly, local hy- is Clinical Professor of Obstetrics and Gynecology at the poestrogenic changes should be reversed in University of California–Irvine and a member of the Board of Directors of Southern California Permanente Medical Group. postmenopausal women before a diagnosis He serves as an OBG ManageMent Contributing Editor. of vulvodynia or vestibulodynia is given. As for other topical therapies, they are widely used. Some women report improvement with application of plain petrolatum.2 Libby edwards, Md, is Adjunct Clinical Associate Professor Response rates of 33% to 46% after use of a of Dermatology at the University of North Carolina in Chapel topical placebo for vestibulodynia are well Hill, NC, and Chief of Dermatology at Carolinas Medical described in the literature.3,4 Center in Charlotte, NC. Dr. Edwards is a Past President and Past Secretary General of the International Society for the Topical analgesics are used frequently, Study of Vulvovaginal Disease. either sporadically (during pain flares) or regularly (daily application). One method of application for localized vestibulodynia Jennifer Gunter, Md, is Director of Pelvic Pain and involves liberally coating a cotton ball with Vulvovaginal Disorders for Kaiser Permanente in San lidocaine 5% and then applying it to the ves- Francisco, Calif. tibule overnight (for at least 8 hours of ex- posure). In this study, after 7 weeks, 76% of women were able to be sexually active, com- pared with 36% before the start of treatment. However, a randomized, placebo-controlled Hope K. Haefner, Md, is Professor of Obstetrics and trial that included lidocaine 5% cream in one Gynecology at the University of Michigan Hospitals and arm identified only a 20% reduction in pain Co-Director of the University of Michigan Center for Vulvar for women who had localized vestibulodyn- Diseases in Ann Arbor, Mich. ia—although, in this trial, the lidocaine was massaged into the vestibule four times daily.5 In this study, interestingly enough, topical lidocaine was less effective than topical pla- 3 The authors report no financial relationships relevant to this article. cebo, which produced a 33% response rate. Lidocaine gel has also been used, although some women report more local irri- Dr. Haefner: For minor degrees of pain, con- tation with gel than with ointment. sider lidocaine 5% ointment. Dr. Lonky: Do we have any data on topical lidocaine/prilocaine (eutectic mixture of application of other drugs? local anesthesia or LMX) may be used but Dr. Gunter: Compounded adjuvant medica- can be irritating. tions have been evaluated. In a retrospective doxepin 5% cream can be applied to skin study of topical gabapentin in a Lipoderm daily, gradually increasing the number of base, women who had generalized or local- daily applications to as many as four. ized vulvodynia applied a dose of 2%, 4%, or Topical amitriptyline 2% with baclofen 6% three times daily. Of these women, 80% 2% in a water washable base has also been experienced a reduction of at least 50% in the used for point tenderness (squirt 0.5 cc from pain score. In addition, 67% of patients who a syringe onto the finger and apply it to the had localized vestibular pain were able to re- affected area three times a day).1 sume intercourse.6 Dr. Gunter: Topical estrogen is prescribed A retrospective review of 38 women who by many providers, but we lack studies sup- used 2% amitriptyline and 2% baclofen in porting its efficacy, except for reversing a lipoderm cream for localized vestibular 30 OBG Management | October 2011 | Vol. 23 No. 10 obgmanagement.com Vulvar pain syndromes pain found that 53% experienced an im- varies, depending on the age of the patient provement in symptoms of at least 60%, but and the particular agent used. Amitripty- there was no change in the frequency of sex- line is often used as a first-line medication. ual intercourse.1 I start the patient on 10 to 25 mg nightly and increase that amount by 10 to 25 mg weekly, not to exceed 150 mg daily. A sample regi- do tricyclic antidepressants men might be 10 mg at bedtime for 1 week. ease chronic pain? If symptoms persist, increase the dose to Dr. Lonky: Let’s talk, for a moment, about 20 mg at bedtime for another week, and so the use of oral tricyclic antidepressants in the on. Once a dose is established that provides treatment of vulvar pain syndromes. What relief, the patient should continue to take do we know? that amount nightly. Advise the patient not Dr. Haefner: Tricyclic antidepressants are to discontinue the drug abruptly. Rather, it a common treatment for vulvar pain. This should be weaned. group of drugs (including amitriptyline In patients who are 60 years or older, [Elavil], nortriptyline [Pamelor], and desip- I give a starting dose of 5 to 10 mg and in- ramine [Norpramin]) has been used to treat crease it by 10 mg weekly. many idiopathic chronic pain conditions. In all age groups, it is important to ad- Published and presented reports indicate vise patients to avoid consuming more than that these drugs elicit about a 60% response one alcoholic beverage daily while taking rate for various pain conditions. A trial by the this medication. And in reproductive-age National Institutes of Health (NIH) is under women, contraception is critical. way, analyzing the use of antidepressants in Dr. Edwards: I call these drugs tricyclic “Because of their women who have vulvar pain. medications rather than antidepressants. low cost and their Although treatment with tricyclic anti- They are extremely useful in managing the effective ness, depressants has generally been reserved for neuropathic component of vulvar pain. De- tricyclic medications women who have generalized vulvodynia, spite a recent, apparently well-conducted are my first-line recent reports have found these medications study showing a lack of benefit, my 25 years therapy” to be helpful in the treatment of vestibu- of personal clinical experience with tricyclics —libby edwards, Md lar pain as well. The mechanism of action convince me that I should wait for follow-up is thought to be related to inhibition of the studies before abandoning this therapy.3 reuptake of transmitters—specifically, nor- The pain literature reports that higher epinephrine and serotonin. However, the doses than previously reported of tricyclic mechanism of action may be more closely medications are needed for optimal man- related to anticholinergic effects. Tricyclics agement of neuropathic pain. Doses from affect sodium channels and the N-methyl-d- 100 to 150 mg are often required for substan- aspartate (NMDA) receptor. tial improvement, and a major design flaw in If you choose to prescribe one of these many studies of the effect of tricyclic medi- medications, consider emphasizing to the cations on vulvodynia is the use of an insuf- patient its effect on the sensation of pain ficient dose.

Load more