N National V Vulvodynia A Association

Volume VI, Issue II Fall 2000 Yeast Infections and Syndrome An Interview with Paul Nyirjesy, M.D.

Dr. Paul Nyirjesy is an Associate Professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences and in the Section of Infectious Diseases, Department of Medicine, at Temple University School of Medicine, Philadelphia. He is the Director of the Temple University Referral Service.

What are the symptoms of Vulvar an intensity that can range from mini- with a negative follow-up culture, Vestibulitis Syndrome? mal to quite severe. and assessed that the patient still A typical patient with VVS will com- meets the criteria for VVS. Our ini- plain of a burning sensation at the What is your initial treatment regi- tial therapy is to give patients a cor- beginning of sexual intercourse. She men for VVS? What percentage of ticosteroid ointment, either triam- may also experience discomfort at patients respond to this regimen? cinolone ointment or desoximetasone, other times when there is contact with We have developed a stepwise ap- twice a day for about a month. In the area at the opening to the proach to treating VVS. In those with general these are well tolerated, al- (the vestibule), such as with concurrent infections, for example, a though patients may develop irrita- insertion. In her day-to-day activities, yeast infection, we don’t even give tion from the ointment, and need to a woman with VVS will have variable the diagnosis of VVS until we’ve amounts of burning and irritation, with eradicated the yeast, documented it See YEAST, page 2

NIH Awards First Vulvodynia Research Grants

his past October, the National Institute of Child Health and Human Development (NICHD) selected four vulvodynia research proposals to receive grants beginning in 2001. Three will be funded under last spring’s Request T For Applications (RFA) on vulvodynia and the fourth was submitted and funded under the NICHD’s ongoing Vulvodynia Program Announcement. In response to the RFA, seventeen research proposals were submitted and reviewed. The total amount allocated in the RFA was $1 million a year for the next five years. The four research projects that were selected will examine multiple aspects of the disorder, ranging from prevalence and risk factors to possible causes and treatments. This article will summarize each of the four projects.

Bernard Harlow, Ph.D., associate professor of gynecology and reproductive epidemiology, Harvard Medical School, and Dr. Elizabeth Stewart, M.D., director of the Stewart-Forbes Specialty Clinic for Vulvovaginal Disorders, submitted a proposal entitled, “Prevalence and etiological predictors of vulvodynia.” The broad goal of this 5-year research study is to estimate the prevalence of vulvodynia and identify risk factors associated with the condition. A key hypothesis addressed by Harlow and Stewart is that vulvodynia may be the consequence of exposure to a wide spectrum of trauma from physical See RESEARCH, page 11 Yeast (from page 1)

be monitored to make sure that The present clinical implications are Early on, several investigators found they don’t develop thinning of the not clear. However, these findings the human papillomavirus (HPV) in skin from the . In our are consistent with an exaggerated tissue samples of women with VVS, experience, about 30 percent of immune response that might be the and attributed VVS to HPV. How- patients improve with . result of a past or current infectious ever, as the tools to detect HPV process. Perhaps it is this infectious have become more sophisticated and For those who do not improve, process which has helped to initiate, accurate, the picture is becoming what is the next line of treatment? or continues to stimulate, the in- murkier. We know that HPV is a For those patients, we have used the flammation that we characteristi- very common virus, present in a antidepressant, amitriptyline (Elavil), cally see with VVS. large percentage of the general and more recently, the anticonvulsant, population. The question is not gabapentin (Neurontin). With amitrip- How would you describe the typical whether HPV is present in women tyline, about 60 percent of patients onset of VVS? Is it usually preceded with VVS, but whether it is found develop satisfactory improvement of by chronic vaginal infections? more often in women with VVS than their symptoms. Typically, most women with VVS in healthy women and whether there describe a sudden episode, often is a cause and effect. In some stud- What dosage of amitriptyline or marked by intense itching and burn- ies, HPV has been found in as few as gabapentin do you prescribe? ing, which eventually goes away but 10 percent of women with VVS. We don’t use a set dose for either leaves the patient with more chronic Women with VVS who harbor HPV of these . We start with burning and pain than she has ever seem to be identical in their histo- a low dose, and then have patients had before. By the time these women ries to women with VVS who do not work their way up until their symp- get to a referral center and are given harbor HPV. Some studies have toms are relieved, the side effects a diagnosis of VVS, it is difficult to found HPV to be present more often become difficult to tolerate, or a tell whether or not the VVS was in women with VVS, but the com- maximum daily dose (150 mg. preceded by a vaginal infection. parison group may not be closely amitriptyline or 3200 mg. gaba- Most women with VVS report hav- enough matched to the study group. pentin) is reached. ing been in good health until this For now, I feel that the nature of the problem began. This history of an association remains unanswered. What differences have been acute event is suggestive of some found in the vulvar tissue of VVS sort of infection at the beginning. Do you think that patients as compared to normal (yeast) plays a role in the devel- vulvar tissue? What are the clini- In a study by Sarma and colleagues opment of VVS? If so, how might cal implications of this research? (1999), women with VVS were five this occur? In general, biopsies of women with times more likely to have had a A possible association between VVS demonstrate findings con- physician-diagnosed yeast infection yeast infections and VVS has not sistent with chronic inflammation. than women who did not have VVS. been studied very much, although In their biopsies, Chaim and Sobel What we don’t know is whether these I think that there is a link between (1997) have also found a greater women truly had an infection or the two conditions. In 1989, preponderance of mast cells, in- whether they had VVS from the be- Ashman and Ott proposed that flammatory cells that release his- ginning and were simply treated for VVS could be the result of tamine and are commonly found yeast with the hope that yeast was the candidiasis. They suggested that in association with allergic re- cause of their symptoms. women who get a lot of yeast in- sponses. However, they have not fections develop a cross-reactive found other local changes that one Is there an association between would associate with allergy. human papillomavirus and VVS? See YEAST , page 3

Page 2 NVA News/Fall 2000 Yeast (from page 2) immune response. This might occur which resemble those of the yeast gic response, which helps to lay the if there are antigens on the yeast organism. Despite the absence of a groundwork for the next yeast in- organism that resemble the patient’s yeast infection, she then develops a fection. These patients get into a own antigens. As the patient tries to constant inflammatory response, pattern of recurrent yeast infections fight off the yeast infections, her which is stimulated by the body’s which they can’t break out of. Some body would develop an immune re- response to her own antigens. factors that lead to an increased sponse to those of her own antigens propensity to yeast infections may Most investigators who have stud- be genetic in nature. For example, ied VVS have not done cultures for two studies have shown that women NVA News yeast, and a possible link between who get recurrent yeast infections National Vulvodynia Association P.O. Box 4491 the two conditions has not been ad- are more likely to be negative for Silver Spring, Md. 20914-4491 equately explored. In our experi- Lewis antigens a and b. These anti- (301) 299-0775 ence, about 50 percent of women gens are proteins expressed on red FAX: (301) 299-3999 www.nva.org with VVS will at some point during blood cells. They are also found in their care with us have a positive vaginal cells, where they may block culture for yeast. This 50 percent is the binding of Candida albicans to The NVA News is published three greater than the 15-20 percent cul- vaginal cells. Women who lack these times per year. ture positivity rate in the general proteins may therefore be more prone population. As I mentioned earlier, to having yeast. Most women with Editor: Sarma’s study found that women recurrent yeast infections seem to Phyllis Mate with VVS were more likely to have have a healthy immune system in been treated for yeast infections than other ways, and very few have pre- Layout: control women. disposing factors such as diabetes or Andrea Hall HIV infection. The role of behav- Contributors: Why are some women susceptible ioral factors in causing recurrent Phyllis Mate to recurrent yeast infections? yeast infections remains relatively Christin Veasley As noted above, about 15-20 per- unstudied. cent of all women harbor yeast in the vagina (usually Candida albicans). Do you recommend the use of over- The National Vulvodynia Associa- In most of these women, the yeast the-counter antifungal medication tion is an educational, nonprofit doesn’t cause any problems, or may in VVS or vulvodynia patients? organization founded to disseminate information on treatment options for at most cause an intermittent infec- In general , I don’t recommend over- vulvodynia. The NVA recommends tion here or there that responds quite the counter antifungal medications that you consult your own health nicely to antifungal therapy. How- for VVS patients. First of all, I think care practitioner to determine which ever, a subgroup of women will suf- that it’s important to have an accu- course of treatment or medication is fer recurrent yeast infections, de- rate diagnosis, which is impossible appropriate for you. fined as four or more infections in a if the patient self-treats and never 12-month period. makes it into the office. Not all NVA News, copyright 2000 by the yeast infections are caused by Can- National Vulvodynia Association, Current studies suggest that in many dida albicans, and having a posi- Inc. All Rights Reserved. Permis- women with recurrent yeast infec- tive culture makes it a lot easier to sion for republication of any tions, local immune factors play a figure out how best to treat the in- article herein may be obtained by key role. In these women, there ap- fection. Furthermore, in women with contacting the NVA Executive Director at 301-299-0775. pears to be an abnormal local re- sponse to yeast, almost like an aller- See YEAST , page 8

NVA News/Fall 2000 Page 3 Treatment of Clitoral Pain

By C. Paul Perry, M.D., FACOG Dr. Perry is the Director of the Center, Brookwood Women’s Medical Center, Birmingham, Alabama. He serves as Chairman of the Board of Directors of the International Pelvic Pain Society.

Clitoral pain is a specific subset of examination. The key to a diag- ever, light touch of the vulvodynia produced by nostic history is the localization will reproduce the pain. of the anterior division of the pu- of the pain to the clitoral and peri- dendal nerve. It is manifested by clitoral area. Patients may have a Treatment pain localized to the clitoris with difficult time describing the loca- or without associated pain such as tion of their pain, but often report The treatment regimen for clitoral vulvar vestibulitis and pelvic floor pain with intercourse, tight cloth- neuralgia includes both medica- myalgia. ing, and exercise. It has been noted tions known to benefit neuropathic that stress usually aggravates the pain and therapeutic desensitiz- Unlike classical pudendal neural- pain. Sometimes simply sitting in- ing blocks of the dorsal nerve to gia, i.e, dysesthetic vulvodynia, creases the pain, for example, the clitoris with local anesthetics. the pain is very localized and may riding in a car for extended peri- Drugs that may be beneficial in- have more of an aching quality ods. Constant “aching” and “sore- clude: amitriptyline, gabapentin, than the more commonly reported ness” are the most commonly used diphenylhydantoin, divalproex burning sensation that character- adjectives to describe the pain. Oc- sodium, trazodone, doxepin hy- izes classical pudendal neuralgia. casionally, patients describe the pain drochloride, and lamotrigine. In as shooting or burning. cases of severe unresponsive pain, Possible causes chronic time contingent opioid Sexual stimulation is painful be- therapy may be necessary. Anti- The etiology may be metabolic, cause clitoral engorgement aggra- depressants should be used fre- traumatic, or idiopathic (un- vates the pain, making intercourse quently since most patients with known). The determinative factor impossible in many cases. Patients this have some de- is that the signaling mechanism of often suffer without seeking medi- gree of serotonin deficiency from clitoral sensation becomes abnor- cal care because of embarrass- this stressful condition. Psycho- mal. Trauma from violent stimula- ment. In some cases, marriages social counseling may be benefi- tion, tight clothing, or straddle may be threatened because of mis- cial for many marriages. injuries may produce these understanding or lack of commu- neuropathic changes. Other pos- nication between spouses. The dorsal nerve to the clitoris is a sible causes include vulvar laser division of the . It vaporization or chemical ablation On physical exam, the absence of divides from the posterior branch for human papilloma viral lesions diffuse involvement of the entire after leaving Alcock’s canal and (venereal warts). Metabolic disor- vulvar and perineal area distin- travels anteriorly in the labia- ders such as diabetes can produce guishes it from the more common crural fold toward the pubis. At clitoral pain. The majority of cases, dysesthetic neuralgia. The tissues the mons, it takes an almost 180 however, will have no discernible appear healthy with no evidence degree turn to innervate the clito- cause. of inflammation or distortion. The ral corpus. The nerve can be easily Q-tip test of the minor vestibular blocked on each side by injecting Diagnosis glands, which is so characteristi- 5mls. of 0.5% bupivacaine about cally positive in vulvar vesti- 2 cm. lateral and 1cm. anterior to The diagnosis is made after care- bulitis, is negative in pure ful history taking and physical neuropathic clitoral pain. How- See CLITORAL PAIN, page 5

Page 4 NVA News/Fall 2000 Clitoral Pain If It’s Not Vulvar Vestibulitis, (from page 4) What Is It? By Richard Marvel, M.D. the root of the clitoral corpus. The Dr. Marvel is an Assistant Professor in the Department of Obstetrics, frequency of these blocks depends Gynecology and Reproductive Sciences at the University of Maryland on the patient’s response and can in Baltimore. vary from weekly to once every few months. Vulvar vestibulitis syndrome (VVS), Vulvovaginal disorders that produce a subset of vulvodynia, is a chronic similar symptoms to those associ- Patients with chronic pelvic pain vulvar pain condition associated with ated with VVS can be divided into from clitoral neuralgia have found (painful sexual inter- several categories including infec- that loose clothing, nontraumatic course). This syndrome has been tion, dermatoses, , exercises, and either cold or warm described for more than 100 years, iatrogenic (treatment-induced) con- compresses will decrease the pain. beginning with a publication by ditions, atrophy, and dysesthetic Some patients have noted im- Skene (1889) entitled, “Treatise on vulvodynia. provement after modifying their the Diseases of Women.” The first diet (avoiding spicy foods, in- modern U.S. publication on VVS by Infection creasing fiber and water intake to Woodruff and Parmley (1983) re- prevent constipation). Stress re- ferred to the condition as “infection of One of the most common vulvo- duction, meditation, and compas- the minor vestibular glands.” The term vaginal disorders is yeast infection, sionate counseling may help these vulvar vestibulitis was coined by characterized by itching, burning, patients to cope with their pain Friedrich (1987) who established three and a thick white discharge. Recur- and changing lifestyle. Increasing criteria based on his observations of rent yeast infection, which may be social contacts and distraction 87 patients. According to this defini- an initiating factor for VVS, should with career and recreational ac- tion, women should be diagnosed with be ruled out by careful wet mount tivities may also be beneficial. VVS when they present with: 1) se- evaluation (KOH preparation), as vere pain on vestibular touch or at- well as culture. A culture is impor- Conclusion tempted vaginal entry; 2) tenderness tant for several reasons: 1) the sen- to pressure localized within the vul- sitivity of a wet mount, i.e., the With proper diagnosis and treat- var vestibule and 3) physical find- likelihood of seeing yeast organ- ment, this condition can be helped. ings confined to vestibular erythema isms when present, is only 70 per- As with any neuropathic pain, the (redness) of varying degrees. cent; 2) non-candidal albican yeasts longer the pain is present and the are difficult to identify microscopi- more intense the discomfort, the The evaluation of patients with vul- cally; and 3) non-candidal yeasts less likely treatment outcomes will var pain and dyspareunia requires are less likely to respond to com- be successful. a careful investigation to rule out mon yeast treatments. If identified, other causes for the pain, local- recurrent yeast infections usually re- Reference: ized tenderness and erythema. If spond to appropriate anti-fungal treat- additional physical findings or ment, although a prolonged course of Perry CP. Vulvodynia. In Pelvic treatable conditions exist, this pre- therapy may be required. A regimen Pain: Diagnosis and Manage- cludes a diagnosis of VVS. The that I have found successful in about ment. Edited by, Howard FM, differential diagnosis is extensive 50 percent of women with recurrent Perry, CP, Carter JE, El-Minawi and requires taking a thorough his- yeast infection is Diflucan 100-200 AM. Philadelphia:Lippincott tory as well as performing a physi- mg weekly for 3-4 months. Williams & Wilkins 2000; 204- cal examination and laboratory 210. n tests. See OTHER DIAGNOSES, page 6

NVA News/Fall 2000 Page 5 Other Diagnoses (from page 5) Cyclic vulvovaginitis, a similar, generally acute conditions and tend sions of the vaginal and vestibular possibly identical syndrome to re- not to be confused with VVS. mucosa. Some experts believe that current yeast infection, has been desquamative vaginitis is a severe described by Dr. Marilynne McKay. Dermatoses form of . When this Patients experience entry dyspare- disease affects the vagina and/or the unia, vestibular burning, itching, ir- There are several dermatologic con- , it is treated with the same ritation and aching after intercourse. ditions that can cause symptoms simi- regimen as lichen planus, i.e., The symptoms are usually cyclic, lar to those of VVS. intravaginal suppositories of hydro- i.e., they wax and wane. Cyclic is a common skin disease that can cortisone, alternating with 2% vulvovaginitis is believed to be due affect the vulva and produce symp- clindamycin cream for two weeks, to subclinical candidal infection and, toms of itching and burning. The then completing the course of vagi- likewise, responds to 100-200 mg of disorder causes visible skin changes nal hydrocortisone. Diflucan weekly for 4-6 months. I with thickening or sometimes thin- usually treat patients for 4 months ning of the skin of the vestibule, Dermatitis and then wean the dosage to once vulva, perineum and perianal skin. a month as a prophylactic regimen Lichen sclerosus usually presents as Over time, exposure to local vagi- to prevent recurrence of symptoms. thin, white parchment-like skin with nal/vulvar irritants can lead to con- wrinkling. It is diagnosed by vulvar tact dermatitis, producing burning, A bacterial infection that may be biopsy and generally responds to itching, and painful intercourse. confused with VVS is cytolytic treatment with a potent topical cor- There are a multitude of vulvar irri- vaginosis. In this condition there is ticosteroid for several weeks. tants that can cause contact derma- an overgrowth of the normal lacto- titis. Some common offenders are bacilli of the vagina. This leads to an Lichen planus is a generalized skin scented or deodorant soaps, douches, overproduction of hydrogen perox- disease that sometimes affects only perfumes, feminine sprays and dyes ide resulting in a burning discomfort the vulva. Patients present with burn- in toilet tissues. Because these irri- and pain with intercourse. History ing, irritation, soreness and dyspare- tants may cause symptoms similar to reveals a cyclic pattern–symptoms unia. In some cases of lichen planus, those of a yeast infection, many are usually most significant in the the vestibule has ulcerations and the patients who have contact dermatitis luteal phase of the menstrual cycle entire mucosa is eroded. Patients with are treated with an anti-fungal cream. and relieved by menses. A wet mount this disorder may also present with Instead of finding relief, some of reveals no pathogenic organisms, an sores in the oral cavity: oral examina- these patients have a negative reac- increase in the normal bacteria, cel- tions frequently reveal a reticulated, tion to the medication’s carrier mol- lular debris, and naked nuclei from gray, lacy pattern of whitened mucosa ecules (e.g., propylene glycol), as epithelial cells. The symptoms can in the mouth. Diagnosis is confirmed discussed by Dr. Ledger in a recent be easily controlled with one or two by vulvar biopsy. Treatment consists NVA newsletter. (See Spring 2000 douches in the second half of the of local or systemic steroids; one-half issue.) This can create a vicious menstrual cycle using 1 teaspoon of of a 25 mg hydrocortisone supposi- cycle, resulting in a prolonged exac- baking soda dissolved in one quart tory can be inserted intravaginally erbation of symptoms. of water. twice a day for two months. Once improvement is noted, the medica- The best treatment approach for con- Cytolytic vaginosis, cyclic vulvo- tion may then be used once or twice a tact dermatitis is to eliminate all vaginitis and recurrent yeast infec- week for maintenance. irritants to the vulva and provide tion must be ruled out before a pa- symptomatic relief through warm tient is diagnosed with VVS. Other Desquamative vaginitis is a derma- soaks with Tannic acid (tea) or common vaginal infections should tological condition with purulent dis- be excluded as well, but they are charge, severe erythema, and ero- See OTHER DIAGNOSES, page 7

Page 6 NVA News/Fall 2000 Other Diagnoses

(from page 6) Domborrow’s solution (a soothing cations and post-coital irritation or vaginitis which may cause burning, astringent). Other helpful measures swelling. Examination reveals irritation and pain with intercourse. include wearing loose clothing and erythema, telangiectasia (abnormal On exam, the vagina is pale, there is white cotton undergarments to pro- blood vessels) and a papular rash. thinning of the vaginal mucosa, and vide adequate ventilation and keep This condition, rebound a yellow may be the vulva dry. After bathing, using a dermatitis, is treated by tapering the present. This condition responds hair dryer to dry the vulva is recom- potent steroid cream over several well to treatment with a vaginal mended. In some cases, a low poten- weeks. A low potency steroid, such as cream which often re- cy corticosteroid cream may be 1% hydrocortisone, can then be solves the symptoms. prescribed. For many patients, symp- used for maintenance and relief with- toms tend to resolve with this ap- out the risk of rebound dermatitis. Dysesthetic Vulvodynia proach, but in severe cases systemic Potent steroids should be reserved corticosteroids may be required. exclusively for biopsy proven Dysesthetic vulvodynia is a dermatoses such as lichen sclerosus. neuropathic pain condition charac- If vulvar itching is the predominant terized by constant vulvar burning. symptom, or there is a history of Atrophy It is not limited to focal areas of adverse reaction to a treatment, al- tenderness and is not necessarily lergic contact dermatitis should be In postmenopausal women, a lack of suspected. Many agents included in estrogen can lead to severe atrophic See OTHER DIAGNOSES, page 8 topical preparations, e.g., preserva- tives, cause allergic reactions which can be diagnosed by patch testing. Some common substances that can Shop Online and Donate to the NVA! result in allergic reactions are local The NVA is now connected in the land of e-commerce. We are anesthetics (e.g., Benzocaine), per- pleased to announce that we have affiliated with two philan- fumes, clotrimazole, butalbital, thia- thropic Internet sites that offer a simple way to support the NVA. bendazole, benzol peroxide, and Created to foster cooperation between non-profit organizations even topical corticosteriodscorticosteroids them- and online shopping enterprises, our partners, Charitableway and selves. A repeated open application Amazon, promote charitable giving among online shoppers. These test (ROAT) for allergens can be affiliations are at no cost to the consumer. Each time an NVA performed by applying the suspected supporter, friend or family member shops online through one of product three times a day to a 5 x 5 these programs, a percentage of the purchase price will be donated cm area on the forearm and then to the NVA. Amazon sells books, music, DVDs, electronics, checking for a reaction. If specific computer games, toys and many other items. When you link to allergens are identified in any of the Charitableway from the NVA Website, you can choose from a products or treatment agents the variety of vendors, including Land’s End, Sharper Image, Office patient is using, they should be Max, Esprit and Borders. discontinued immediately. Online shopping through these sites is safe and convenient. We The local application of potent or hope that next time you feel like shopping on the net, you’ll first super potent steroid creams for more log onto www.nva.org, and then click on the Amazon or than three to four weeks can also Charitableway icon. cause dermatitis. After prolonged use of these creams, the vulvar skin If you have any questions about these programs, please contact can become irritated and patients Christin Veasley at [email protected]. report poor tolerance of local medi-

NVA News/Fall 2000 Page 7 Other Diagnoses Yeast (from page 7) (from page 3) exacerbated by touch or pressure. diagnosis is the key to successful VVS who already have inflamed skin, This disorder is more common in treatment. creams or suppositories to treat yeast postmenopausal women or younger infections often worsen their irrita- women with a history of back in- References: tion and burning. This irritation is jury. Treatment usually involves noticeable enough in patient histories the use of tricyclic antidepres- Skene AJC: Treatise on the Dis- that Marinoff and Turner have stud- sants such as amitriptyline or anti- eases of Women. N.Y., D. Appleton ied whether topical antifungals could convulsants such as Neurontin. & Co., 1889. be the cause of VVS. Finally, in those Surgical resection is not recom- women who do have a yeast infection mended for dysesthetic vulvo- Woodruff, JD, Parmley, TH: Infec- and VVS, a week of antifungal cream dynia as the failure rate is signifi- tion of the Minor Vestibular Gland. isn’t really an adequate therapy. cant. Obstet/Gynecol 62:5, 609-612, 1983. As a rule, how often should VVS Genital fissures patients be cultured for candidiasis? Friedrich, ED Jr.: Vulvar Vestibulitis Since many investigators who treat Patients who have chronic, non- Syndrome. J Reprod Med 323: 2, VVS don’t agree with me that yeast healing posterior fissures (small tears 110-114, 1987. contributes to VVS, I don’t think I in genital skin) also present with should be suggesting any general rules! vulvar pain, burning and entry Bauer A, et al: Allergic Contact With the patients that we see, we dyspareunia. Many complain of a Dermatitis in Patients with Ano- practice the philosophy of “culture “tearing” sensation with intercourse genital Complaints. J Reprod Med everyone for yeast and culture often.” as well as post-coital spotting. On 45: 649-654, 2000. n I am constantly struck by the number exam, these patients have an area of of patients that we see who have scarring, usually at the most poste- initial negative cultures, then get a rior portions of the fourchette ,which Clitoral Pain Study positive one, and finally see all of can easily tear upon even gentle their symptoms improve once they separation of the labia. A modified Investigators in Toronto are seek- get started on antifungal therapy. We posterior with vagi- ing information on women with may be overtreating some patients nal advancement is the most suc- clitoral and/or nipple pain. The where the yeast is an innocent by- cessful treatment for this condition. researchers would like to create stander, but I prefer that to ignoring a In this , skin of the a database and a protocol for potential cause of symptoms. How- perineum and posterior vestibule evaluating and treating women ever, except for rare occasions, we is removed and vaginal tissue is with these problems. will not treat someone for yeast unless brought down and sutured to the we have culture corroboration. I surrounding skin. You do not have to live in Can- should emphasize that I believe that ada to participate in this project. these principles apply mainly to a Summary If you experience clitoral and/or patient population with chronic nipple pain, or nipple pain and vulvovaginal problems. Although the foregoing is by no vestibular pain, and would like means a comprehensive list of more information, please con- If a VVS patient tests positively for vulvovaginal disorders, I have re- tact Dr. Allan Gordon, Wasser candidiasis, what regimen of anti- viewed the conditions that are most Pain Management Centre, Mount fungal therapy do you prescribe? likely to be confused with VVS. As Sinai Hospital, at 416-586-5181 Most of our VVS patients test posi- is the case with all medicine, a or [email protected]. tive for Candida albicans so we thorough evaluation and careful See YEAST, page 9

Page 8 NVA News/Fall 2000 Yeast (from page 8) give them six months of fluconazole By the time they get to me, most in selected cases. (Diflucan). For most patients, 100 or women are following all the standard 200 mg once or twice a week will recommendations about white cotton Do many of your patients concur- keep them culture negative. This underwear, avoiding wet bathing suits, rently suffer from dysesthetic prolonged therapy helps to keep the etc. Although I agree with those rec- vulvodynia and VVS? yeast infections out of the picture ommendations, I think that they’re not Although there is probably an over- while we focus on other symptoms enough to prevent recurrent yeast lap between VVS and dysesthetic (and often the other symptoms dis- infections in susceptible women. vulvodynia patients, I consider these appear before we have a chance to two entities as separate conditions. treat them). Six months of daily What hypothesis led you to try Women with VVS will have defin- ketoconazole (100 mg daily) has cromolyn cream in the treatment of able point tenderness on examination been shown to decrease the chance VVS? Have you had any positive which reproduces their burning pain, that the yeast infections will recur results using cromolyn cream in these whereas the dysesthetic patients will after therapy. Our experience with patients? have an essentially normal examina- fluconazole suggests that it has a simi- Chaim and Sobel’s work in Detroit tion and burn all the time. lar protective effect. has shown that women with VVS have more mast cells in biopsy specimens How do your treatments of In your clinical experience, are there than control women. We thought that dysesthetic vulvodynia and VVS any other measures (diet, acidophi- if mast cells play a role in VVS, a differ? lus, etc.) that can help to minimize medication that inhibits mast cell func- I don’t try corticosteroids in dyses- the recurrence of yeast infections? tion might help women with VVS. thetic vulvodynia patients, and tend In general, I think that dietary mea- Cromolyn, a commonly used allergy to use amitriptyline right away. If sures can be very difficult to follow, drug, prevents mast cells from releas- dysesthetic vulvodynia patients also and that they have an uncertain ben- ing histamine. We developed a cream have low back problems, I’ll refer efit. For every patient I see who has with cromolyn as an active ingredient. them early on for pelvic floor and tried the “yeast-free” diet and swears In an initial pilot study, 9 of 11 patients lower back muscle rehabilitation. by it, I have 7 or 8 who stuck to the exhibited a dramatic response to this restrictive diet and found that it made therapy. We then did a placebo- References: their lives miserable and didn’t help controlled, double-blind study (nei- Ashman RB, Ott AK. Autoimmu- their yeast infections. Acidophilus ther patients nor physicians knew nity as a factor in recurrent pills, taken either by mouth or vagi- which cream they were getting). vulvovaginal candidosis and the nally, are used by many women with Overall, 11 of 26 patients (42 per- minor vestibular gland syndrome. J vaginal problems. However, current cent) felt at least 50 percent better. Reprod Med 1989;34:264-6. studies suggest that a lack of lacto- Unfortunately, there was no differ- bacilli is not the cause of recurrent ence between the placebo and Chaim W, Foxman B, Sobel JD. yeast infections. Furthermore, aci- cromolyn groups. Clinically, I have Association of recurrent vaginal dophilus preparations do not contain had patients who have done remark- candidiasis and secretory ABO and the right types of lactobacilli (those ably well with this treatment after Lewis phenotype. J Infect Dis that produce hydrogen peroxide), having no success with other treat- 1997;176:828-30. and many contain viruses that may ment approaches; they refuse to stop have activity against a woman’s own using it because they feel so much Sarma AV, Foxman B, Bayirli B, lactobacilli. For these reasons, I dis- better. Our placebo-controlled study Haefner H, Sobel JD. Epidemiol- courage use of acidophilus prepara- suggests that some other factors may ogy of vulvar vestibulitis syndrome: tions to reduce the recurrence of be responsible for their improvement, An exploratory case control study. yeast infections. but I continue to use cromolyn cream Sex Trans Inf 1999;75:320-6. n

NVA News/Fall 2000 Page 9 Women’s Health Research in the 21st Century

The National Institutes of Health bined! According to a 1995 Gallup next five years (See NIH article on (NIH) have developed an ambi- poll, 32 percent of primary care page 1). tious agenda for studying women’s physicians did not know that heart health in the 21st century, accord- disease is the leading cause of death In recent years, it has become in- ing to Dr. Vivian Pinn, director of among women. The unfortunate re- creasingly accepted that a healthy the Office of Research on sult of this lack of awareness is that lifestyle can help prevent the devel- Women’s Health (ORWH). In her many physicians are not counseling opment of serious disorders such as opening remarks at an NIH lec- their female patients about behav- osteoporosis and heart disease. As a ture for the public, Dr. Pinn cred- ioral changes that could decrease result, the NIH is committed to sup- ited women’s health advocacy their risk of heart disease. porting research on disease preven- groups for the important role they tion as well as treatment. One of the played in focusing attention on In her discussion of women and can- NIH’s most ambitious undertakings the need to include female sub- cer risk, Dr. Pinn asked the audi- to date has been the Women’s Health jects in clinical research. Begin- ence which cancer causes the most Initiative, one of the largest primary ning with the creation of the deaths in American women. At least prevention studies in postmeno- ORWH in 1990, the NIH has dem- half the audience responded “breast pausal women in the US. This com- onstrated a commitment to recti- cancer,” whereas the correct answer prehensive longitudinal research is fying this situation. Previously, is lung cancer. Dr. Pinn also high- examining 1) the effect of a low-fat the term “women’s health re- lighted some recent advances in the diet on the prevention of breast and search” referred primarily to stud- study of cancer, such as the discov- colon cancer and coronary heart dis- ies of the reproductive system dur- ery of a genetic basis for some breast ease, 2) the effect of hormone re- ing a woman’s childbearing years. cancers and the link between HPV placement therapy on prevention of The revised NIH women’s health infection and cervical cancer. She coronary heart disease and osteo- research agenda encourages stud- also pointed out that research on porotic fractures, and 3) the effect ies on every body system across a cancer prevention is underway, cit- of calcium and Vitamin D supple- woman’s entire lifespan, as well ing studies on the use of tamoxifen mentation on prevention of as an examination of sex and gen- in the prevention of breast cancer. osteoporotic fractures and colon der differences and similarities. cancer. This multi-center research Among current women’s health re- project began in 1993, but the ini- In addition to summarizing cur- search priorities are the auto- tial results will not be available rent research priorities, Dr. Pinn immune diseases such as rheuma- until 2005. expressed concern regarding some toid arthritis, lupus and multiple scle- widespread misconceptions about rosis. It has been known for some Dr. Pinn is confident that the imple- women’s health. First and fore- time that auto-immune diseases, in mentation of the NIH’s women’s most, she contradicted the widely which the immune response is di- health research agenda for the 21st held belief that breast cancer is rected at the body’s own tissues, century will lead to many important the leading cause of death among disproportionately affect women. research findings and clinical appli- women in the United States. To Rheumatoid arthritis is the most cations in the next few decades. The the contrary, heart disease has been common chronic pain condition in results of this research will ulti- the number one killer of women women. Other chronic pain condi- mately lead to improved women’s for nearly a century, accounting tions on the women’s health research health care, as physicians and con- for about 57 percent of deaths in agenda include pelvic pain and sumers become better-informed women. Cardiovascular disease vulvodynia. Last month, the NIH about the prevention and treatment kills almost twice as many Ameri- announced that four vulvodynia stud- of disorders that are prevalent in can women as all cancers com- ies will receive funding over the women. n

Page 10 NVA News/Fall 2000 Research (from page 1) or sexual abuse, accidental or new pharmacologic and dietary in- The fourth proposal, “Cognitive iatrogenic (treatment-induced) injury, terventions will be evaluated. behavior therapy for vulvodynia or exposure to environmental irritants, patients,” was submitted by Robin abrasives, or topical treatments for Barbara Reed, M.D., associate pro- Masheb, Ph.D., associate research vaginal disorders. fessor of family medicine at the Uni- scientist in the Department of Psy- versity of Michigan Medical School, chiatry of Yale University School To assess the prevalence of will investigate potential causes of of Medicine. The primary aim of vulvodynia and test the hypothesis vulvodynia in a study titled, “Neuro- this study is to evaluate the effi- described above, the investigators and cytokine alterations cacy of cognitive-behavioral will first determine the current preva- in vulvodynia.” The broad, long-term therapy as a complementary inter- lence of chronic vulvar pain symp- objectives of this proposal are to as- vention for women with vulvo- toms in a general population sample sess the differences in specific neuro- dynia. Cognitive behavioral ther- of 16,000 women between 20 and immunological characteristics be- apy is a well-established psycho- 59 years of age. Based upon a sec- tween women with vulvodynia and social intervention that has been ondary screening assessment within asymptomatic controls. The specific shown to decrease pain severity, the subset of all women reporting aims include review of: 1) the indi- physical disability, and emotional vulvar pain symptoms, they will uti- vidual cytokine/neurokine produc- distress for various chronic pain lize diagnostic criteria to estimate tion response to stimulation of periph- conditions. the age specific prevalence for cur- eral blood; 2) local changes in nerve rent vestibulodynia (pain in vesti- fiber, mast cell, Substance P and se- This study is designed to compare bule only) or dysesthetic vulvodynia. rotonin density in vulvar tissue; and the outcome of cognitive behav- 3) the interactions of the systemic and ioral therapy vs. supportive psycho- The second research project, local immunologic systems assessed therapy. Since Vulvar Vestibulitis “Vulvodynia prevalence and effi- in 1) and 2). Syndrome (VVS) and Dysesthetic cacy of four interventions,” was sub- Vulvodynia are the most common mitted by Gloria Bachman, M.D., The final step will be a multivariable and enigmatic vulvodynia subtypes, professor of obstetrics, gynecology assessment of laboratory results with this study will enroll only women and medicine at the University of historical risk factors for vulvodynia, who have been diagnosed with one Medicine and Dentistry of New Jer- in an attempt to explore whether of these conditions. Over three years, sey. This proposal is divided into these pathophysiological mechan- 60 participants with VVS or three sections: epidemiology, edu- isms might account for the historical dysesthetic vulvodynia will be ran- cation, and intervention. The aim of risk factors identified. domly assigned to 10 weeks of ei- the epidemiology section is to up- ther cognitive behavioral therapy or date prevalence data, determine The research design involves a case- supportive psychotherapy. which age groups are most affected control review of 100 women with by vulvodynia and assess whether vulvodynia, 100 controls matched Current applications any similarities/risk factors exist in for ethnicity, and 100 African-Ameri- the vulvodynia population. The edu- can control women, using question- Until further notice, vulvodynia cational portion of the project will naires, physical examinations and research proposals should be sub- disseminate information on vulvodynia clinical laboratory data. Results from mitted under the NICHD’s ongo- to the medical community and this study should lead to improved ing Program Announcement (PA- women’s health organizations. The understanding of neuro-immunologic 98-112). The Website address for third section is designed to compare alterations in women with vulvodynia this PA is http://www.nih.gov/ the efficacy of different treatments and the development of therapeutic grants/guide/pa-files/PA-98- for vulvodynia ; both traditional and strategies for this disorder. 112.html. n

NVA News/Fall 2000 Page 11 National Vulvodynia Association Membership/Donation Form

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Page 12 NVA News/Fall 2000