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Vulvar Pain Syndromes: Causes and Treatment of Vestibulodynia

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Vulvar Pain Syndromes: Causes and Treatment of Vestibulodynia Last of 3 parts Vulvar pain syndromes: Causes and treatment of vestibulodynia Although the origins of vestibulodynia are incompletely understood, this subset of vulvar pain is manageable and—good news—even curable in some cases Neal M. Lonky, MD, MpH, moderator; Libby Edwards, MD, Jennifer Gunter, MD, and Hope K. Haefner, MD, panelists his three-part series concludes with What do we know about the a look at vestibulodynia—pain that causes of vestibulodynia? In thIs is localized to the vulvar vestibule. Dr. Lonky: What are the causes of provoked Article T Much is known about this disorder, com- vestibulodynia (PVD), also known as vulvar Look for depression pared with our knowledge base in the recent vestibulitis syndrome? And what are the the- in women given past, but much remains to be discovered. ories behind those causes? a diagnosis of Among the questions explored by the panel- Dr. Haefner: The specific cause is unknown. vulvodynia ists in this article is whether vestibulodynia Most likely, there isn’t a single cause. Theories page 30 and generalized vulvodynia are distinct enti- that have been proposed include abnormali- ties—or different manifestations of the same ties of embryologic development, infection, Is vestibulodynia process. inflammation, genetic and immune factors, curable? Other questions addressed here: and nerve pathways. page 31 • Do oral contraceptives (OCs) contribute to Patients who have vestibulodynia may vestibulodynia? also have interstitial cystitis. It has been not- • What about herpes and genital warts? Are ed that tissues from the vestibule and blad- Vestibulectomy they causes of vestibular pain? der have a common embryologic origin and, technique • Are some women more vulnerable to ves- therefore, are predisposed to similar patho- page 32 tibulodynia than others? logic responses when challenged.1,2 • Is the disorder curable? Candida albicans infection in patients • Does vestibulectomy provide definitive who experience vestibular pain has also been treatment? studied. The exact association is difficult to Part 1 of this series, which appeared in determine because many patients report the September 2011 issue, focused on gen- Candida infections without verified testing eralized vulvar pain and its causes, features, for yeast. Bazin and colleagues found a very and diagnosis. Part 2, in the October issue, weak association between infection and pain took as its subject the treatment of vulvar on the vestibule.3 pain. Both are available in the archive at Inflammation—the “itis” in vestibu- obgmanagement.com. litis—has been excluded from the recent continued on page 28 24 OBG Management | November 2011 | Vol. 23 No. 11 obgmanagement.com Vulvar pain syndromes had dyspareunia or tampon intolerance, the OBG ManaGeMent expert panel raising the issue of a genetic predisposition. Another genetic connection was found in a Neal M. Lonky, MD, MpH, moderator of this discussion, study evaluating gene coding for interleukin is Clinical Professor of Obstetrics and Gynecology at the 1-receptor antagonist.6–8 University of California–Irvine and a member of the Board of Directors of Southern California Permanente Medical Group. Krantz examined the nerve character- 9 He serves as an OBG ManageMent Contributing Editor. istics of the vulva and vagina. The region of the hymeneal ring was richly supplied with free nerve endings. No corpuscular endings of any form were observed. Only free nerve Libby Edwards, MD, is Adjunct Clinical Associate Professor endings were observed in the fossa navicu- of Dermatology at the University of North Carolina in Chapel laris. A sparsity of nerve endings occurred in Hill, NC, and Chief of Dermatology at Carolinas Medical the vagina, as compared with the region of Center in Charlotte, NC. Dr. Edwards is a Past President and Past Secretary General of the International Society for the the fourchette, fossa navicularis, and hyme- Study of Vulvovaginal Disease. neal ring. More recent studies have analyzed the nerve factors, thermoreceptors, and noci- ceptors in women with vulvar pain.10,11 Jennifer Gunter, MD, is Director of Pelvic Pain and Dr. Edwards: I feel strongly that vestibulo- Vulvovaginal Disorders for Kaiser Permanente in San dynia and generalized vulvodynia are the Francisco, Calif. same process. For example, tension head- aches are supposed to be occipital, but some people experience tension headaches that are periorbital. Both are tension headaches despite the different locations. And almost all Hope K. Haefner, MD, is Professor of Obstetrics and patients who experience any subset of vulvo- Gynecology at the University of Michigan Hospitals and dynia have provoked vestibular pain. So the Co-Director of the University of Michigan Center for Vulvar only thing that separates vestibulodynia from Diseases in Ann Arbor, Mich. other patterns of vulvodynia is the option of vestibulectomy for therapy. I don’t think that vulvodynia and ves- tibulodynia are “wastebasket” names for The authors report no financial relationships relevant to this article. undiagnosable vulvar pain; rather, they are specific disease processes produced by pelvic floor dysfunction that predisposes a woman International Society for the Study of Vul- to neuropathic pain with a trigger or to a sys- vovaginal Disease (ISSVD) terminol- temic pain syndrome that includes an abnor- ogy because studies found no association mal pelvic floor. between excised tissue and inflammation. Dr. Gunter: There are probably many causes Bohm-Starke and colleagues found low ex- of PVD, as Dr. Haefner suggested. There may pression of the inflammatory markers cyclo- be an ignition hypothesis, whereby some out- oxygenase 2 and inducible nitric oxide syn- side inflammatory trigger or trauma produces thase in the vestibular mucosa of women local neurogenic inflammation. However, who had localized vestibular pain, as well as given the prevalence of other pain disorders, in healthy women in the control group.4 there is probably also a need to have a lowered Goetsch was one of the first research- threshold for these changes to occur—basi- ers to explore a genetic association with cally, a vulnerable neurologic platform. localized vulvar pain.5 Fifteen percent of For some women, local neural hyperpla- patients questioned over a 6-month period sia is probably a factor. It is possible that there were found to have localized vestibular pain. are different causes for primary and second- Thirty-two percent had a female relative who ary vestibulodynia. continued on page 30 28 OBG Management | November 2011 | Vol. 23 No. 11 obgmanagement.com Vulvar pain syndromes difference for patients. Topical estrogen sup- Look for depression in women given a diagnosis plementation in the occasional OC user who of vulvodynia has signs of low estrogen has been useful at times. Vulvodynia and depression often travel together. They are such common comorbidities, in fact, that some physicians theorize that vulvodynia may be a symptom of an underlying mood disorder, such as depression, or that depression may be one manifestation of Do herpes or genital warts chronic vulvar pain. Suffice it to say that chronic pain and depression contribute to pVD? are often associated, and it is frequently difficult to determine whether Dr. Lonky: Does a history of vulvar herpes the relationship is one of cause and effect. or genital warts have any impact on the inci- Comprehensive care of the patient who has vulvar pain, there- dence of PVD? fore, should include a thorough history, looking specifically for Dr. Edwards: No. depression (including sleep disorders) and eliciting information on any Dr. Gunter: I agree that it has no impact. suicidal thoughts or intentions. Dr. Haefner: Herpes is sometimes associ- Although many patients who have vulvodynia are treated with an antidepressant, the dose that relieves pain may not be high enough ated with vulvar pain. The lesions resolve, to attenuate an accompanying mood disorder. My approach is to but pain may continue as post-herpetic neu- team up with a psychiatrist or psychologist who is familiar with vulvar ralgia. As with shingles, a low threshold for pain syndromes. Together, we monitor the patient and fine-tune the starting a patient on gabapentin to control therapeutic response. pain after herpes may be beneficial. Neal M. Lonky, MD, MpH Genital warts rarely cause vulvar pain— but the treatment may. Patients sometimes — feel pain following topical treatment, as well Do oral contraceptives as pain from surgical wart treatment. contribute to vestibulodynia? Dr. Lonky: Is PVD more prevalent among OC users? Effect of demographic variables “Herpes is some- Dr. Haefner: Controversy surrounds the Dr. Lonky: Does race, skin type, or hair or times associated with question of whether vestibulodynia and OC eye color make a difference in the preva- vulvar pain. the use are linked. Some studies suggest no as- lence, manifestation of symptoms, or treat- lesions resolve, but sociation12–14 and others suggest a possible ment of PVD? pain may continue effect of OCs on vulvodynia.15–17 A study by Dr. Gunter: I am not aware of any studies as post-herpetic neuralgia.” Reed and colleagues found no association that confirm an association between vulvo- between taking OCs or hormone therapy at dynia and those factors. —Hope K. Haefner, MD enrollment and incident vulvodynia only in Dr. Edwards: I don’t know whether any of the univariable analysis, but not when con- these variables make a difference. My own trolling for age at enrollment.18 This reflects impression—confirmed by informal study in the finding that younger age was associated my office—is that vulvodynia patients weigh with incident disease; younger age and use of less than my general dermatology patients OCs are similarly associated. and are better educated. I sometimes get the Dr. Gunter: I am not a believer in a cause- sense that my vulvodynia patients are more and-effect relationship between OC use and likely to be fair. vestibulodynia. I do not find the studies dem- Dr. Lonky: What age group is most com- onstrating an association convincing.
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