On the case... for a dozen years in a young woman By Susan Hoffstetter, PhD, WHNP-BC, FAANP

Why has a 30-year-old woman never been able to enjoy pain-free sex?

30-year-old woman named CL presents to A the office as a new pa - tient. Her health history is no - table for ; irritable bowel syndrome (IBS), diarrhea dominant; and dyspareunia since the onset of sexual activity at age 18. CL has never been pregnant. CL tells the nurse practitioner (NP) that her dysmenorrhea has been well managed since age 15 with combination oral contracep - tives (COCs) and an occasional NSAID on day 1 of her period. She does not take any for her IBS, and she avoids foods that She goes on to tell the NP that periencing itching and burning in might cause bouts of diarrhea. CL she has been dating her current the vulvar area. The symptoms are tells the NP she is seeking relief of partner for 6 months and that they present on most days and worsen the pain she experiences during have had sex 3 times, which caused with her period. She ascribes the sex, which has worsened over the great discomfort. She says she tried symptoms to yeast infections (3-4 past 6 months and which she various over-the-counter (OTC) lu - in the past year), which she treats fears might ruin her current rela - bricants and different positions, to with OTC antifungal creams. She tionship. She tearfully tells the NP no avail. Although CL says she en - also reports that, in the past year, that three prior relationships joys cuddling and kissing with her she has been treated by another ended badly because she was un - partner, she has been avoiding healthcare provider (HCP) for bac - able to have comfortable, enjoy - this type of contact for the past 2 terial vaginosis with a vaginal gel. able sex. Although she said she months because of fear that it In addition, she has gone to an ur - was able to tolerate sexual touch - would lead to intercourse. At the gent care center twice for treat - ing and intercourse in the past, same time, she wants to enjoy in - ment of urinary tract infections— her symptoms have been gradu - tercourse and please her partner. even though she is unsure ally getting worse. whether the urine culture findings What else would be were positive or negative. We invite readers to submit helpful to know about CL’s A year ago, at the suggestion of interesting and elucidating case symptoms and health a friend to whom she mentioned reports. Please see our Guidelines history? the painful sex, CL went to a clinic for Authors A for more information about this short-form article option. CL tells the NP she feels she is “a for sexually transmitted disease mess down there.” She reports ex - testing and a Pap smear with a hu -

22 February 2016 Women’s Healthcare www.NP WOMENS HEALTHCARE .com man papillomavirus (HPV) co-test. and burning, significant vestibular pain on a scale of 0-10 at each lo - She reports that all findings were pain during and after sex, and cation ( Figure ). CL’s cotton-swab negative but adds that she hesi - vaginal pain with thrusting. These test produces scores of 0 on the tates to “go through that again” symptoms may have similar or inner thighs and majora, 2 at because the speculum examina - overlapping causes such as: the , and 2 at the perineal tion was very painful. She says, “I • ; body. Pain at the vestibular gland don’t even use because • Vulvar dermatoses (e.g., lichen duct openings is rated at 6-7 for they hurt too much.” She tells the sclerosus); the Skene’s glands and 7-8 for the NP that she wears a panty liner • (pruritus is the Bartholin glands. every day because she does not most common early symptom); Because CL has high vestibular take her COC consistently; when • Vulvovaginal atrophy (associ - pain scores, the NP does not per - she forgets to take a pill or takes it ated with the patient’s pro - form a speculum exam. The NP late, she has some spotting. She longed COC use); remarks that she never feels really • ; and clean because of the frequent di - • . In the absence of arrhea, and uses feminine wipes daily. What would you include in abnormal visible As she tears up again, CL tells your problem-focused findings other than mild the NP that, over the past few physical examination? months, she has felt more stressed The NP begins with inspection of erythema of the labia than usual because of worries the and vestibule to assess about her relationship and be - for anatomic changes or varia - majora, the NP performs cause of work pressures with a tions, pigmentation changes, a cotton-swab new boss. She laughs a little as she lesions, and integrity of vulvar tis - says, “I don’t drink, use drugs, or sues. The inspection reveals nor - test to specifically smoke, but when I get home from mal vulvar structures and mildly localize any areas of work, all I want to do is take a long erythematous, dry hot bath with some scented oils to with no other pigmentation altered sensation in the help me relax and feel clean.” changes or lesions. The labia mi - The NP seeks more details nora are moist and pink. Vulvar vulvar area. about the dyspareunia, and asks hair is absent; CL reports that she CL to rate the pain she experi - has been removing this hair with a uses a cotton swab to obtain a ences during and after sexual in - razor and shaving cream for years. vaginal specimen for pH and mi - tercourse using a Likert scale, with In the absence of abnormal vis - croscopic wet mount evaluation. 0 = no pain and 10 = maximum ible findings other than mild ery - The pH is 4.0. A whiff test is nega - pain. CL rates the pain she feels in thema of the labia majora, the NP tive. Mature squamous epithelial the vestibule area when her part - performs a cotton-swab test to cells are present, with no pseudo - ner’s penis enters the as an specifically localize any areas of hyphae, clue cells, or motile 8, and describes it as burning or a altered sensation in the vulvar trichomonads seen on the wet “razor blade” sensation. During pe - area. The test is done prior to digi - mount. A vaginal specimen is sent nile thrusting, she experiences tal palpation and an attempt at in - for fungal culture to assess for in - vaginal pain rated as a 6. After sex - sertion of a speculum. A standard fection caused by atypical Candida ual touching, she has heightened cotton tip applicator is used to species. The culture results are burning pain in the vestibule area apply light touch starting on the negative. rated as a 4; the pain lasts 12-24 upper inner thigh and following Pelvic floor muscle (PFM) as - hours. in a clockwise fashion in a manner sessment is done using one finger that includes the labia majora, the inserted into the vagina without Which differential vestibular duct openings for touching the vestibule. The Oxford diagnoses would you Skene's and Bartolin glands, the Grading System uses a 6-point consider at this point? clitoris/hood, and the perineum. scale to measure PFM strength: 0 CL describes chronic vulvar itching The patient is asked to rate her = no contraction; 1 = flicker; 2 = www.NP WOMENS HEALTHCARE .com February 2016 Women’s Healthcare 23 Figure. Cotton-swab test checkpoints monal changes, 6 or dietary ox - alates. 7,8 Chronic inflammation re - lated to the contact irritants, re - Pubis Inner thigh Inner thigh current infections, hormonal changes, or chronic skin condi - tions acts as a trigger. Normal sen - sations are perceived as abnormal, Clitoris resulting in heightened sensitivity. Urethral meatus Estimates of vulvodynia preva - Skene’s gland os Skene’s gland os lence range from 3% to 18%. 9 On - set is most likely to occur between Labia majora Labia majora the ages of 18 and 25. Among symptomatic women, 60% see an Labia minora average of three HCPs before re - Introitus ceiving the correct diagnosis and 40% remain undiagnosed. 9 Bartholin’s gland Bartholin’s gland Vulvodynia is classified as local - duct os duct os ized or generalized. Localized vul - vodynia is subdivided into pri - Perineum mary, in which vestibular pain begins during the first attempt at Anus vaginal penetration, or secondary, in which pain occurs after a period of pain-free sex. Generalized vul - vodynia may include all of the vulva or be limited to one side, weak; 3 = moderate; 4 = good tact irritants. CL’s physical exam with pain occurring in the absence (with lift); and 5 = strong. CL’s PFM and wet mount findings tend to of a triggering event. Of note, strength is rated a 4. Palpation of rule out infection as the cause of about 10% of women with gener - the levator ani group and obtura - the vulvitis. The labia majora dry - alized vulvodynia have a co-exist - tor internus muscles reveals hy - ness may be related to prolonged ing pain syndrome such as inter - pertonicity and tenderness. use of COCs. stitial cystitis/painful bladder Vulvodynia is defined as vulvar syndrome, IBS, fibromyalgia, or Based on the history and discomfort (usually described as chronic fatigue syndrome. 10 exam findings, what is the burning pain) occurring in the ab - Prolonged use of COCs as a risk diagnosis? sence of relevant visible findings factor for vulvodynia is controver - CL has three interconnected diag - or a specific, clinically identifiable, sial. Several studies have sup - noses contributing to the dyspa - neurologic disorder. 1 It is a diag - ported the theory that use of COCs reu nia: contact vulvitis, vulvo dyn - nosis of exclusion when all other or progesterone-only contracep - ia, and vaginismus. potential causes have been ruled tives in females younger than age Vulvitis may be caused by out and when symptoms persist 18 causes down-regulation of es - chronic or recurrent infection by longer than 3 months. 1 The etiol - trogen receptors, leading the pathogens such as Candida , her - ogy of vulvodynia is unknown but vestibular epithelium to become pes simplex virus, or HPV; contact may be related to genetic suscep - thin and fragile. 11,12 Although with allergens or irritants; or in - tibility, 2 chronic inflammation, 3 a some women with vulvodynia jury/trauma. CL has reported regu - combination of factors (e.g., PFM have increased perception of pain lar use of vulvar contact irritants abnormalities, neuropathic pain, when taking COCs, stopping COCs such as panty liners, feminine anxiety, primary/secondary sexual does not necessarily lead to resolu - wipes, shaving cream, and scented dysfunction), 4 regionally elevated tion of the symptoms. 12 bath oils. Pubic hair shaving may cytokines produced by vulvar Vaginismus is defined as recur - heighten one’s sensitivity to con - vestibule-specific fibroblasts, 5 hor - rent or persistent involuntary

24 February 2016 Women’s Healthcare www.NP WOMENS HEALTHCARE .com spasm of the musculature of the Self-management is essential Cream bases contain more preserv - outer third of the vagina that in - in CL’s case. She is educated to atives and stabilizers, which can act terferes with vaginal penetration avoid use of feminine hygiene as contact irritants and cause burn - and that causes personal distress wipes/washes, panty liners (at ing upon application. or interpersonal difficulties. 13 times other than menses), and The next line of treatment is the repetitive use of OTC antifungals. 9 use of oral neuropathic pain mod - What can the NP offer CL She is encouraged to stop remov - ulators, either antidepressants as first-line treatment? ing her vulvar hair, which provides (e.g., amitriptyline, desipramine, Because studies on the cause and a protective barrier for sensitized venlafaxine) or anticonvulsants treatment of vulvodynia are lim - vestibular tissues. She is advised (e.g., gabapentin, pregabalin, ited, the American College [now to avoid exposure to very hot wa - lamotrigine, topiramate). 17 Side- Congress] of Obstetricians and ter in bathtubs and hot tubs, effect profiles and patient toler - Gynecologists recommends that which can exacerbate vestibular ance drive dosing regimens. Pruri - therapy be based on evidence discomfort. Application of un - tus can be managed with an from descriptive studies, expert scented, hypoallergenic emol - antihistamine such as hydroxyzine reports, and clinical experience— lients to the vulvar skin and sitz or cetirizine. In addition, nerve with the understanding that the baths in lukewarm water can be blocks, topical nitroglycerin, topi - condition is difficult to treat and soothing, however. cal capsaicin, interferon injection, that no single approach is success - CL and her partner should ex - and trigger point injections have ful for all women. 14 plore alternatives to penetrative shown some efficacy in treating Individualized treatment usu - sex (e.g., light physical contact with vulvodynia. 17 Vaginal valium, in - ally involves multiple therapies her genitalia). As pain diminishes jectable , and top - over time. 9 Treatment is consid - with treatment over time, CL can ical baclofen have been used in ered in a step-wise progression, consider restarting penetrative sex. the treatment of vaginismus. starting with self-management The NP advises her to implement and moving upward on the scale strategies for PFM relaxation, to What role does physical of complexity. Total symptom res - adopt positions during intercourse therapy play in CL’s olution can be unrealistic. Primary that minimize pressure on sensitive treatment? goals are symptom reduction, re - areas, and to use liberal amounts of Pelvic floor (PT) turn of satisfactory sexual func - water-soluble lubrication. is an essential component of tion, and improved quality of life. A low-oxalate diet has been treatment for CL once she can Patient education concerning the suggested to reduce high levels of withstand cotton-swab touch manageability yet chronicity of oxalate in urine. However, little ev - with lowered vestibular pain this neuropathic condition is es - idence supports the efficacy of scores. A person with expertise in sential in setting realistic goals this dietary modification in reduc - pelvic floor PT may use a combi - and in instituting a treatment plan ing vulvar pain. 7,8 nation of interventions to de - that leads to improvement and crease CL’s dyspareunia and to satisfaction. What types of improve her sexual function. 17,18 Mental health counseling is pharmacologic agents are Interventions include (1) bio- an important component. Approx - appropriate? feedback, which can help CL imately 50% of women with vulvo - Topical can be used learn to relax her PFMs; (2) exter - dynia have a concordant diagnosis on a short-term basis. 17 Options in - nal soft tissue mobilization and of anxiety. 15 An increased occur - clude 5% ointment, dox - myo fascial release techniques; rence of childhood physical/sexual epin 5% cream in water-soluble (3) trigger point pressure; and (4) abuse in women with vulvodynia base, gabapentin 2%-6% in water- transcutaneous electrical stimu - has been reported. 16 Referral to a soluble base, and amitriptyline 2% lation applied to the sacral mental health specialist with ex - with baclofen 2% in water-soluble nerve. The physical therapist or pertise in women’s sexual health base. When topicals are used, those NP may teach CL how to use and conditions can with an ointment base, rather than vaginal dilators to gradually be helpful. a cream base, are preferred. 17 overcome the tension in the

www.NP WOMENS HEALTHCARE .com February 2016 Women’s Healthcare 25 PFMs. When CL is ready to re - mercial product named in this 12. Goldstein AT, Krapf J, Belken Z. sume sexual activity, she can use article. Do oral contraceptive pills cause vul - vodynia? Time to finally end the con - the dilator to prepare herself for troversy. International So - and facilitate penetration. References ciety Blog. October 2015. pelvic 1. Haefner HK. Report of the Inter - pain.org/professional/blog/ipps-blog/ national Society for the Study of Vul - june-2014/do-oral-contraceptive-pills- When is an option? vovaginal Disease terminology and cause-vulvodynia-time.aspx For women who continue to expe - classification of vulvodynia. J Low rience intractable symptoms after Genit Tract Dis . 2007;11(1):48-49. 13. Curtis M, Linares S, Antoniewicz L. Glass’ Office Gynecology . 7th ed. all other treatments have been 2. Goldstein AT, Kim N, Burrows LJ, Philadelphia, PA: Wolters Kluwer Goldstein I. Genetic differences may tried, —excision of Health; 2014. the vestibule with vaginal ad - reflect differences in susceptibility to vulvodynia in general or in sponta - 14. American College of Obstetricians vancement—is an option. Patient neous remission propensity: a re - and Gynecologists. 2006. Committee selection is critical for success; sponse. J Sex Med . 2015;12(2):578-579. Opinion Number 345. Vulvodynia. women can consider this option 3. Akopians AL, Rapkin AJ. Vulvo - Washington, DC: American College of only if symptoms are confined to dyn ia: the role of inflammation in the Obstetricians and Gynecologists; 2006. the vestibule. Success rates range etiology of localized provoked pain of 15. Tribo MJ, Andio O, Ros S et al. from 60% to 85%. 19,20 Referral to a the vulvar vestibule (vestibulodynia). Clinical characteristics and psycho - Semin Reprod Med . 2015;33(4):239-245. pathological profile of patients with pelvic and reconstructive surgeon vulvodynia: an observational and de - is advised in these cases. 4. Edwards L. Vulvodynia. Clin Ob - stet Gynecol . 2015;58(1):143-152. scriptive study. Dermatology . 2008; 216(1):24-30. 5. Foster DC, Piekarz KH, Murant Reflection for practice TI, et al. Enhanced synthesis of proin - 16. Harlow BJ, Stewart EG. Adult on - Vulvodynia is a complex chronic flammatory cytokines by vulvar set vulvodynia in relation to child - pain condition. The interrelated vestibular fibroblasts: implications for hood violence victimization. Am J physical, psychological, and psy - . Am J Obstet Gy - Epidemiol . 2005;161(9):871-880. chosexual components make necol . 2007;196(4):346e1-8. 17. Haefner HK, Collins ME, Davis management challenging for both 6. Eva LJ, MacLean AB, Reid WM, et GD, et al. The vulvodynia guideline. J Low Genit Tract Dis . 2005;9(1):40-51. clinician and patient. CL has al. receptor expression. Am J Obstet Gynecol . 2003;189(2):458-461. sought an NP’s help in seeking re - 18. DeBevoise TM, Dobinsky AF, Mc - Curdy Robinson CB, et al. Pelvic floor lief of her dyspareunia. The treat - 7. Greenstein A, Militscher I, Chen J, et al. Hyperoxaluria in women with physical therapy: more than Kegels. ment plan focuses on symptom vulvar vestibulitis syndrome. J Reprod Womens Healthcare . 2015;3(2):34-41. reduction to allow for sexual func - Med . 2006;51(6):500-502. 19. McCormack WM, Spence MR. tioning that provides intimacy and 8. Harlow BL, Abenhaim HA, Vito - Evaluation of surgical treatment of vul - satisfaction. Total relief of pain nis AF, Harnack L. Influence of di - var vestibulitis. Eur J Obstet Gynecol may not be achievable. A multidis - etary oxalates on the risk of adult on - Reprod Biol . 1999;86(2):135-138. ciplinary approach to treatment set vulvodynia. J Reprod Med . 2008; 20. Haefner HK. Critique of new gy - 53(3):171-178. may produce the best results. In necologic surgical procedures: surgery for vulvar vestibulitis. Clin Obstet Gy - fact, when available, referral to 9. Harlow BL, Stewart EG. A popu - lation based assessment of chronic necol . 2000;43(3):689-700. vulvovaginal disease specialists unexplained vulvar pain: have we un - can facilitate an individualized, co - derestimated the prevalence of vulvo - Web resource ordinated, comprehensive ap - dynia? J Am Med Womens Assoc . A. npwomenshealthcare.com/author- proach to treatment. = 2003;58(2):82-88. instructions/ 10. Reed BD, Harlow SD, Sen A, et al. Susan Hoffstetter is a Fellow in Relationship between vulvodynia and the International Society of the chronic comorbid pain conditions. Ob - stet Gynecol . 2012;120(1):145-151. Study of Vulvovaginal Diseases and an Associate Professor at 11. Bohm-Starke N, Johannesson U, Saint Louis University School of Hilliges M, et al. Decreased mechani - cal pain threshold in the vestibular Medicine in St. Louis, Missouri. mucosa of women using oral contra - The author states that she does ceptives: a contributing factor in vul - not have a financial interest in or var vestibulitis? J Reprod Med . other relationship with any com- 2004;49(11):888-892.

26 February 2016 Women’s Healthcare www.NP WOMENS HEALTHCARE .com