March 2021

Complaint: Vulvar pain lasting at least 3 months duration without a clear identifiable cause. Yep, that is vulvodynia. Last month’s post reviewed diagnosis; this month our post continues with options for treating the condition. Noor Dasouki Abu-Alnadi, MD, MS, who specializes in chronic pain syndromes such as vulvodynia, presented a 1-hour master class on the topic at the recent Contraceptive Technology conference,[1] and shared how she helps when sex hurts because of vulvodynia. “Keep these initial treatments in your wheelhouse,” she said, because you will make use of them repeatedly.

First begin with easy things that patients can modify in their day-to-day behaviors to help manage their pain. A retrospective cohort study compared the behavioral practices of 230 women with and 230 women without vulvodynia to reveal some expected but also some unexpected findings:[2]

1. Wearing tight fitting pants substantially increases the risk by over 2-fold. However, the type of underwear does not increase the risk of developing vulvodynia. It does not matter whether the patient wears a thong or wears granny panties. Although in Abu-Alnadi’s experience, nylon fabric and daily wear of pantyliners can irritate the vulva over time.
2. Grooming practices in which the hair is removed around the vulva and vagina, and specifically the Mons, substantially increases risk. Removing hair along the thighs does not increase the risk.
3. Washing routines and products did not appear to matter, according to the study. However, Abu-Alnadi believes some women can be sensitive to lotions and fragrances. The same applies to lubricants; hypoallergenic products are best. “My rule of thumb is ‘wash your upper body and then just let the water run down,’ she said. Explain to your patient that the vulva and the vagina have a self-rinse cycle—they auto-clean.

Next, try topical treatments that contain active drug but have less systemic absorption with fewer and smaller side effects overall than do oral medications.

• Lidocaine ointment, 2 to 5%. The purpose is simply to desensitize the vulva. The patient should apply the lidocaine on a cotton swab and then rest it against the area to let the lidocaine absorb. The longer the lidocaine stays on the vulva, the deeper anesthesia. Patients need to use it consistently. The patient should use the lidocaine before sex and have a partner use a condom or other barrier. Because lidocaine tends to be expensive and is usually not covered by insurance, a cheaper option to suggest is over-the-counter lidocaine labelled for rectal use.
• Steroids? No, do not prescribe steroids. Even though the biopsy shows nonspecific inflammation, steroids do not help. Moreover, they increase the risk of conditions such dermal atrophy or steroid dermatitis.
• Topical antifungals? No, these do not help.
• Home remedies are good for patients with a lot of symptoms but who not tolerate other topical medications or who do not want to use a pharmaceutical. These remedies do not resolve vulvodynia, but they do calm the irritation and many are hypoallergenic. Many patients like vitamin E oil, coconut oil or petrolatum jelly. Some patients in the South swear by Crisco.

Estrogen. Clinicians sometimes place patients on Premarin or Estrace, but Abu-Alnadi said that these generally do not contain high enough estrogen doses to make a difference. Her institution has for several years compounded lidocaine with a topical high-dose estrogen (about 5 times the amount in Premarin or Estrace), a treatment currently undergoing trial. The lidocaine controls the active pain and the estrogen builds up the tissue and promotes moisture. In Abu-Alnadi’s experience, compounding estrogen with testosterone does not seem to provide benefit, although there are mixed data on that treatment.

What about narcotics for the pain of vulvodynia? No, said Abu-Alnadi. There are no data to show that narcotics work with this type of chronic pain. If the patient has been taking narcotics, or if you prescribe a short-term regimen for the patient to use until she can get an appointment with a chronic pain specialist, your goal is to wean the her off this medication onto a medication that will work at the level of the brain or spinal cord, helping to change the way the pain is interpreted.

Neuropathics can be helpful when the more basic approaches have not helped enough. Clinicians in family or internal medicine who will have had previous experience in prescribing pregabalin, gabapentin, or lamotrigine may feel more comfortable prescribing these drugs. Clinicians in gynecology or advanced care practitioners in women’s health, with less or no experience in prescribing these drugs, may feel it daunting to use them, said Abu-Alnadi. These drugs are taken orally; however, they can be compounded into an ointment for topical use.

• Tricyclics are supported by strongest evidence in neuropathic pain, specifically in vulvodynia. Nortriptyline causes less sedation than amitriptyline. Start with a bedtime dose at the lowest dose possible and increase every 1 to 2 weeks, depending upon risk factors. It also has the potential to help with mood. Remind patients that it takes time to work, so they will not notice any improvement for another 4 to 6 weeks.
• Duloxetine is also an off-label use. It is used for patients with fibromyalgia or IBS, so it is helpful when you have a patient who has more than one chronic pain disorder. Vulvodynia is associated with patients who have not just chronic pelvic pain but additionally conditions such as IBS and fibromyalgia as well. The maximum pain response comes at 60 milligrams (doses for mood control are higher). Duloxetine could potentially cause serotonin syndrome, so be on the alert for interactions with other drugs.
• Gabapentinoids. The data on gabapentin are mixed. However, said Abu-Alnadi, you can play a lot with the dose. She starts with “a baby dose” of 100 milligrams. By taking it an hour before bedtime, patients can mitigate some of the some of the sedative effect. Increase by 100 milligrams up to 600 milligrams and then perhaps try BID or TID dosing. Pregabalin can also work well. You have to wait 1 to 2 weeks before you can determine whether these drugs will work. Remember that some patients can and will abuse these drugs. Carefully assess the way that a patient is taking the drugs and make sure they’re not mixing it with other things such as benzodiazepines or alcohol.
• Anticonvulsants. You may see a patient who has been placed on one of the third-line agents—anticonvulsants—to manage the vulvodynia. Most nonspecialists would not feel comfortable prescribing anticonvulsants, which require blood monitoring. However, some patients respond to this treatment, so referral is an option.

Does the patient’s vulvodynia seem recalcitrant or do you prefer to avoid prescribing drugs with which you have little experience?  Do not hesitate to refer, encourages Abu-Alnadi. The longer patients have to deal with vulvodynia, the more negatively it affects their sexual identities, their relationships with their partners, and their quality of life.

You can refer to chronic pain specialists who can prescribe a broad array of medications, including those that require complex titration and monitoring. Those who also perform surgery can perform a vestibulectomy, which has a high rate of patient satisfaction. Consider, too, referring to a physical therapist who treats pelvic floor pain.

[1] Abu-Alnadi ND. Sex shouldn’t hurt: managing vulvodynia and pelvic floor dysfunction. Contraceptive technology conference, Sept. 23, 2020.

[2] Klann AM, Rosenberg J, Wang T, et al. Exploring hygienic behaviors and vulvodynia. J Low Gen Tr Dis 2019;23:220-5. doi: 10.1097/LGT.0000000000000477