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Vulvar pain of unknown cause (vulvodynia): Treatment

Vulvar pain of unknown cause (vulvodynia): Treatment
Literature review current through: Jan 2024.
This topic last updated: Oct 19, 2022.

INTRODUCTION — Vulvodynia, or vulvar pain of an unknown cause, has a significant negative impact on a woman's health, self-esteem, relationships, quality of life, and work productivity. Women can have vulvar pain from a specific etiology, pain without an identifiable cause, or both. Treatment must therefore address a wide range of potential etiologies as well as provide an approach for women whose pain is not understood by available paradigms.

This topic will review our approach to treatment of vulvodynia. The evaluation of women with vulvar pain, approach to the woman with sexual pain, and evaluation and treatment of vulvar pain from specific etiologies are reviewed separately.

(See "Female sexual pain: Evaluation".)

(See "Vulvar pain of unknown cause (vulvodynia): Clinical manifestations and diagnosis".)

(See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis".)

(See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

DEFINITION — At the Fourth International Consensus of Sexual Medicine (ICSM) in 2015, experts representing several international societies dedicated to the study of vulvar pain established revised nomenclature for vulvar pain conditions, based upon available research and clinical expertise. These new terminologies acknowledged vulvar pain and vulvodynia as complex, multifactorial pain syndromes with varied etiologies and implied that treatment should be tailored to each individual based upon their clinical presentation (table 1) [1,2].

Based on the revised nomenclature, we use the following terminology [1]:

Vulvar pain describes symptoms related to a specific disorder (eg, inflammatory, infectious, neoplastic, etc).

Vulvodynia refers to idiopathic, chronic vulvar pain of at least three months' duration. Vulvodynia can be localized or generalized; provoked, spontaneous, or mixed; primary or secondary in timing of onset; and of varying temporal patterns (eg, intermittent, persistent, constant, immediate, or delayed).

Localized vulvar pain syndrome, formerly known as provoked vestibulodynia or vulvar vestibulitis, is a common vulvodynia that typically occurs in vulvar vestibule or clitoral regions. (See "Vulvar pain of unknown cause (vulvodynia): Clinical manifestations and diagnosis".)

Dyspareunia refers to a symptom of genital pain, including vulvodynia, during penetrative sexual activities.

ASSESSMENT — The assessment of women with chronic vulvar pain includes a detailed history that includes discussion of pain symptoms, sexual practices, gynecologic and medical issues, and a comprehensive physical examination. (See "Female sexual pain: Evaluation", section on 'Diagnostic evaluation'.)

OUR APPROACH — As vulvodynia is a chronic condition, in which symptoms are managed but may be ongoing and characterized by periods of remission and flare, one goal of treatment is to set realistic expectations. We help women understand that improvement can be a slow process and, because there is not a "one size fits all" treatment, that finding the correct therapy for them can take some trial and error, time, and patience.

We take the following approach to treating women with sexual pain:

Evaluation – We begin with a detailed history and physical examination to identify known causes of vulvodynia, which are then treated. (See "Female sexual pain: Evaluation", section on 'Diagnostic evaluation'.)

Behavior modification – Individuals with residual vulvodynia typically begin with behavior modification to reduce exacerbating factors, such as pain anxiety and fear-avoidance patterns [3], and improve stress reduction [2].

Multidisciplinary approach – Next we proceed with a multidisciplinary approach that includes pelvic floor physical therapy, common medical treatments, and counseling [2].

Treatment progression – Patients with persistent or inadequately treated pain then progress through treatments based on the cost, regional availability, and patient preference.

As there are limited trial data on which to base treatment of idiopathic female sexual pain, most clinicians rely on clinical experience and expert opinion in conjunction with information gleaned from research to devise an individualized treatment plan. Research suggests that successful treatment programs are multimodal and involve the interdisciplinary team of a medical clinician, a physical therapist, and a cognitive-behavioral psychotherapist and/or sex therapist [4].

BEHAVIOR MODIFICATION — We review behaviors that can be helpful, or may be harmful, with our patients.

Vulvar hygiene – Good vulvar hygiene is the first and easiest step women can take to alleviate irritation and discomfort (table 2). We ask women to avoid applying soap, fragrance, or other products to the affected area as any product can cause a topical dermatitis.

While the supporting data are sparse, we advise women follow the additional lifestyle changes proposed by the American College of Obstetricians and Gynecologists and by the authors of the Vulvodynia Guideline, who note that gentle care of the vulva can contribute significantly to pain reduction [5,6]. Specific strategies that they advise include wearing nonconstrictive cotton underwear during the day and none during hours of sleep; avoiding pantyhose, tights, and tight pants; using mild soap for bathing and water only for cleansing the vulva; avoiding douches, commercial vaginal wipes, deodorants, bubble bath, deodorants, tampons, or pads; using water-based nonscented, nonwarming, nonallergic lubricants for intercourse; applying cool gel packs to the vulva before and/or after sex to reduce pain and swelling; and avoiding activities that place pressure directly on the vulva such as bicycling.

Symptom relief – Soaking in warm baths with either Epsom salt or colloidal oatmeal can be soothing. Application of ice packs to the vulva for 10 to 15 minutes at a time every four to six hours can reduce burning sensations.

Stress reduction – We encourage stress reduction and relaxation techniques because data suggest women with vulvodynia have higher levels of stress and anxiety than healthy controls [7-11]. As stress may exacerbate symptoms of vulvodynia and vulvodynia symptoms tend to worsen stress, stress reduction may break this cycle. (See "Complementary and alternative treatments for anxiety symptoms and disorders: Physical, cognitive, and spiritual interventions".)

Lubrication – Over-the-counter personal lubricants and moisturizers can be both helpful and harmful to patients with vulvodynia and female sexual pain. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Initial therapy with moisturizers and lubricants'.)

Topical lubricants – Topical lubricants are generally water or silicone based, used on all partners, and applied episodically before and during sexual activity to reduce friction and add to pleasure.

Intravaginal moisturizers – Intravaginal moisturizers are bio adhesive, moisture-attracting agents, such as hyaluronic acid, that are placed in the vagina two to three times per week, irrespective of the timing of sexual activity. They provide long-lasting moisture for daily comfort.

Possibly helpful – Anecdotally, products such as coconut, olive, avocado, soybean, or vitamin E oil appear to reduce symptoms, but supporting data are limited [12].

Products to avoid – Products that contain alcohol, parabens, fragrances, and other irritants; those that are hyperosmolar; and those that contain warming agents can cause mucosal irritation and worsen painful symptoms.

Exercise – While exercise can be helpful to reduce stress and anxiety, we advise avoiding activities that can directly irritate the vulva, such as spinning class or bicycling, at least while the patient is symptomatic. Gentle yoga is generally well tolerated.

Diet – While yeast has been implicated in vulvodynia with limited evidence to support the efficacy of specific dietary changes, some practitioners advocate following a low-oxalate diet or other diet that limits linoleic acid (eg, limit nuts, red meat) and yeast prophylaxis. These are likely to do little harm and can easily be trialed in patients who don't respond to other therapies [7,13-17].

PELVIC FLOOR PHYSICAL THERAPY

Rationale — In accordance with multiple medical associations, we advise pelvic floor physical therapy as a primary treatment for vulvodynia because of the numerous studies demonstrating treatment efficacy [2,18-22]. Women with vulvodynia and sexual pain commonly exhibit myofascial trigger points and increased muscle tension in the pelvis, abdominal, back, and pelvic floor muscles [5,18,23-28]. The hypertonicity results from increased tissue inflammation, altered perfusion, and abnormal neural patterns, all of which contribute to muscle restriction and decreased mobility in these areas. (See "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis", section on 'Pathogenesis'.)

Treatment of vulvodynia and sexual pain associated with pelvic muscle dysfunction can be exceedingly complex because the pelvic floor muscles surround the urethral opening, the anorectal opening, and the vaginal opening. The resultant widespread muscle tension and nociceptors that tend to be sensitized by prolonged stimulation, making them respond to other sensations as well, can contribute to a self-perpetuating pain cycle and produce symptoms such as stabbing, shooting, or referred pain; vulvovaginal sensitivity; burning with penetration; pain with intravaginal thrusting; pain with orgasm; and/or postcoital pain. Pelvic floor physical therapy works to restore proper muscle length, decrease muscle tension, and decrease pain, which ultimately decreases dyspareunia and restores function [29-32]. (See "Myofascial pelvic pain syndrome in females: Treatment", section on 'Pelvic floor physical therapy'.)

Techniques — Pelvic floor physical therapy involves a variety of modalities, including pelvic and core mobilization and stabilization; connective tissue, visceral, and neural mobilization; internal and external myofascial trigger point release, biofeedback, and electrical stimulation [29,33]. After a comprehensive assessment, the pelvic floor physical therapist begins treatment with manual connective tissue manipulation to decrease restrictions in pelvic muscles and nerves and improve circulation to ischemic areas and those with pelvic congestion. (See "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis", section on 'Diagnostic evaluation' and "Myofascial pelvic pain syndrome in females: Treatment", section on 'Pelvic floor physical therapy'.)

A crucial aspect of pelvic floor and sexual rehabilitation is therapist-assisted stretching of the muscles of the hips, back, gluteus, and abdomen. The therapist then augments stretching exercises with strengthening techniques that address muscle weakness, with the goal of restoring balance and stability. Education regarding the progression and rate of strengthening is very important because restricted neural and connective tissue can become more irritated if these techniques are initiated prematurely [25]. In addition to external tissue release and core stabilization, direct internal transvaginal/transrectal release of muscles is a central aspect of pelvic floor physical therapy and sexual rehabilitation [25,31,32]. Internal manual therapy techniques reduce tissue adherence and restore skeletal alignment. These interventions allow women to sit more comfortably, participate in work/home activities, and enjoy improved bladder, bowel, and sexual function. During internal treatment, therapists educate patients through proprioceptive neuromuscular facilitation, verbal cueing, biofeedback, and electrical stimulation techniques which coordinate mind-body control of the pelvic floor and down-train overactive muscles [23,24,34].

Home program — As part of pelvic floor rehabilitation, the therapist develops a "home program" which may include abdominal, hip, pelvic, lower extremity, and back stretching; daily relaxation and breathing exercises; patient-performed manual techniques on external and internal tissue; and bladder and bowel re-training, as indicated [23,24]. Vaginal dilators may be recommended to normalize the tone of the muscles, desensitize previously hypersensitive areas of the vulva/vagina, and restore sexual function [30-32,35]. When needed, techniques such as guided imagery and mindfulness meditation can be incorporated into the patient's home program to facilitate neural down-regulation. Learning relaxation, self-release, and gentle strengthening techniques can empower patients and instill confidence so that sexual rehabilitation can continue at home after discharge from therapy [36,37].

PSYCHOLOGICAL INTERVENTION — Psychological interventions focus on reducing pain, restoring sexual function and strengthening the couple relationship by targeting the thoughts, emotions, behaviors, and couple interactions associated with sexual pain [22]. Interventions can be done in an individual, couple-based, or group format.

Cognitive behavioral therapy — Cognitive behavioral therapy (CBT) is one of the most commonly used and studied psychological interventions for pain, including vulvar and sexual pain. We prescribe individual, couple, and group CBT for our vulvodynia patients because this approach is a validated and noninvasive therapeutic option for sexual pain. (See "Overview of psychotherapies", section on 'Cognitive and behavioral therapies' and "Approach to the management of chronic non-cancer pain in adults", section on 'Cognitive-behavioral therapy'.)

In CBT for vulvodynia, the woman and/or partner are given psycho-education on the multidimensional impact of pain on the individual and the relationship. Concepts including the role of psychological and relationship factors in coping with pain and in the maintenance of pain are explored. Patients are instructed to use a daily pain diary to raise awareness about pain topography and factors that positively or negatively influence pain and to track progress toward recovery (pain reduction and improved function). With the help of the therapist, patients learn to identify personal maladaptive coping strategies that may increase pain and sexual dysfunction (eg, catastrophizing, hypervigilance to pain, pain anxiety) and learn about, and develop strategies, to alter the fear and resultant avoidance of activity associated with the pain [38]. Partner behaviors that maintain or intensify distress (such as responses to intimacy that range from low involvement to overly solicitous or hostile) are also be identified. Throughout the course of therapy, the therapist continuously focuses on skill consolidation and maintenance of gains. Issues such as childhood trauma and significant relationship conflict are also addressed if considered integral to the onset or maintenance of pain during sexual activity.

Trials assessing the impact CBT on vulvodynia are challenging in terms of selecting a control group. Despite this difficulty, trials that have compared CBT for the treatment of vulvodynia with vulvar vestibulectomy, biofeedback, corticosteroid cream, physical therapy, and supportive psychotherapy have reported symptom improvement with CBT that was at least equal, and often superior, to the other treatments [39-43]. In addition, CBT benefits were maintained at intervals ranging from 6 months to 2.5 years post-treatment [39,40].

Sex therapy and couple-based therapy — Sex therapy or couple-based therapy, which are types of CBT, as well as mindfulness-based cognitive therapy, can address the impact of the pain on sexual function. Some of the goals of sex or couple-based therapy include skill building in techniques to reduce pain anxiety (such as systematic desensitization and gradual reintroduction of feared sexual activities), optimize emotion regulation, learn better communication and assertiveness, and find methods to reconnect with each other through nonsexual physical and emotional intimacy. Sex therapy typically includes guiding females or couples to expand their sexual repertoire to focus on nonpenetrative sexual activities and pleasure instead of performance. (See "Overview of sexual dysfunction in females: Management", section on 'Couples therapy and sex therapy'.)

In a prospective study of eight couples (in which the woman was diagnosed with provoked vulvodynia) participating in a 12-session couple-based therapy intervention, participants reported significant improvements in sexuality outcomes, pain-related cognitions, anxiety and depression for both members of the couple, and high treatment satisfaction, in addition to reduction of the woman's pain [44].

In a study of 130 women who received either eight weeks of CBT treatment or eight weeks of mindfulness treatment for provoked vulvodynia (formerly vulvar vestibulitis), both groups demonstrated statistically significant improvement in pain with penetration and sex-related distress, with outcomes maintained at 12 months of follow-up [45].

MEDICATION — Nonsurgical medical therapy for the treatment of vulvodynia includes the use of topical preparations, oral medications, and injection therapy. Of note, these treatment options are not specifically approved for the treatment of vulvodynia and therefore represent off-label use. In addition, the optimal treatment, dose, or route of administration are not known. As comparative data are sparse, the grouping below reflects our clinical experience, balance of risks and benefits, product availability, and cost.

Commonly used — We typically use medication therapy in conjunction with behavior modification and psychological interventions. There are numerous topical medications available and used in clinical practice, but few controlled trials have been done to verify their efficacy or determine superiority. Many patients prefer topical preparations due to their low incidence of systemic side effects, ease of use, and ready availability. As with application of any topical agent to the vulva and vestibule, care must be taken to avoid irritating components.

Topical lidocaine ointment — Topical lidocaine is typically used only for short-term symptom control [2]; long term use (12 weeks) does not reduce symptoms more than placebo [46]. Episodic use of lidocaine 2% or 5% ointment can mitigate the pain and discomfort associated vulvodynia, particularly prior to bothersome sexual activities or intercourse [22]. We prescribe 5 percent lidocaine ointment to be applied to only the affected area as needed for symptom control after sex-play [47]. The advantages of lidocaine ointment include that it can be used only when needed, is applied only to the affected tissue, is low cost, and is readily available. Studies of topical lidocaine in treating vulvar pain suggest efficacy ranging from not better than placebo to 50 percent reduction of symptoms. A possible complication of topical lidocaine (or any other topical anesthetic) is potential development of allergic contact dermatitis, particularly with prolonged use [2,46,48,49].

Topical hormonal cream — Although the data are inconsistent, we find topical estradiol 0.01% cream or compounded estradiol 0.01% plus testosterone 0.05% to 0.1% cream, applied at bedtime to the vulvar vestibule, reduces symptoms in some patients with vulvodynia and/or pain with sexual activity (particularly those whose pain began after starting combined hormonal contraceptives or those in perimenopause). For patients with signs or symptoms of intravaginal atrophy or those who experience deep dyspareunia related to dryness (eg, patients with genitourinary syndrome of menopause), we advise biweekly nighttime dosing of 0.5 g estradiol to the vagina (in addition to topical application on the vestibule) [50]. Other dosing regimens are available [51]. Our practice is consistent with the National Vulvodynia Association and expert opinion that supports treatment of women with atrophic changes in the vulva and vestibule with topical estrogen or topical estrogen and testosterone cream [52,53].

The role of hormones, particularly estrogen, with vulvodynia remains an enigma as data regarding association and treatment effect are conflicting. For menopausal females, studies have reported both that menopause status, estrogen levels, and vaginal atrophy are not correlated with symptom severity. The use of combined hormonal contraceptives has been associated with both onset of vulvodynia symptoms as well as no effect [54-59]. As a result of the conflicting data, we recommend an individualized approach to each patient, with careful history-taking and analysis of inciting events that predated development of pain to guide recommendations for hormonal cream treatment. Experts from the International Consensus of Sexual Medicine panel stated that further studies are needed before universal recommendations for hormonal treatments can be made for the treatment of vulvodynia [2].

Formulations with unclear benefit — Topical formulations of limited or unclear benefit include amitriptyline cream, capsaicin cream, and topical cannabis products [22].

Second tier — Second-tier pharmacotherapy for vulvodynia typically consists of antidepressants, anticonvulsants, muscle relaxants, steroid injections, antifungal agents, and/or topical creams, although data supporting these treatments are limited [60]. As with other medical treatments for vulvodynia, most pharmacotherapy trials are without standardized dosing, are nonrandomized, are not placebo-controlled, and do not control for concurrent therapies.

Antidepressants — Antidepressants treat chronic pain syndromes by effecting levels of serotonin and norepinephrine, impacting histamine receptors, and modulating sodium channels [61].

Tricyclic antidepressants (TCAs) – Although none of the TCAs carries an indication for pain management, they have, in the past, been a pharmacologic mainstay in a variety of chronic pain states, with or without coexisting depression [62]. Pain relief is independent of antidepressant effects of TCAs and, therefore, may be achieved at much lower doses than those needed to treat depression [61]. Historically, the most common TCAs used in the treatment of vulvodynia have been amitriptyline, desipramine, or nortriptyline starting at doses between 10 and 25 mg increasing by 10 mg every 7 to 10 days to an average of 50 to 75 mg per day. Maximum dose is 150 mg per day; however, over 100 mg per day, there is a higher risk of sudden cardiac death [63]. For patients taking 100 to 150 mg of nortriptyline, serum levels are measured and maintained in the range of 50 to 150 mg/mL [64]. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Antidepressants'.)

While several small, retrospective chart reviews or single case studies reported TCA treatment results ranging from 27 to 100 percent improvement or complete remission of female sexual pain, two randomly-assigned placebo-controlled trials did NOT report any therapeutic difference in pain relief between TCA and placebo, we continue to use low-dose TCAs as one option in our multimodal treatment armamentarium for vulvodynia [2].

Selective norepinephrine reuptake inhibitors (SNRI) – In our practice, we find treatment with the SNRIs duloxetine and milnacipran most helpful; other SNRIs that appear to improve vulvodynia symptoms include venlafaxine and desvenlafaxine [61,63]. We begin duloxetine treatment with a 20 mg oral dose daily and increase to 60 mg daily, if needed for symptom control. Women taking milnacipran begin with an oral dose of 50 mg twice a day, and increase to 100 mg twice a day as needed. Selection of duloxetine or milnacipran is based on cost and availability.

SNRIs are efficacious at treating neuropathic pain and typically have fewer side effects than TCAs [62]. In a 12-week open-label trial of 22 women with provoked vulvodynia, milnacipran use was associated with a significant reduction in vulvar pain [65]. Nearly 80 percent of women receiving milnacipran reported at least one adverse event, most commonly nausea (48 percent), headache (43 percent), hot flushes (24 percent) and dizziness (19 percent). No one participating in the study discontinued due to adverse effects. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Antidepressants'.)

Selective serotonin reuptake inhibitors (SSRI) – There are no controlled data on SSRIs in the treatment of vulvodynia, and they are generally not recommended in the treatment of other chronic neuropathic pain syndromes, as other types of antidepressants provide superior pain relief with fewer side effects [61-63].

When prescribing antidepressants or anticonvulsants, we start at a low dose and slowly titrate every 7 to 10 days to give the patient ample time to acclimate to any adverse effects. We educate women that they may not reach the full pain response for four to six weeks after they reach the therapeutic dose.

Neuropathic pain agents — Based on the more than 40 years of data on this drug class for the treatment of chronic pain, we offer this therapy to our patients with vulvodynia and sexual pain in conjunction with behavior modification, pelvic floor physical therapy, and/or therapy, as discussed above. Three antiseizure medications (gabapentin, pregabalin, and carbamazepine) are approved by the US Food and Drug Administration for the treatment of neuropathic pain [66]. Of them, gabapentin has been the most studied and utilized in the treatment of vulvodynia, with efficacy rates of 50 to 80 percent reported in small observational studies and case reports [67-71]. By contrast, a crossover trial comparing extended-release gabapentin (1200 to 3000 mg/day) with placebo in 89 women with primary or secondary provoked vestibulodynia vulvodynia reported no difference between the groups in tampon test pain, sexual intercourse pain, or daily pain [72]. In subset analysis, gabapentin use was associated with a minimal reduction in tampon test symptoms for women with vulvar pain for more than five years and women not using oral contraceptives, but no definitive conclusion could be made because the sample and effect sizes were both small. Of the 26 percent of women who discontinued treatment, a greater proportion stopped during the placebo phase than the active medication phase (32 versus 20 percent). However, a secondary analysis of the trial reported improvement in sexual function, as measured by the Female Sexual Function Index, in women receiving gabapentin compared with control women [73]. Thus, while this trial does not support the use of gabapentin as monotherapy in women with vulvodynia, in our practice we find it helpful as an adjunct treatment. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Gabapentin and pregabalin'.)

Therapeutic dosing for gabapentin can range between 100 mg to 3600 mg/day. In our practice, we typically start patients with a 100 mg oral dose at bedtime, as sleepiness is a common side effect. After approximately 3 to 4 days, we then increase the dose to 100 mg orally three times a day. For women who tolerate the daytime dosing, we then increase the dose, every 7 to 14 days, to three divided doses of 300 mg or more per dose. Some patients require doses of 1200 mg orally three times a day (maximum dose is 1200 mg orally given three times per day). For women who note drowsiness with daytime doses, we titrate the single bedtime dose up to 300 mg, rather than the three times a day dosing regimen. As with TCAs, we educate patients that once they reach a therapeutic dose, they should be prepared to remain there for at least four to six weeks before assessing efficacy.

Antifungal therapy — Emerging clinical data and basic science research (mouse model) have linked recurrent exposure to vulvovaginal fungal pathogens with the onset of vulvodynia in some patients [74,75]. Successful treatment has been reported with suppressive oral antifungal therapy (itraconazole 400 mg per day for five to eight weeks) [75]. A pilot study including 106 patients reported reduced cotton swab test-associated pain of the vestibule in over 69 percent and complete symptom resolution in over 35 percent of study subjects. Liver function studies were monitored at three- to four-week intervals. Side effects included gastrointestinal disturbances. Although larger studies are needed to determine the reproducibility of these results, we advise frequent interval fungal cultures for all vulvodynia patients and suppressive therapy for those with evidence of fungal infections.

(See "Candida vulvovaginitis: Clinical manifestations and diagnosis".)

(See "Candida vulvovaginitis in adults: Treatment of acute infection".)

Vaginal prasterone — Vaginal prasterone (commercial name Intrarosa) is a synthetic dehydroepiandrosterone (DHEA) used in the treatment of moderate to severe dyspareunia related to vulvar or vaginal atrophy of menopause [76]. The efficacy of prasterone for the treatment of vulvodynia is not yet known because prasterone was only studied in patients with vulvovaginal atrophy, a symptom of genitourinary syndrome of menopause. Although use of vaginal prasterone for vulvar or vaginal atrophy in breast cancer survivors is not contraindicated, United States labeling advises caution as estrogen is a metabolite of DHEA [77] and vaginal prasterone has not been studied in women with a history of breast cancer. However, systemic absorption of estradiol and testosterone is extremely low [78]. The risks and benefits of vaginal prasterone therapy and other treatments for vulvovaginal atrophy are discussed separately. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Dehydroepiandrosterone (prasterone)'.)

Ospemifene — Ospemifene is indicated for treatment of vulvovaginal pain and dyspareunia associated with genitourinary syndrome of menopause. One clinical trial investigating daily oral ospemifene 60 mg in patients with burning pain and dyspareunia reported decreased mean pain scores, vestibular trophic scores and cotton swab "vestibular touch test" scores, and a positive change in objective current perception threshold nerve measures in the vestibule after 60 days of treatment [79].

In our practice, ospemifene can be a useful option for postmenopausal individuals with vulvodynia-associated burning pain who prefer not to use estrogen or testosterone or who cannot tolerate any topical treatments due to hypersensitivity. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Ospemifene'.)

Capsaicin cream — As prospective trial data are not available, the expert panel of the 2015 ICSM advised the use of capsaicin only if other treatments had failed or as an alternative to surgery [2]. The rationale for treatment with capsaicin is that women with vulvodynia have been found to have increased vanilloid receptors (VR1) in the peripheral terminals of nociceptor cells [80]. Topical capsaicin has an agonist effect on VR1 (TRPV1), thereby producing desensitization to burning and decreased pain [81]. Two observational studies of topical capsaicin cream for the treatment of vulvodynia reported symptom improvement with treatment [82,83]. However, both studies premedicated women with topical lidocaine prior to the application of capsaicin, which makes it impossible to determine if improvement was due to either cream or a combination of both.

Of note, over-the-counter capsaicin has alcohol in the base and is highly irritating to women with vulvodynia. When prescribed, we use compounded topical capsaicin cream that contains 0.025% to 0.05% cream in a hypoallergenic base. It is applied for 20 minutes per day to the vestibule and then removed. The initial regimen is performed daily for 12 weeks and then only as needed for symptom control. In our practice, compliance with this regimen improves when women pretreat the vestibule with 5% lidocaine ointment for 10 minutes, then remove the lidocaine and apply topical capsaicin for 20 minutes.

Third tier

Botulinum neurotoxin-A — In our practice, we limit the use of botulinum neurotoxin-A (BoNT-A, commercial name Botox) to the third tier of treatment because of its high cost and temporary effect. Benefits typically last from 3 to 12 months. BoNT-A is used for the treatment of multiple chronic pain disorders because it blocks the release of glutamate and substance-P from nociceptive neurons [84,85]. Although one randomly assigned trial, two case series, and two case reports have reported conflicting data on BoNT-A efficacy for vulvodynia, differing study designs and sites of injection limit comparison of outcomes or definitive conclusions [86-90]. As the noncontrolled studies reported significant efficacy, the expert panel of the 2015 ICSM concluded that BoNT-A is a reasonable treatment for vulvodynia, noting that the effect is far greater if the BoNT-A is injected into hypertonic pelvic floor muscles rather than into the vestibular ostium [2]. Adverse effects are self-limiting; however, dysphagia and respiratory blockade can be life threatening [2]. We consent women to all possible adverse effects and reactions prior to injection with this medication.


Intravaginal diazepam — Diazepam is a benzodiazepine with muscle relaxant properties that is used to aid pelvic muscle relaxation during pelvic floor physical therapy, although available data are mixed [91-93]. In a systematic review including five studies, two observational studies reported subjective improvement rates of 71 to 96 percent while three small trials reported similar pain scores between patients receiving vaginal diazepam versus placebo [93]. Diazepam can be compounded as a suppository, 2.5 to 10 mg, used intravaginally every other night. A study evaluating pharmacokinetic profile of a 10 mg diazepam vaginal suppository reported peak diazepam serum concentrations of 31.0 ng/mL at a mean time of three hours after suppository placement [94]. Fatigue was reported by 3 of 8 participants. Intravaginal diazepam should not be used for extended periods because of concerns for dependence. Intravaginal diazepam is an alternative to muscle injections with botulinum neurotoxin-A; the two treatments should not be used together.

Compounded products — A compounding pharmacist can be an important member of the treatment team because they can suggest hypoallergenic bases for creams and ointments and avoid vehicles that may exacerbate symptoms, while still achieving maximum therapeutic effect. Disadvantages of compounded products include limited availability of compounding pharmacies and high cost. We discuss with our patients that use of these products for the treatment of vulvodynia is off-label.

Gabapentin cream — Gabapentin 4 to 10% topical preparations have been used in the treatment of vulvodynia (both localized and generalized) with good tolerability and low incidence of systemic effects. For women with generalized burning pain, we prescribe gabapentin compounded in transdermal base and ask women to apply it three times a day. In a retrospective review of 51 women with vulvodynia (19 with generalized and 32 with localized) treated with 2%, 4%, and 6% topical gabapentin, 80 percent of the patients improved by at least 50 percent, and 29 percent of the patients achieved full improvement [95]. Topical application of all doses were well tolerated. Limitations of this study include lack of a comparison group and inclusion of various concurrent treatments.

Amitriptyline-based topical preparations — Compounded topical amitriptyline/ketamine or amitriptyline/baclofen creams are an option for women with vulvodynia who wish to avoid untoward side effects of oral TCAs such as fatigue, weight gain, constipation, and drying of mucous membranes [96]. Compounded amitriptyline creams are an alternative to compounded gabapentin cream for women with generalized burning vulvodynia. In a prospective study of 150 women with vulvodynia treated with amitriptyline 2% cream, 56 percent (84/150) reported slight to excellent improvement and 10 percent (15/84) of the improved participants reported intercourse as comfortable and pain-free [97]. Forty-four percent of women did not respond to the questionnaire and were therefore considered treatment failures. Other studies have reported a modest effect of amitriptyline cream in combination with 2% baclofen cream or 0.5% ketamine cream [96].

Cromolyn — Cromolyn cream, a mast cell stabilizer, has been proposed as a topical treatment for vulvodynia. We find topical cromolyn, 5 to 10% in a petrolatum base, helpful for women whose primary symptom of vulvodynia is itching. A placebo-controlled trial of cromolyn 4% in 34 women with refractory vulvodynia reported that more women treated with cromolyn had at least 50 percent improvement in dyspareunia and pain compared with placebo treatment, although this finding was not statistically significant [98]. A subsequent case-control study of 100 women reported no difference in vestibular mast cell density in racially-matched women with vulvodynia compared with control women [99].

Injectable steroids — As there is a paucity of data regarding the long-term efficacy of injectable steroids, we do not use them regularly. Submucosal injection of corticosteroids, typically mixed with lidocaine, is believed to have anti-inflammatory effects (ie, reduction of interleukin-beta) and appears treat pain in women with vulvodynia [100-105]. Topical steroids do not appear to be helpful [2]. The ICSM panel concluded topical corticosteroids were not recommended for the management of vulvodynia because of the lack of efficacy of low-dose corticosteroids and the potential side effects of high-potency corticosteroids [2].

COMPLEMENTARY AND ALTERNATIVE TREATMENTS — Complementary and alternative treatments appear to have a net positive benefit for chronic pain syndromes, although individual study data are conflicting [106]. Specific modalities that have been reported to reduce vulvodynia symptoms include acupuncture [107-110], hypnosis [111], transcutaneous electrical nerve stimulation [60]. In two small prospective studies, acupuncture treatment reduced dyspareunia and improved sexual functioning as well as reduced vulvar pain [107,110]. As these modalities appear to be helpful and low in risk, we offer them to our patients. Major limitations are high cost and lack of insurance coverage for many of these treatments.

SURGERY — Surgery is generally considered a treatment for individuals with localized, provoked vulvodynia (PVD, formerly vulvar vestibulitis) who have failed to improve with conservative modalities, and it is performed on a case-by-case basis [22,112]. As surgical success and patient satisfaction rates of 60 to 90 percent have been reported, some experts have questioned whether or not surgery should be more readily offered to women with PVD [2,113,114]. However, as surgery can cause scarring and worsened pain, we reserve surgery for women with localized symptoms only who have not responded to the above treatment options. Surgery is not advised for generalized pain disorders.

LASER AND ENERGY-BASED DEVICES — Laser therapy for the treatment of vulvodynia is an area of developing research, and some early studies show promise in treating some vulvar conditions causing vulvodynia. However, in July 2018, the US Food and Drug Administration published a statement warning women and health care providers about serious concerns for safety with the use of laser and energy-based devices for gynecologic conditions beyond those for which the devices had been approved or cleared [115]. We do not advise use of laser or energy-based systems for the treatment of vulvar pain of unknown cause outside of the research setting. Of note, this therapy differs from other laser systems used for the treatment of genitourinary syndrome of menopause in that the treatment is only to the vulvar vestibule and a vaginal probe is not used. The use of laser treatment for genitourinary syndrome of menopause is discussed separately. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Laser or radiofrequency devices'.)

Data suggesting a role for these treatments are from small studies. In a pilot study of 70 women treated with micro-ablative fractional CO2 laser to the vulvar vestibule, improvement was reported in dyspareunia and pain scores, with gradual improvement occurring over four months of follow-up [116]. Two-thirds of women reported they were either "very improved" or "improved." No major adverse events were reported. In a trial of 34 women with provoked vulvodynia comparing low-level laser therapy with placebo (sham treatment), more women treated with laser therapy reported improvement (78 versus 44 percent), and 57 percent of the improved women maintained improvement at one year of follow-up [117]. Further studies are underway.

RESOURCES FOR PATIENTS AND CLINICIANS

2021 European Guideline for the management of vulval conditions

American College of Obstetricians and Gynecologists (ACOG) – A professional membership organization dedicated to women's reproductive health, ACOG publishes FAQ (frequently asked questions) sheets for patients that are open access, including FAQ: Vulvodynia and FAQ: When Sex is Painful.

National Vulvodynia Association – Publishes Vulvodynia: A Self-Help Guide for patients and clinicians.

International Society for the Study of Vulvovaginal Disease – Provides a resource library for patients and clinicians.

International Society for the Study of Women's Sexual Health.

Sexual health and menopause by The Menopause Society, a nonprofit organization dedicated to promoting the health and quality of life of all women during midlife and beyond.

American Sexual Health Association for information about sexuality, infections and communicating with a partner.

When sex gives you more pain than pleasure by the National Women's Health Resource Center, a nonprofit, independent health information resource for patients and clinicians.

Society for Sex Therapy & Research (SSTAR) – SSTAR is a "community of professionals who have clinical and/or research interests in human sexual concerns. Its goals are to facilitate communication among clinicians who treat problems of sexual function, sexual identity, and reproductive life."

Section on Women's Health (SoWH) of the American Physical Therapy Association – The SoWH is dedicated to addressing abdominal, back, and pelvic floor disorders. The Physical Therapy Locator can help patients and clinicians find a physical therapist in their area.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Female pelvic pain".)

SUMMARY AND RECOMMENDATIONS

Description – Vulvodynia refers to idiopathic, chronic vulvar pain of at least three months' duration. Vulvodynia can be localized or generalized; provoked, spontaneous, or mixed; primary or secondary in timing of onset; and of varying temporal patterns (eg, intermittent, persistent, constant, immediate, or delayed). (See 'Definition' above.)

Evaluation – The assessment of women with chronic vulvar pain includes a detailed history that includes discussion of pain symptoms, sexual practices, gynecologic and medical issues, and a comprehensive physical examination. (See 'Assessment' above.)

Treatment expectations – As vulvodynia is a chronic condition, in which symptoms are managed but may be ongoing and characterized by periods of remission and flare, one goal of treatment is to set realistic expectations. We help women understand that improvement can be a slow process and, because there is not a "one size fits all" treatment, that finding the correct therapy for them can take some trial and error, time, and patience. (See 'Our approach' above.)

Behavior modification – We review behaviors that can be helpful, or may be harmful, with our patients. We educate women on vulvar hygiene, stress relief, symptom reduction, lubrication, and exercise. (See 'Behavior modification' above.)

Pelvic floor physical therapy – In accordance with multiple medical associations, we advise pelvic floor physical therapy as a primary treatment for vulvodynia because of the numerous studies demonstrating treatment efficacy. Women with vulvodynia and sexual pain commonly exhibit myofascial trigger points and increased muscle tension in the pelvis, abdominal, back, and pelvic floor muscles. Pelvic floor physical therapy involves a variety of modalities, including pelvic and core mobilization and stabilization; connective tissue, visceral, and neural mobilization; internal and external myofascial trigger point release, biofeedback, and electrical stimulation. (See 'Pelvic floor physical therapy' above.)

Psychological interventions – Psychological interventions focus on reducing pain, restoring sexual function and strengthening the couple relationship by targeting the thoughts, emotions, behaviors, and couple interactions associated with sexual pain. Cognitive behavioral therapy (CBT) is one of the most commonly used and studied psychological interventions for pain, including vulvar and sexual pain. We prescribe individual and group CBT for our vulvodynia patients because this approach is a validated and noninvasive therapeutic option for sexual pain. (See 'Psychological intervention' above.)

Medical therapy – Nonsurgical medical therapy for the treatment of vulvodynia includes the use of topical preparations, oral medications, and injection therapy. Of note, these treatment options are not specifically approved for the treatment of vulvodynia and therefore represent off-label use. In addition, the optimal treatment, dose, or route of administration are not known. As comparative data are sparse, the grouping below reflects our clinical experience, balance of risks and benefits, product availability, and cost. (See 'Medication' above.)

Complementary and alternative therapies – Complementary and alternative treatments appear to have a net positive benefit for chronic pain syndromes, although individual study data are conflicting. Specific modalities that have been reported to reduce vulvodynia symptoms include acupuncture, hypnosis, and transcutaneous electrical nerve stimulation. (See 'Complementary and alternative treatments' above.)

Limited role for surgery – Surgery is generally considered a treatment well suited for women with localized, provoked vulvodynia (formerly vulvar vestibulitis) who fail to improve with physical, cognitive behavioral, topical, and/or oral therapies and is performed on a case-by-case basis. (See 'Surgery' above.)

ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Elizabeth Gunther Stewart, MD, and Roya Rezaee, MD, FACOG, who contributed to an earlier version of this topic review.

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  1. Bornstein J, Goldstein AT, Stockdale CK, et al. 2015 ISSVD, ISSWSH and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia. Obstet Gynecol 2016; 127:745.
  2. Goldstein AT, Pukall CF, Brown C, et al. Vulvodynia: Assessment and Treatment. J Sex Med 2016; 13:572.
  3. Maunder L, Dargie E, Pukall CF. Moderators of the Relationship Between Pain and Pain-Related Sexual Disability in Women with Provoked Vestibulodynia Symptoms. J Sex Med 2022; 19:809.
  4. Brotto LA, Yong P, Smith KB, Sadownik LA. Impact of a multidisciplinary vulvodynia program on sexual functioning and dyspareunia. J Sex Med 2015; 12:238.
  5. http://www.acog.org/Patients/FAQs/Vulvodynia (Accessed on October 31, 2016).
  6. Haefner HK, Collins ME, Davis GD, et al. The vulvodynia guideline. J Low Genit Tract Dis 2005; 9:40.
  7. Arnold LD, Bachmann GA, Rosen R, et al. Vulvodynia: characteristics and associations with comorbidities and quality of life. Obstet Gynecol 2006; 107:617.
  8. Khandker M, Brady SS, Vitonis AF, et al. The influence of depression and anxiety on risk of adult onset vulvodynia. J Womens Health (Larchmt) 2011; 20:1445.
  9. Edwards L. Vulvodynia. Clin Obstet Gynecol 2015; 58:143.
  10. Tersiguel AC, Bodéré C, Schollhammer M, et al. Screening for Neuropathic Pain, Anxiety and Other Associated Chronic Pain Conditions in Vulvodynia: A Pilot Study. Acta Derm Venereol 2015; 95:749.
  11. Sutton K, Pukall C, Wild C, et al. Cognitive, psychophysical, and neural correlates of vulvar pain in primary and secondary provoked vestibulodynia: a pilot study. J Sex Med 2015; 12:1283.
  12. Borghi A, Corazza M, Minghetti S, et al. Avocado and soybean extracts as active principles in the treatment of mild-to-moderate vulvar lichen sclerosus: results of efficacy and tolerability. J Eur Acad Dermatol Venereol 2015; 29:1225.
  13. Arnold LD, Bachmann GA, Rosen R, Rhoads GG. Assessment of vulvodynia symptoms in a sample of US women: a prevalence survey with a nested case control study. Am J Obstet Gynecol 2007; 196:128.e1.
  14. Gordon AS, Panahian-Jand M, Mccomb F, et al. Characteristics of women with vulvar pain disorders: responses to a Web-based survey. J Sex Marital Ther 2003; 29 Suppl 1:45.
  15. Harlow BL, Caron RE, Parker SE, et al. Recurrent Yeast Infections and Vulvodynia: Can We Believe Associations Based on Self-Reported Data? J Womens Health (Larchmt) 2017; 26:1069.
  16. Ramirez De Knott HM, McCormick TS, Do SO, et al. Cutaneous hypersensitivity to Candida albicans in idiopathic vulvodynia. Contact Dermatitis 2005; 53:214.
  17. Sadownik LA. Clinical profile of vulvodynia patients. A prospective study of 300 patients. J Reprod Med 2000; 45:679.
  18. American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice, American Society for Colposcopy and Cervical Pathology (ASCCP). Committee Opinion No 673: Persistent Vulvar Pain. Obstet Gynecol 2016; 128:e78. Reaffirmed 2021.
  19. Amercian Urological Association. Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. Amended 2014. https://www.auanet.org/education/guidelines/ic-bladder-pain-syndrome.cfm (Accessed on November 04, 2016).
  20. De Andres J, Sanchis-Lopez N, Asensio-Samper JM, et al. Vulvodynia--An Evidence-Based Literature Review and Proposed Treatment Algorithm. Pain Pract 2016; 16:204.
  21. Morin M, Dumoulin C, Bergeron S, et al. Multimodal physical therapy versus topical lidocaine for provoked vestibulodynia: a prospective, multicentre, randomized trial. ajog 2020.
  22. van der Meijden WI, Boffa MJ, Ter Harmsel B, et al. 2021 European guideline for the management of vulval conditions. J Eur Acad Dermatol Venereol 2022; 36:952.
  23. FitzGerald MP, Kotarinos R. Rehabilitation of the short pelvic floor. II: Treatment of the patient with the short pelvic floor. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14:269.
  24. FitzGerald MP, Kotarinos R. Rehabilitation of the short pelvic floor. I: Background and patient evaluation. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14:261.
  25. Travell J, Simons D. Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol 2, 1st ed, Williams and Wilkins, Baltimore 1992.
  26. Prendergast SA, Weiss JM. Screening for musculoskeletal causes of pelvic pain. Clin Obstet Gynecol 2003; 46:773.
  27. https://www.auanet.org/education/guidelines/ic-bladder-pain-syndrome.cfm (Accessed on October 31, 2016).
  28. FitzGerald MP, Anderson RU, Potts J, et al. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urol 2009; 182:570.
  29. Hartmann D, Nelson CA. Ten years after physical therapy for vulvodynia: are there lasting benefits? J Reprod Med 2008; 53.
  30. Bergeron S, Brown C, Lord MJ, et al. Physical therapy for vulvar vestibulitis syndrome: a retrospective study. J Sex Marital Ther 2002; 28:183.
  31. Hartmann D. Chronic vulvar pain from a physical therapy perspective. Dermatol Ther 2010; 23:505.
  32. Hartmann D. The perceived effectiveness of physical therapy treatment on women complaining of chronic vulvar pain and diagnosed with either vulvar vestibulitis syndrome or dysesthetic vulvodynia. J Womens Health Phy Ther 2001; 25:13.
  33. Gentilcore-Saulnier E, McLean L, Goldfinger C, et al. Pelvic floor muscle assessment outcomes in women with and without provoked vestibulodynia and the impact of a physical therapy program. J Sex Med 2010; 7:1003.
  34. Weiss JM. Chronic pelvic pain and myofascial trigger points. The Pain Clinic 2000; 2:13.
  35. Kellogg-Spadt S, Iorio J, Fariello J, Whirmore KE. Vaginal dilation: when its indicated and tips for teaching it. OBG Management 2012; 24:1.
  36. Hilton S, Vandyken C. The puzzle of pelvic pain - a rehabilitation framework for balancing tissue dysfunction and central sensitization. J Womens Phys Ther 2011; 35:103.
  37. Bo K, Berghmans B, Morkved S, Van Kampen M. Evidence-Based Physical Therapy for the Pelvic Floor: Bridging Science and Clinical Practice, 1st ed, Churchill Livingstone, Philadelphia 2007.
  38. Vlaeyen JWS, Crombez G, Linton SJ. The fear-avoidance model of pain. Pain 2016; 157:1588.
  39. Bergeron S, Khalifé S, Glazer HI, Binik YM. Surgical and behavioral treatments for vestibulodynia: two-and-one-half year follow-up and predictors of outcome. Obstet Gynecol 2008; 111:159.
  40. Bergeron S, Khalifé S, Dupuis MJ, McDuff P. A randomized clinical trial comparing group cognitive-behavioral therapy and a topical steroid for women with dyspareunia. J Consult Clin Psychol 2016; 84:259.
  41. Masheb RM, Kerns RD, Lozano C, et al. A randomized clinical trial for women with vulvodynia: Cognitive-behavioral therapy vs. supportive psychotherapy. Pain 2009; 141:31.
  42. Brotto LA, Basson R, Smith KB, et al. Mindfulness-based group therapy for women with provoked vestibulodynia. Mindfulness 2015; 6:417.
  43. Goldfinger C, Pukall CF, Thibault-Gagnon S, et al. Effectiveness of Cognitive-Behavioral Therapy and Physical Therapy for Provoked Vestibulodynia: A Randomized Pilot Study. J Sex Med 2016; 13:88.
  44. Corsini-Munt S, Bergeron S, Rosen NO, et al. Feasibility and preliminary effectiveness of a novel cognitive-behavioral couple therapy for provoked vestibulodynia: a pilot study. J Sex Med 2014; 11:2515.
  45. Brotto LA, Bergeron S, Zdaniuk B, Basson R. Mindfulness and cognitive behavior therapy for provoked vestibulodynia: Mediators of treatment outcome and long-term effects. J Consult Clin Psychol 2020; 88:48.
  46. Foster DC, Kotok MB, Huang LS, et al. Oral desipramine and topical lidocaine for vulvodynia: a randomized controlled trial. Obstet Gynecol 2010; 116:583.
  47. Lidocaine ointment. US Food and Drug Administration (FDA) approved product information. Revised January, 2016. US National Library of Medicine. (Available online at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a18d2e07-fe58-4641-b03b-d9d56642f13c (Accessed on November 02, 2016)).
  48. Bohm-Starke N, Brodda-Jansen G, Linder J, Danielsson I. The result of treatment on vestibular and general pain thresholds in women with provoked vestibulodynia. Clin J Pain 2007; 23:598.
  49. Corazza M, Toni G, Zedde P, et al. Contact Dermatitis of the Vulva. Allergies 2021; 1:206.
  50. Estrace [package insert]. Rockaway, NJ: Warner Chilcott (US), LLC; 2011. http://www.allergan.com/assets/pdf/estrace_pi (Accessed on November 02, 2016).
  51. Goetsch MF, Garg B, Lillemon J, Clark AL. Treating where it hurts-a randomized comparative trial of vestibule estradiol for postmenopausal dyspareunia. Menopause 2023; 30:467.
  52. Burrows LJ, Goldstein AT. The treatment of vestibulodynia with topical estradiol and testosterone. Sex Med 2013; 1:30.
  53. http://www.nva.org/what-is-vulvodynia/treatment/ (Accessed on November 14, 2016).
  54. Kao A, Binik YM, Amsel R, et al. Biopsychosocial predictors of postmenopausal dyspareunia: the role of steroid hormones, vulvovaginal atrophy, cognitive-emotional factors, and dyadic adjustment. J Sex Med 2012; 9:2066.
  55. Kao A, Binik YM, Kapuscinski A, Khalife S. Dyspareunia in postmenopausal women: a critical review. Pain Res Manag 2008; 13:243.
  56. Leclair CM, Goetsch MF, Li H, Morgan TK. Histopathologic characteristics of menopausal vestibulodynia. Obstet Gynecol 2013; 122:787.
  57. Goldstein A, Burrows L, Goldstein I. Can oral contraceptives cause vestibulodynia? J Sex Med 2010; 7:1585.
  58. Goldstein AT, Belkin ZR, Krapf JM, et al. Polymorphisms of the androgen receptor gene and hormonal contraceptive induced provoked vestibulodynia. J Sex Med 2014; 11:2764.
  59. Reed BD, Harlow SD, Legocki LJ, et al. Oral contraceptive use and risk of vulvodynia: a population-based longitudinal study. BJOG 2013; 120:1678.
  60. Damsted-Petersen C, Boyer SC, Pukall CF. Current perspectives in vulvodynia. Womens Health (Lond) 2009; 5:423.
  61. Sansone RA, Sansone LA. Pain, pain, go away: antidepressants and pain management. Psychiatry (Edgmont) 2008; 5:16.
  62. Ferreira GE, Abdel-Shaheed C, Underwood M, et al. Efficacy, safety, and tolerability of antidepressants for pain in adults: overview of systematic reviews. BMJ 2023; 380:e072415.
  63. Janakiraman R, Hamilton L, Wan A. Unravelling the efficacy of antidepressants as analgesics. Aust Fam Physician 2016; 45:113.
  64. Nortriptyline HCL capsule. US Food and Drug Administration (FDA) approved product information. Revised Oct, 2022. US National Library of Medicine. www.dailymed.nlm.nih.gov (Accessed on October 18, 2022).
  65. Brown C, Bachmann G, Foster D, et al. Milnacipran in provoked vestibulodynia: efficacy and predictors of treatment success. J Low Genit Tract Dis 2015; 19:140.
  66. Dobecki DA, Schocket SM, Wallace MS. Update on pharmacotherapy guidelines for the treatment of neuropathic pain. Curr Pain Headache Rep 2006; 10:185.
  67. Ventolini G, Barhan S, Duke J. Vulvodynia, a step-wise therapeutic prospective cohort study. J Obstet Gynaecol 2009; 29:648.
  68. Bates CM, Timmins DJ. Vulvodynia--new and more effective approaches to therapy. Int J STD AIDS 2002; 13:210.
  69. Ben-David B, Friedman M. Gabapentin therapy for vulvodynia. Anesth Analg 1999; 89:1459.
  70. Harris G, Horowitz B, Borgida A. Evaluation of gabapentin in the treatment of generalized vulvodynia, unprovoked. J Reprod Med 2007; 52:103.
  71. Reed BD, Haefner HK, Cantor L. Vulvar dysesthesia (vulvodynia). A follow-up study. J Reprod Med 2003; 48:409.
  72. Brown CS, Bachmann GA, Wan J, et al. Gabapentin for the Treatment of Vulvodynia: A Randomized Controlled Trial. Obstet Gynecol 2018; 131:1000.
  73. Bachmann GA, Brown CS, Phillips NA, et al. Effect of gabapentin on sexual function in vulvodynia: a randomized, placebo-controlled trial. Am J Obstet Gynecol 2019; 220:89.e1.
  74. Farmer MA, Taylor AM, Bailey AL, et al. Repeated vulvovaginal fungal infections cause persistent pain in a mouse model of vulvodynia. Sci Transl Med 2011; 3:101ra91.
  75. Rothenberger R, Jones W, MacNeill C. Itraconazole Improves Vulvodynia in Fungus Culture-Negative Patients Post Fluconazole Failure. Sex Med 2021; 9:100383.
  76. Intrarosa [package insert]. Quebec City, Canada: Endoceuticals Inc; 2016. http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/208470s000lbl.pdf (Accessed on December 21, 2016).
  77. INTRAROSA-prasterone insert. US Food and Drug Administration (FDA) approved product information. Updated November, 2019. US National Library of Medicine. (Available online athttps://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=df731acd-7276-4fef-b037-bc7f30c112cb).
  78. Martel C, Labrie F, Archer DF, et al. Serum steroid concentrations remain within normal postmenopausal values in women receiving daily 6.5mg intravaginal prasterone for 12 weeks. J Steroid Biochem Mol Biol 2016; 159:142.
  79. Murina F, Di Francesco S, Oneda S. Vulvar vestibular effects of ospemifene: a pilot study. Gynecol Endocrinol 2018; 34:631.
  80. Tympanidis P, Casula MA, Yiangou Y, et al. Increased vanilloid receptor VR1 innervation in vulvodynia. Eur J Pain 2004; 8:129.
  81. Baron R. Capsaicin and nociception: from basic mechanisms to novel drugs. Lancet 2000; 356:785.
  82. Steinberg AC, Oyama IA, Rejba AE, et al. Capsaicin for the treatment of vulvar vestibulitis. Am J Obstet Gynecol 2005; 192:1549.
  83. Murina F, Radici G, Bianco V. Capsaicin and the treatment of vulvar vestibulitis syndrome: a valuable alternative? MedGenMed 2004; 6:48.
  84. Beal BR, Wallace MS. An Overview of Pharmacologic Management of Chronic Pain. Med Clin North Am 2016; 100:65.
  85. Cui M, Khanijou S, Rubino J, Aoki KR. Subcutaneous administration of botulinum toxin A reduces formalin-induced pain. Pain 2004; 107:125.
  86. Petersen CD, Giraldi A, Lundvall L, Kristensen E. Botulinum toxin type A-a novel treatment for provoked vestibulodynia? Results from a randomized, placebo controlled, double blinded study. J Sex Med 2009; 6:2523.
  87. Pelletier F, Parratte B, Penz S, et al. Efficacy of high doses of botulinum toxin A for treating provoked vestibulodynia. Br J Dermatol 2011; 164:617.
  88. Dykstra DD, Presthus J. Botulinum toxin type A for the treatment of provoked vestibulodynia: an open-label, pilot study. J Reprod Med 2006; 51:467.
  89. Romito S, Bottanelli M, Pellegrini M, et al. Botulinum toxin for the treatment of genital pain syndromes. Gynecol Obstet Invest 2004; 58:164.
  90. Brown CS, Glazer HI, Vogt V, et al. Subjective and objective outcomes of botulinum toxin type A treatment in vestibulodynia: pilot data. J Reprod Med 2006; 51:635.
  91. Carrico DJ, Peters KM. Vaginal diazepam use with urogenital pain/pelvic floor dysfunction: serum diazepam levels and efficacy data. Urol Nurs 2011; 31:279.
  92. VALIUM- diazepam tablet. US Food and Drug Administration (FDA) approved product information. Revised November, 2019. US National Library of Medicine. www.dailymed.nlm.nih.gov (Accessed on July 12, 2022).
  93. Stone RH, Abousaud M, Abousaud A, Kobak W. A Systematic Review of Intravaginal Diazepam for the Treatment of Pelvic Floor Hypertonic Disorder. J Clin Pharmacol 2020; 60 Suppl 2:S110.
  94. Larish AM, Dickson RR, Kudgus RA, et al. Vaginal Diazepam for Nonrelaxing Pelvic Floor Dysfunction: The Pharmacokinetic Profile. J Sex Med 2019; 16:763.
  95. Boardman LA, Cooper AS, Blais LR, Raker CA. Topical gabapentin in the treatment of localized and generalized vulvodynia. Obstet Gynecol 2008; 112:579.
  96. Poterucha TJ, Murphy SL, Rho RH, et al. Topical amitriptyline-ketamine for treatment of rectal, genital, and perineal pain and discomfort. Pain Physician 2012; 15:485.
  97. Pagano R, Wong S. Use of amitriptyline cream in the management of entry dyspareunia due to provoked vestibulodynia. J Low Genit Tract Dis 2012; 16:394.
  98. Nyirjesy P, Sobel JD, Weitz MV, et al. Cromolyn cream for recalcitrant idiopathic vulvar vestibulitis: results of a placebo controlled study. Sex Transm Infect 2001; 77:53.
  99. Papoutsis D, Haefner HK, Crum CP, et al. Vestibular Mast Cell Density in Vulvodynia: A Case-Controlled Study. J Low Genit Tract Dis 2016; 20:275.
  100. Eppsteiner E, Boardman L, Stockdale CK. Vulvodynia. Best Pract Res Clin Obstet Gynaecol 2014; 28:1000.
  101. Foster DC, Hasday JD. Elevated tissue levels of interleukin-1 beta and tumor necrosis factor-alpha in vulvar vestibulitis. Obstet Gynecol 1997; 89:291.
  102. Snyder DS, Unanue ER. Corticosteroids inhibit murine macrophage Ia expression and interleukin 1 production. J Immunol 1982; 129:1803.
  103. Murina F, Tassan P, Roberti P, Bianco V. Treatment of vulvar vestibulitis with submucous infiltrations of methylprednisolone and lidocaine. An alternative approach. J Reprod Med 2001; 46:713.
  104. Segal D, Tifheret H, Lazer S. Submucous infiltration of betamethasone and lidocaine in the treatment of vulvar vestibulitis. Eur J Obstet Gynecol Reprod Biol 2003; 107:105.
  105. Dede M, Yenen MC, Yilmaz A, Baser I. Successful treatment of persistent vulvodynia with submucous infiltration of betamethasone and lidocaine. Eur J Obstet Gynecol Reprod Biol 2006; 124:258.
  106. Nahin RL, Boineau R, Khalsa PS, et al. Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States. Mayo Clin Proc 2016; 91:1292.
  107. Curran S, Brotto LA, Fisher H, et al. The ACTIV study: acupuncture treatment in provoked vestibulodynia. J Sex Med 2010; 7:981.
  108. Powell J, Wojnarowska F. Acupuncture for vulvodynia. J R Soc Med 1999; 92:579.
  109. Danielsson I, Sjöberg I, Ostman C. Acupuncture for the treatment of vulvar vestibulitis: a pilot study. Acta Obstet Gynecol Scand 2001; 80:437.
  110. Schlaeger JM, Xu N, Mejta CL, et al. Acupuncture for the treatment of vulvodynia: a randomized wait-list controlled pilot study. J Sex Med 2015; 12:1019.
  111. Pukall CF, Young RA, Roberts MJ, et al. The vulvalgesiometer as a device to measure genital pressure-pain threshold. Physiol Meas 2007; 28:1543.
  112. Wu C, Goldstein A, Klebanoff JS, Moawad GN. Surgical management of neuroproliferative-associated vestibulodynia: a tutorial on vestibulectomy with vaginal advancement flap. Am J Obstet Gynecol 2019; 221:525.e1.
  113. Das D, Davidson ERW, Walters M, et al. Patient-Centered Outcomes After Modified Vestibulectomy. Obstet Gynecol 2020; 135:113.
  114. David A, Bornstein J. Evaluation of Long-Term Surgical Success and Satisfaction of Patients After Vestibulectomy. J Low Genit Tract Dis 2020; 24:399.
  115. FDA Safety Communication: FDA warns against use of energy-based devices to perform vaginal 'rejuvenation' or vaignal cosmetic procedures. US Food and Drug Administration. US Department of Health and Human Services. July 2018. www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm615013.htm (Accessed on October 30, 2018).
  116. Murina F, Karram M, Salvatore S, Felice R. Fractional CO2 Laser Treatment of the Vestibule for Patients with Vestibulodynia and Genitourinary Syndrome of Menopause: A Pilot Study. J Sex Med 2016; 13:1915.
  117. Lev-Sagie A, Kopitman A, Brzezinski A. Low-Level Laser Therapy for the Treatment of Provoked Vestibulodynia-A Randomized, Placebo-Controlled Pilot Trial. J Sex Med 2017; 14:1403.
Topic 110586 Version 33.0

References

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