Hope K. Haefner

The vulvodynia guideline

Objective. To provide a review of the literature and make known expert opinion regarding the treatment of vulvodynia. Materials and Methods. Experts reviewed the existing literature to provide new definitions for vulvar pain and to describe treatments for this condition. Results. Vulvodynia has been redefined by the International Society for the Study of Vulvovaginal Disease as vulvar discomfort in the absence of gross anatomic or neurologic findings. Classification is based further on whether the pain is generalized or localized and whether it is provoked, unprovoked, or both. Treatments described include general vulvar care, topical medications, oral medications, injectables, biofeedback and physical therapy, dietary changes with supplementations, acupuncture, hypnotherapy, and surgery. No one treatment is clearly the best for an individual patient. Conclusions. Vulvodynia has many possible treatments, but very few controlled trials have been performed to verify efficacy of these treatments. Provided are guidelines based largely on expert opinion to assist the patient and practitioner in dealing with this condition.

Quantitative sensory testing in vulvodynia patients and increased peripheral pressure pain sensitivity.

OBJECTIVE: To assess both regional (vulvar) and overall (generalized) pain sensitivity in women with vulvodynia to determine whether both are increased, suggestive of altered central pain processing. METHODS: Seventeen patients (aged 18–60 years) with vulvodynia and 23 age-matched control subjects were included in this cross-sectional study. Pressure pain thresholds in the vulvar area were evaluated in 23 defined locations using a newly developed vulvodolorimeter. Peripheral pressure pain sensitivity was assessed by applying 1) continuously ascending pressures to 3 bilateral locations (thumb, deltoid, and shin), and 2) discrete pressure stimuli to the thumb using both an ascending and random sequence of varying pressures. RESULTS: Pain thresholds at all vulvar locations were lower in the women with vulvodynia than in pain-free control subjects. Similarly, peripheral pain thresholds were lower at the thumb in women with vulvodynia when obtained by discrete ascending or random staircase paradigms, as well as at the thumb, deltoid, and shin when tested by dolorimeter (P < .05). Findings were similar in both those with generalized vulvar dysesthesia and those with localized vestibulodynia. The quantitative results obtained with the vulvodolorimeter and with the more subjective cotton-tipped swab testing routinely used in diagnosis were strongly correlated. CONCLUSION: Women with vulvodynia displayed significantly increased pressure pain sensitivity in both the vulvar region and in peripheral body regions, suggesting a “central” component to the mechanisms mediating this disorder. Both the novel vulvodolorimeter and the thumb pressure stimulator may assist in future experimental tests of this and related hypotheses. LEVEL OF EVIDENCE: II-2

Vulvar lichen sclerosus: Pathophysiology and treatment

AbstractLichen sclerosus is a chronic disorder of the skin and mucosal surfaces, and is most commonly seen on the female genital skin. It also occurs on other areas of the body. Any age group may be affected, although it is seen more often in elderly women. The exact cause of lichen sclerosus is unknown. There have been reports of family members with lichen sclerosus; thus it may have a genetic link. There is also the possibility of an autoimmune connection. Currently, ultra-potent topical corticosteroids are the medical treatment of choice. Other treatments that have been utilized for this condition include testosterone, progesterone, tacrolimus, surgery, and phototherapy. Surgery should be reserved for symptomatic patients who fail to respond to multiple medical treatments, as there is a high recurrence rate following surgery. The risk of developing squamous cell carcinoma of the vulva approaches 5% in women with vulvar lichen sclerosus, and therefore close surveillance by the healthcare provider and patient is needed. This review discusses the history, clinical features, pathophysiology, and treatment of lichen sclerosus of the vulva, as well as pregnancy issues and sexual function in patients with this condition. In addition, problems specific to children with lichen sclerosus are reviewed.

Reliability and validity of self-reported symptoms for predicting vulvodynia.

OBJECTIVE: To evaluate the reliability and validity of self-reported symptoms to predict vulvodynia, compared with examination-based confirmation. METHODS: Between August 5, 2004, and December 13, 2004, 1,046 members of the University of Michigan Women’s Health Registry were surveyed regarding the presence of symptoms suggestive of vulvodynia. Diagnoses of vulvodynia and of control status based on survey responses were made, and a subset of these respondents was evaluated in the office. RESULTS: One thousand forty-six of 1,447 (72.3%) eligible women, aged 19 to 92 years, completed the survey. Seventy-nine (7.6%) of the survey respondents who reported ongoing vulvar pain lasting more than 3 months were predicted to have vulvodynia, while women reporting no current pain with intercourse and no history of prolonged vulvar pain were predicted to be controls (N=543). Agreement between the history taken at the office and that reported on the survey was very good (reliability: Cohen’s &kgr;=0.86, 95% confidence interval 0.73–0.99). Of the 28 women predicted to have vulvodynia who were examined in the office, 27 (96.4%) were confirmed to have vulvodynia, and 28 of the 34 (82.4%) asymptomatic women examined did not have increased vulvar sensitivity (Cohen’s &kgr;=0.78, 95% confidence interval 0.64–0.92). CONCLUSION: Excellent reliability and validity of survey responses for predicting vulvodynia were demonstrated. LEVEL OF EVIDENCE: II-2

Treatment of vulvodynia with tricyclic antidepressants: efficacy and associated factors.

Objective. To determine the efficacy of tricyclic antidepressants (TCAs) as treatment for vulvodynia, and to identify demographic factors and pain characteristics associated with improvement. Materials and Methods. Between January 2001 and April 2004, women diagnosed with vulvodynia were offered TCA therapy. The patients rated their worst recent pain on a 10-point scale at baseline and at follow-up; improvement was classified as at least 50% reduction in reported pain from baseline. Results. Of 271 women diagnosed with vulvodynia, 209 (77.1%) were treated initially with a TCA (amitriptyline [n = 183], desipramine [n = 23], and other tricyclic medications [n = 3]). One hundred sixty-two (59.8%) of the women were followed up at a median period of 3.2 months after their initial visit, including 122 women who had started on a TCA. Of 83 women taking a TCA at the first follow-up, 49 (59.3%) improved by more than 50%, compared with 30 of 79 women not taking TCA at follow-up (improvement rate = 38.0%; p =.007; odds ratio = 2.35; 95% CI = 1.23-4.42). Multivariate analysis indicated that age, severity of pain, diagnosis (localized vs generalized vulvar pain), length of time with pain before treatment, age at menarche, use of oral contraceptives, and the number of previous pregnancies were not associated with the outcome; however, taking a TCA at the time of the first follow-up was strongly associated with improvement (p <.001; odds ratio = 4.23; 95% CI = 1.98-9.01). Repeated analysis including only those women prescribed with amitriptyline rather than any tricyclic revealed similar results. Conclusions. Women with vulvodynia who were prescribed a TCA in general (or amitriptyline, specifically) were more likely to have pain improvement compared with those women not taking these medications at follow-up. Randomized, controlled studies of TCAs versus other treatments are needed to clarify the overall effectiveness of these drugs.

Pain at the Vulvar Vestibule: A Web-Based Survey

Objective. To assess the prevalence, characteristics, and ethnic distribution of pain in the vulvar vestibule among a national sample of women completing a web-based survey. Methods. Female participants of the SurveySpot Internet research panel (Survey Sampling International) were invited via e-mail to respond to a web-based questionnaire on womens health issues. The frequency and characteristics of reported pain of the vulvar vestibule were assessed among 994 respondents, using univariate and multivariate analyses. Results. Between May 24, 2002, and June 6, 2002, 730 non-African American women and 364 African American women responded to the invitation to participate, and 94.5% completed the survey. A history of pain at the vulvar vestibule was reported by 288 women (27.9%), with 80 (7.8% of the initial 1032) reporting pain within the past 6 months, 31 (3.0%) reporting pain that lasted 3 or more months, and 18 (1.7%) reporting vestibular pain lasting 3 or more months that occurred within the past 6 months. The prevalence of pain was similar in African American and non-African American women. Conclusions. The prevalence of pain at the vulvar vestibule is more common than previously estimated. The perception that vulvar pain is rare among African American women was not supported in this survey.

Placental metastasis of maternal melanoma.

Metastasis of maternal malignant tumor to the products of conception is a rare event. Melanoma is the most common maternal malignant tumor to metastasize to the placenta and the fetus. We report the case of a 28-year-old woman with melanoma during pregnancy. At parturition, histologic evaluation of the placenta revealed metastatic melanoma, and multiple organ metastasis developed. The infant was free of disease. Metastasis to products of conception portends a poor prognosis for the mother. To our knowledge, this report is the first of a patient with melanoma metastasis to the placenta to survive more than 7 months after parturition. As caretakers of patients with melanoma, dermatologists are in a position to coordinate and direct the care and follow-up treatment of affected patients.

Relationship Between Vulvodynia and Chronic Comorbid Pain Conditions

OBJECTIVE: To estimate the relationship among the presence of vulvodynia, fibromyalgia, interstitial cystitis, and irritable bowel syndrome. METHODS: Validated questionnaire-based screening tests for the four pain conditions were completed by women with and without vulvodynia who were participating in the Michigan Woman to Woman Health Study, a longitudinal population-based survey in southeastern Michigan. Weighted population-based estimates of the prevalence and characteristics of participants with these chronic comorbid pain conditions were calculated using regression analyses. RESULTS: Of 1,940 women who completed the survey containing all four screening tests, 1,890 (97.4%) answered all screening questions and were included. The prevalences of the screening-based diagnoses ranged from 7.5% (95% confidence interval [CI] 6.2–9.0) for interstitial cystitis, 8.7% (95% CI 7.3–10.4) for vulvodynia, 9.4% (95% CI 8.1–11.0) for irritable bowel syndrome, to 11.8% (95% CI 10.1–13.7) for fibromyalgia with 27.1% screening positive for multiple conditions. The presence of vulvodynia was associated with the presence of each of the other comorbid pain conditions (P<.001, odds ratio 2.3–3.3). Demographic risk factors for each condition varied. Increasing age was not associated with greater numbers of comorbid conditions, and only low socioeconomic status was associated with having multiple comorbid conditions concurrently. CONCLUSION: Chronic pain conditions are common, and a subgroup of women with vulvodynia is more likely than those without vulvodynia to have one or more of the three other chronic pain conditions evaluated. LEVEL OF EVIDENCE: II

Vulvodynia incidence and remission rates among adult women: a 2-year follow-up study.

OBJECTIVE: To estimate the incidence and remission rates of vulvodynia over a 2-year period. METHODS: A 2-year follow-up survey was sent to the University of Michigan Women’s Health Registry members who had participated in a previously reported, validated survey. Changes in clinical status, incidence, and remission rates for vulvodynia were estimated, as were factors associated with new onset or remission of symptoms, using univariable and multivariable analyses. RESULTS: Of 1,037 women enrolled in the initial study, 744 women (71.7%) completed an online or written follow-up survey between September 2006 and March 2007. Of the 372 asymptomatic women controls at initial enrollment, 13 (3.5%, 95% confidence interval 1.6–5.4%) had developed vulvodynia during the 2-year follow-up period; nine (2.2%) of these had ongoing symptoms. Of 45 women with vulvodynia at initial enrollment, 10 (22.2%, 95% confidence interval 10.1–34.4%) indicated their symptoms had resolved. Factors at enrollment that were associated with incidence of vulvodynia were younger age and history of pain after intercourse. Remission was more common in women who did not have pain after intercourse and in those who reported less severe pain at enrollment. CONCLUSION: Based on 2-year follow-up, each year approximately one in 50 women develop symptoms of vulvodynia, and one in 10 women with vulvodynia report remission of symptoms. LEVEL OF EVIDENCE: II

Augmented central pain processing in vulvodynia

UNLABELLED Vulvodynia (VVD) is a chronic pain disorder wherein women display sensitivity to evoked stimuli at the vulva and/or spontaneous vulvar pain. Our previous work suggests generalized hyperalgesia in this population; however, little is known about central neurobiological factors that may influence pain in VVD. Here we investigated local (vulvar) and remote (thumb) pressure-evoked pain processing in 24 VVD patients compared to 13 age-matched, pain-free healthy controls (HCs). As a positive control we also examined thumb pressure pain in 24 fibromyalgia patients. The VVD and fibromyalgia patients displayed overlapping insular brain activations that were greater than HCs in response to thumb stimulation (P < .005 corrected). Compared to HCs, VVD participants displayed greater levels of activation during thumb stimulation within the insula, dorsal midcingulate, posterior cingulate, and thalamus (P < .005 corrected). Significant differences between VVD subgroups (primary versus secondary and provoked versus unprovoked) were seen within the posterior cingulate with thumb stimulation and within the precuneus region with vulvar stimulation (provoked versus unprovoked only). The augmented brain activation in VVD patients in response to a stimulus remote from the vulva suggests central neural pathology in this disorder. Moreover, differing central activity between VVD subgroups suggests heterogeneous pathologies within this diagnosis. PERSPECTIVE The presence of augmented brain responses to pressure stimuli remote from the vulva was observed in vulvodynia patients. These findings may guide treatment decisions for better response, as brain mechanisms may be a factor in some VVD patients.