LAKE BUENA VISTA, FLA. -- Vulvodynia is not the rarity it has traditionally been considered, and the continuing uncertainty about what causes it is not an obstacle to effective treatment, Dr. Barbara D. Reed said at a meeting of the American Society for Colposcopy and Cervical Pathology.
"We used to think about 150,000-200,000 women in this country had vulvodynia. That number was tossed around for a long time," she said.
"But we did a survey, sending out 3,000 e-mail invitations to women asking them about vulvar pain, and 1,024 responded," she said. Participants ranged in age from 18 to 78 years.
Half reported that they had had vestibular pain with intercourse at some point in their lives, 28% had vestibular pain, and 3% reported that the vestibular pain had persisted for more than 3 months.
Based on the survey results, Dr. Reed now estimates the prevalence of vulvodynia to be 1.7% of the female population. This translates to 15 women in each family physician's practice, and at least double that in each gynecology practice--totaling about 2,400,000 women in the United States, said Dr. Reed, professor of family medicine at the University of Michigan. Ann Arbor.
The condition is characterized by burning, irritating pain and itching and typically is exacerbated with intercourse or tampon use. There is no evidence of an infectious or dermatologic etiology.
Nor is it a psychiatric condition. "Women with vulvodynia are psychologically very similar to controls," she said. They also are not sexually averse, and do not have higher reported rates of childhood sexual or physical abuse, she added.
Preliminary research suggests that local and systemic inflammation involving cytokines such as interleukin-1[beta] may play a role in the pathogenesis.
Many patients have the condition for years and see multiple clinicians and specialists before being given the correct diagnosis. This can be obtained by reproducing the symptoms with the cotton swab test. "I press lightly across the entire area, the labia majora, interlabial sulcus, and along the introitus, to a 2-3 mm depth." Dr. Reed said. Most women rate the pain as 8-10 on a 10-point scale.
Various treatment approaches can be tried, and while little hard data exist concerning efficacy, the majority of patients with this distressing condition can be helped. "Expect improvement. Don't settle for less," she said.
Because vulvodynia is presumed to be a chronic, possibly centrally mediated neuropathic pain syndrome, first-line treatment is usually amitriptyline. Although this recommendation is based only on anecdotal evidence--there are no randomized trials--amitriptyline may work by modulating the transmission of pain impulses, she said.
Most patients tolerate the drug well, starting with a dosage of 25 mg/day and increasing by 25 mg every 2 weeks. Typical effective dosages are 50-100 mg/day, but occasionally dosages up to 250 mg/day are required.
"We also have experience with [selective serotonin reuptake inhibitors] in a small number of women, where there has been a fairly good response to Paxil in particular," she said. Gabapentin also has been helpful for some women in dosages ranging from 900 to 3,600 mg/day.
Another approach that initially showed promise was biofeedback. In a preliminary study that included 33 women with long-term vulvar symptoms, 16 weeks of at-home pelvic floor muscle exercises monitored with a portable electromyographic biofeedback instrument led to an increase in pelvic floor contractions in 95%, decreased resting tension in 68%, and diminished instability of the pelvic floor at rest in 62%.
Before treatment, 28 of the women had abstained from intercourse for an average of 13 months. By the end of the treatment period, 22 of these women had resumed intercourse (J. Reprod. Med. 40:283-90, 1995).
But in a subsequent randomized trial comparing biofeedback with vestibulectomy and cognitive-behavioral therapy, significant improvements in pain were seen in only 24% of the biofeedback patients (Pain 91:297-306, 2001).
"Vestibulectomy, while usually a last resort, is where we have the most data on treatment outcomes," Dr. Reed said. Although the studies have many methodologic limitations, most report at least a 60% response to surgery.
New York Bureau
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