What are the recommended treatments for vulvodynia?

From the Guidelines

Treatments for vulvodynia should prioritize a multimodal approach, starting with topical lidocaine 5% ointment and progressing to amitriptyline for unresponsive cases, as recommended by the most recent and relevant guidelines. When considering treatment options for vulvodynia, it's essential to focus on the most recent and highest-quality studies. According to the study published in 2002 1, xylocaine 5% ointment should be tried first, with progression to amitriptyline in unresponsive cases. However, more recent studies, such as the 2018 guideline adaptation by the American Society of Clinical Oncology 1, suggest a broader range of treatment options, including lubricants, vaginal moisturizers, low-dose vaginal estrogen, and lidocaine for persistent introital pain and dyspareunia.

Key Treatment Considerations

• Topical medications, such as lidocaine 5% ointment, should be applied to the affected area before sexual activity or 3-4 times daily
• Low-dose tricyclic antidepressants like amitriptyline may be prescribed, starting at 10-25mg nightly and gradually increasing to 50-75mg as tolerated
• Physical therapy focusing on pelvic floor exercises can be highly effective for many women, particularly those with muscle tension or spasm
• Lifestyle modifications, including wearing loose cotton underwear, avoiding irritants like scented products, and using lubricants during intercourse, are essential
• For moderate to severe cases, oral medications such as gabapentin or pregabalin may be prescribed
• Cognitive behavioral therapy can help address the psychological impact of chronic pain

Additional Treatment Options

• Low-dose vaginal estrogen can be used for women who do not respond to conservative measures
• Vaginal dehydroepiandosterone may be offered to women with current or a history of breast cancer who are on aromatase inhibitors and have not responded to previous treatment
• The selective estrogen receptor modulator ospemifene can be offered to postmenopausal women without current or a history of breast cancer who are experiencing dyspareunia, vaginal atrophy, or other vaginal pain
• Pelvic floor physiotherapy may be beneficial for patients experiencing symptoms of a potential pelvic floor dysfunction, including persistent pain and urinary and/or fecal leakage.

From the Research

Treatment Options for Vulvodynia

The treatment of vulvodynia, a common and recurrent vulvar pain condition, poses a significant challenge due to its uncertain and likely multifactorial etiology. Various treatment options are available, including:

• Pharmacological treatments:
  • Antinociceptive agents (lidocaine, capsaicin) 2
  • Anti-inflammatory agents (corticosteroids, interferon) 2
  • Neuromodulating medications (anticonvulsants and antidepressants) 2, 3
  • Hormonal agents 2
  • Muscle relaxants (e.g., botulinum toxin) 2, 4
• Non-pharmacological treatments:
  • Psychological therapy 2, 5, 6
  • Pelvic floor physical therapy 2, 5, 4, 6
  • Surgery (i.e., vestibulectomy for provoked vestibulodynia) 2, 4, 6
  • Multimodal treatments 2, 4
  • Alternative therapies: physiotherapy, psychotherapy, acupuncture, hypnotherapy, cognitive behavioral therapy, and laser therapy 3, 4

Recommended Treatments

Strong evidence supports the use of non-pharmacological interventions, including psychological therapy, pelvic floor physical therapy, and surgery (i.e., vestibulectomy for provoked vestibulodynia) 2, 6. Multidisciplinary treatment approaches are also recommended for the management of vulvodynia 6.

Treatment Selection

The selection of treatment methods should be guided by the highest level of evidence and the least invasive options 4. A comprehensive assessment is necessary to understand the pain experience of women presenting with vulvodynia, and treatment typically progresses from less invasive to more invasive options 6.