From the Guidelines
The most appropriate treatment for this patient's condition, which appears to be endometriosis, is hormonal therapy with a combined oral contraceptive pill, as recommended by the American College of Obstetricians and Gynecologists 1. The patient should start with a monophasic combined oral contraceptive pill containing ethinyl estradiol 20-35 mcg and a progestin, taken continuously (skipping the placebo pills) for 3-6 months initially. This approach suppresses ovulation and reduces endometrial growth, which can significantly decrease pain during intercourse (dyspareunia) and menstrual pain (dysmenorrhea) 1. The continuous regimen helps minimize breakthrough bleeding and provides consistent symptom relief. If side effects occur, the patient may try different formulations or consider alternatives like progestin-only pills, the levonorgestrel IUD, or GnRH agonists for more severe cases. The diagnosis of endometriosis is suggested by her symptoms of deep dyspareunia, regular painful periods, and normal physical examination. Endometriosis involves endometrial-like tissue growing outside the uterus, causing inflammation and pain, particularly during intercourse and menstruation. Hormonal suppression is the first-line treatment before considering surgical options like laparoscopy for diagnosis and excision of endometriotic lesions. Additionally, other treatments such as pelvic floor muscle training, vaginal dilators, and vaginal estrogen may be considered for symptom management, as suggested by the NCCN guidelines 1. However, the primary approach should focus on hormonal therapy to address the underlying cause of the symptoms. It is essential to note that the patient's symptoms and treatment response should be regularly evaluated to adjust the treatment plan as needed. In cases where hormonal therapy is not effective, or the patient experiences significant side effects, alternative treatments and surgical options should be considered. The patient's quality of life, including her sexual function and relationship with her partner, should be prioritized throughout the treatment process. Regular follow-up appointments and open communication with the patient are crucial to ensure the best possible outcome and adjust the treatment plan accordingly.
From the Research
Treatment Options for Provoked Vestibulodynia
The patient's symptoms of severe pain during sexual intercourse, particularly with deep penetration, are consistent with provoked vestibulodynia. The most appropriate treatment for this condition is multimodal physical therapy, which has been shown to be effective in reducing pain intensity and improving sexual function.
Evidence for Multimodal Physical Therapy
- A study published in 2021 2 found that multimodal physical therapy was more effective than topical lidocaine in reducing pain intensity during intercourse and improving sexual function in women with provoked vestibulodynia.
- Another study published in 2019 3 reviewed the evidence for pelvic floor physical therapy (PFPT) as a treatment for pelvic floor dysfunction, including provoked vestibulodynia, and found that PFPT can improve or cure symptoms of urinary incontinence, pelvic organ prolapse, and pelvic pain.
- A study published in 2017 4 found that pelvic floor muscle physiotherapy (PFMT) and biofeedback (BF) can benefit patients suffering from bladder dysfunction, bowel dysfunction, pelvic organ prolapse, and sexual dysfunction, including pelvic pain.
Alternative Treatment Options
- Cognitive behavioral therapy (CBT) has also been shown to be effective in treating chronic pelvic pain, including provoked vestibulodynia 5, 6.
- A study published in 2023 6 found that cognitive-behavioral couple therapy (CBCT) can improve pain intensity, sexual distress, and sexual function in women with provoked vestibulodynia, and that decreases in pain catastrophizing may be a mediator of change in CBCT.
Key Findings
- Multimodal physical therapy is a recommended first-line treatment for provoked vestibulodynia.
- Cognitive behavioral therapy (CBT) and cognitive-behavioral couple therapy (CBCT) may also be effective treatment options.
- Decreases in pain catastrophizing may be a mediator of change in CBCT.