What are the treatment options for vulvovaginal pain?

Treatment of Vulvovaginal Pain

Start with lubricants for all sexual activity plus vaginal moisturizers applied 3-5 times weekly to the vagina, vaginal opening, and external vulva, then escalate to low-dose vaginal estrogen if symptoms persist, and add topical lidocaine for persistent introital pain and dyspareunia. 1

Stepwise Treatment Algorithm

First-Line: Conservative Measures

• Apply vaginal lubricants during all sexual activity or touch 1
• Use vaginal moisturizers at high frequency (3-5 times per week) to improve vulvovaginal tissue quality, applying to the vagina, vaginal opening, and external vulvar folds 1
• Apply skin protectants or sealants to external vulvar folds if using pads for leakage or discharge 1

Second-Line: Hormonal and Topical Anesthetics

• Prescribe low-dose vaginal estrogen for patients not responding to conservative measures or those with more severe symptoms at presentation 1
• For women with hormone-positive breast cancer who fail conservative measures, low-dose vaginal estrogen can be considered after thorough discussion of risks and benefits 1
• Offer topical lidocaine for persistent introital pain and dyspareunia 1

Third-Line: Advanced Pharmacologic Options

• Vaginal dehydroepiandrosterone (DHEA) may be offered to women with current or history of breast cancer on aromatase inhibitors who have not responded to previous treatments 1
  • Caveat: Limited supportive data exists for women with cancer history or on endocrine therapy, so risk/benefit is not fully known 1
• Ospemifene (selective estrogen receptor modulator) may be offered to postmenopausal women without current or history of breast cancer experiencing dyspareunia, vaginal atrophy, or other vaginal pain 1
  • Critical warning: Has not been evaluated in women with cancer history or on endocrine therapy 1

Adjunctive Therapies

Physical and Behavioral Interventions

• Vaginal dilators should be offered for vaginismus and/or vaginal stenosis, particularly important for women treated with pelvic or vaginal radiation therapy—start early regardless of sexual activity or orientation 1
• Pelvic floor physiotherapy should be offered for symptoms of pelvic floor dysfunction including persistent pain, urinary incontinence, or fecal leakage 1
• Cognitive behavioral therapy and pelvic floor (Kegel) exercises may decrease anxiety, discomfort, and lower urinary tract symptoms 1

Pain Management for Specific Populations

• Offer pain relievers to women on aromatase inhibitors experiencing arthralgia that interferes with intimacy 1

When to Exclude Infectious Causes

Before attributing pain to atrophy or vulvodynia, rule out:

• Vulvovaginal candidiasis: characterized by pruritus, white discharge, normal pH (≤4.5), and erythema 2, 3
  • Treat uncomplicated cases with topical azoles (clotrimazole, miconazole) for 3-14 days or oral fluconazole 150mg single dose 1, 2
• Trichomoniasis: diffuse, malodorous yellow-green discharge with vulvar irritation 1, 2
  • Treat with oral metronidazole 2g single dose and treat sexual partners 1, 3
• Bacterial vaginosis: vaginal discharge with fishy odor, particularly after KOH application 3

Critical Pitfalls to Avoid

• Do not use oral fluconazole in pregnant women—only 7-day topical azole therapies are safe 1, 3
• Do not recommend self-medication with OTC preparations unless the patient has been previously diagnosed with the same condition and experiences identical symptoms 1, 3
• Do not delay referral to urology, urogynecology, or colorectal surgery for persistent urinary or fecal incontinence 1
• Patients whose symptoms persist after OTC treatment or recur within 2 months should seek medical evaluation 1, 3

Special Populations

• HIV-infected women should receive the same treatment regimens as non-HIV-infected women 1, 3
• Pregnant women require only topical azole therapies for 7 days; avoid all oral antifungals 1, 3