Mary Ellen Rousseau, CNM, MS; Sarabeth F. Gottlieb, CNM, MSN

Disclosures

J Midwifery Womens Health. 2004;49(6) 

In This Article

Vulvodynia and Dyspareunia

It is commonly believed that women have increased sexual and vaginal problems after menopause, including decline in libido, onset or increase in dyspareunia, and vulvitis, all of which have been traditionally attributed to urogenital atrophy.[32] However, studies on menopause most commonly reflect the findings of women who are seeking care.[33] In a longitudinal, prospective, observational population study to distinguish whether changes in sexual function are associated with menopause or aging, Dennerstein and coauthors found that both aging and menopause adversely affected sexual responsivity, as did partner ability to perform sexually.[34] Although the menopause transition is a time of psychosocial change, concomitant factors, such as presence of a sexual partner, the health of the partner, the quality of the relationship, social class, stressors, employment, and physical and psychological health, can change and also affect sexual functioning.

The following conditions may be experienced by the perimenopausal and postmenopausal woman and can be a cause of pain that causes her to seek gynecologic care.

Vulvodynia is defined as chronic vulvar discomfort with symptoms including burning, stinging, irritation, and rawness. Ninety-five percent of the time vulvodynia occurs in white women and 62% of the time in women who have not been pregnant.[35] Data from a population-based study found that 15.4% of women with chronic vulvar pain reported lower genital tract discomfort lasting 3 months or longer.[36] The syndrome, which can occur in both premenopausal and postmenopausal women, is further delineated into various categories.

Vulvitis, or vulvar inflammation, is frequently associated with vulvovaginitis caused by bacterial vaginosis, trichomoniasis, candidiasis, herpes, or condyloma acuminata. Several other conditions must be considered in the differential diagnosis, including contact and irritant dermatitis (from soaps, deodorants, or spermicides), chronic dermatitis, psoriasis, and tinea. Iatrogenic causes include allergic reaction to drugs, rebound after use of topical steroids, cryosurgery, application of trichloroacetic acid, or laser treatments.[37]

Vulvar dermatoses include dermatologic conditions, such as lichen sclerosus, in which the skin of the vestibule and labia minora becomes pale, thin, and friable ("parchment paper"). Areas of acanthosis (velvety thickening and hyperpigmentation) with lichen sclerosus may be associated with epithelial atypia or malignancy and usually require biopsy. The mainstay of therapy for lichen sclerosus over the past 30 years has been topical testosterone cream; more recently, the drug of choice is clobetasol dipropionate (Clobex, Olux, and Temovate).[38] Lichen planus is a chronic, shallow mucositis of unknown etiology in which desquamating and ulcerating lesions of the vaginal mucosa spread out onto the vestibule. Both lichen conditions can cause introital pain and dyspareunia.

Vestibulitis involves chronic vulvar discomfort, especially pain with touch or vaginal entry during sexual activity. It may be caused by infection, cancer, dermatoses, or allergies. Topical steroids, such as clobetasol dipropionate, and anesthetics, such as Xylocaine jelly, have been used. Some women find it helpful to reduce dietary intake of foods high in oxalates (sharp crystals excreted in the urine), which may irritate the vulva.[39] A low-oxalate diet requires limiting chocolate, alcohol, wheat, and certain fruits and vegetables. Calcium citrate inhibits formation of the crystals; therefore, taking 400 mg of calcium citrate by mouth 3 times daily may decrease vulvar pain.[37] Self-help measures include wearing loose clothing, using mild soaps, avoiding cold water detergents, and double rinsing laundry to thoroughly remove detergent from clothing and linens. Plain water washes after voiding may be helpful. Non-irritating emollients, such as vegetable oils, might offer relief. Long-term antifungal drugs may improve symptoms in women who have concurrent fungal infection. Biofeedback, relaxation training, and physical therapy also offer possible relief. In women diagnosed with human papilloma virus (HPV), interferon therapy has been used. Use of low-potency steroids may offer short-term relief, but they are likely to get rebound irritation when they discontinue the steroids.[37]

Essential or dysesthetic vulvodynia is a vulvar vestibulitis marked by chronic pain that exists even without tactile contact and without physical findings. The predominant physical finding is vestibular erythema. Symptoms can occur not only with touch or intercourse but may be constant or intermittent without apparent triggers. Causes may include previous surgery, horseback riding, or bicycle injuries. It can appear at any age but seems to be most common after age 30.[40] Benefits may be obtained from topical anesthetics and medications that are used for neuropathic pain such as amitriptyline, gabapentin, valproic acid, or carbamazepine.[41] In some cases, low-dose antidepressants, such as amitriptyline, starting at 10 mg/day and gradually increasing to 75 to 100 mg/day, imipramine, and desipramine, have been shown to be effective. These drugs are best used at doses of less then 20 mg/day to decrease the likelihood of side effects.[40] Care must be taken when prescribing these medications for the elderly because they are more susceptible to side effects.

Urogenital atrophy occurs when the external and internal female genitalia undergo changes over the decades following the menopause. The changes are problematic for some women and not for others. These changes are thought to be the result of decreasing levels of estradiol at the time of menopause. The vaginal mucosa is thin, pale, and sometimes friable. The patient may report pain, dryness, itching, urinary frequency, and dysuria. The vaginal pH is greater than 4 due to a lack of lactobacilli. Treatment has traditionally been local estrogen therapy; current standard recommendations for HT and the patient's full medical history and physical examination must be taken into account. Options include vaginal estrogencreams, a vaginal ring containing estradiol (Estring), or a vaginal tablet with estrogen (Vagifem). The lowest dose needed to improve symptoms should be used.[41]

An alternative nonestrogen treatment for vaginal complaints including pain is Replens. It can carry up to 60 times its weight in water and delivers both electrolytes and water to the vaginal tissue. The product has a low pH (2.8) and has the ability to keep the pH of the vagina in the physiologically normal range (4.5 to 5.5, or fairly acid), thereby making it less susceptible to bacterial infection. It is used 3 times a day for all symptoms of vaginal atrophy.[43]

After a careful history to identify associated symptoms, physical examination of the vulva should include observation of the vulva for redness, erosions, crusting, ulcers, and hypopigmentation. A cotton swab may be used to identify painful areas within the vestibule. The vagina should be observed for redness, ulcers, erosions, foreign bodies, pallor, and dryness. The discharge should be evaluated microscopically, the pH assessed, and cultures for gonorrhea, chlamydia, aerobes (e.g., group B strep), anaerobes, and mycoplasmas.[39] A biopsy of specific skin findings should be performed if an uncommon lesion or growth is observed.

In addition, it is important to evaluate the effect of these conditions on the woman's quality of life. Comprehensive treatment of these vulvo/vaginal disorders must include addressing the psychosocial issues that may accompany them when they are severe or long-lasting. Affected women may suffer depression, low self-esteem, hold negative attitudes about sexuality, and may withdraw from intimate interpersonal relationships. Clinicians can offer educational materials; encourage the women to find alternative intimate options to intercourse; encourage her to involve her partner in the exchange of feelings such as fear, guilt, or shame; or seek professional psychological counseling.

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