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Sexual Health
CMECNE

Evaluating Vulvodynia – Making the Diagnosis and Key Management Points

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Relate the key elements of the physical exam needed to make a diagnosis of vulvodynia
2. Restate some of the treatment options available for vulvodynia

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

Vulvar pain is a symptom and not a diagnosis. If symptoms persist for a minimum of three months and no other pathology can be identified, consider the diagnosis of vulvodynia.

  • Obtain a history and physical to determine other causes of vulvar pain such as infection (e.g., candidiasis), inflammation (e.g, lichen planus), trauma, hormonal deficiency or iatrogenic (radiation induced)
  • On physical examination, determine the location of the pain (see ACOG Committee Opinion in ‘Learn More – Primary Sources’ for illustrations on anatomy and how to perform the following test)
    • Using a Q-tip on the vestibule, press on the vulva to determine which locations illicit a pain response
    • To determine a baseline, place significant pressure on labia majora, interlabia sulci and labia minora
    • Touch, using the Q-tip, lateral and medial to Hart’s line
    • If sensitive to touch medial to Hart’s line a diagnosis of vestibulodynia can be established

Classification

Multisocietal Definition Consensus (ISSVD, ISSWSH, and IPPS)

  •  Location
    • Localized (e.g. vestibulodynia) | Generalized (involves whole vulva)
  • Provocation
    • Provoked (discomfort provoked by physical contact, sexual or nonsexual) | Spontaneous (can occur without any provoking physical contact)
  • Onset
    • Primary (occurs with first provoking physical contact) | Secondary (did not occur with the first provoking physical contact)
  • Temporal Pattern
    • Persistent (at least 3 months, constant  or intermittent) | Constant (symptoms always present) | Intermittent (symptoms not always present) | Immediate (occurs during the provoking physical contact) | Delayed (symptoms occur after the provoking physical event)

SYNOPSIS:

Symptoms may include burning, stinging, itching and may be constant or only upon contact (provoked).  When the pain is primarily localized to the vestibule, the term vestibulodynia can be used. With respect to timing, pain can be persistent or cyclical. Most cases of vulvodynia can be treated hormonally or through pelvic floor physiotherapy. In the most extreme cases of vestibulodynia, rarely a vestibulectomy may be indicated.

KEY POINTS:

Treatment of generalized vulvodynia or vestibulodynia may include the following

  • Review and discontinuation of products being used by patient (soaps, shampoo, pads)
  • If the pain is hormonally mediated, use of local topical hormonal creams (e.g., estrogen)
  • If pain is thought to be due to high pelvic tone, referral to a pelvic floor physical therapist may be appropriate
  • Consider pain medications such as tricyclics and Gabapentin: Start with lower dosage than typically used for depression or epilepsy
    •  Amitriptyline (usually first-line): 5–25 mg po nightly and increased by 10–25 mg weekly (maximum 150 mg daily)
      • If plan to stop tricyclics: Wean off (do not stop suddenly) by reducing dose 10–25 mg every few days
    • Gabapentin: 300 mg total daily to a maximum 3,600 mg daily (1,200 mg by mouth three times a day)
      • Adjust dose based on adverse effects

Note: Above medications will need to be tritrated, often over 3 to 4 weeks to arrive at optimal dose | Adverse effects include sedation, dry mouth, and dizziness (some patients will develop tolerance)

Additional Treatment Options

  • Use of topical medications such as lidocaine
  • Transcutaneous electrical nerve stimulation (TENS)
  • If the vestibulodynia is primary and other treatments have failed, further neurologic workup and surgical approaches may be required

LEARN MORE – PRIMARY SOURCES:

ACOG ASCCP Committee Opinion 673: Persistent Vulvar Pain

2015 ISSVD, ISSWSH, and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia

Descriptors of Vulvodynia: A Multisocietal Definition Consensus (International Society for the Study of Vulvovaginal Disease, the International Society for the Study of Women Sexual Health, and the International Pelvic Pain Society)

New topical treatment of vulvodynia based on the pathogenetic role of cross talk between nociceptors, immunocompetent cells, and epithelial cells

Recent advances in understanding provoked vestibulodynia

Localised provoked vestibulodynia (vulvodynia): assessment and management

Nature Reviews Disease Primers: Vulvodynia

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Related ObG Topics:

Is Catechol-O-Methyltransferase a Cause of Pain in Vulvodynia?
Pelvic Floor Physical Therapy – PFPT and When to Use it
Practical info for your gynecology practice
Diagnosing Vaginitis – Why the Office Visit Still Matters
Does Gabapentin Improve Sexual Function in Women with Vulvodynia?

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This website (the “Website”) is a service made available by The ObG Project LLC, its partners, affiliates or subsidiaries (“Provider”). This Website provides general information related to the law and is designed to help users safely cope with their own legal needs. This website does not provide legal advice and Provider is not a law firm. None of our customer service representatives are lawyers and they also do not provide legal advice. Although we go to great lengths to make sure our information is accurate and useful, we recommend you consult a lawyer if you want legal advice. No attorney-client or confidential relationship exists or will be formed between you and Provider or any of our representatives.
This website is not intended to be a source for legal advice, and thus the reader should not rely on any information provided in this website as such. Readers should not consider the information provided to be an invitation for an attorney-client relationship, and should always seek the advice of competent counsel in the reader’s home jurisdiction. Provider may provide links to third party websites. These links are provided only as a convenience. Linked websites are not reviewed, controlled or examined by Provider and Provider is not responsible for the information, advertising, products, resources or other materials, of any linked site or any link contained in a linked site. The inclusion of any link does not imply endorsement by Provider. In addition, please be aware that your use of any linked site is subject to the terms and conditions applicable to that site. Please direct any questions regarding linked sites to the webmaster of that site.

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OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

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This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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