The diagnosis and management of chronic vulvovaginal disease requires attention to several issues. Psychological factors are usually important, because women worry about malignancy, impaired sexuality and self-image, fertility, and sexually transmitted diseases. Multifactorial processes are common due to the risk of secondary candidiasis, contact dermatitis, effects of low estrogen in postmenopausal women and women on oral contraceptives, and so forth. Undertreatment of inflammatory dermatoses is common, because clinicians use topical corticosteroids that are of inadequate potency and for insufficient duration. All of these issues must be considered for optimal benefit in the therapy of chronic vulvovaginal diseases.
The management of chronic vulvovaginal symptoms is a challenge that requires attention to several unique issues. Vulvovaginal diseases are often multifactorial. Successful treatment requires attention to all aspects of the disease. Often these components need to be addressed simultaneously; however, this is not difficult with an organized approach. Much like a complete approach to other chronic dermatologic diseases, such as atopic dermatitis, patients must be educated about the disease and daily skin care; the primary disease and also secondary infections must be treated, adverse effects must be anticipated; and rescue care for acute flares must be offered. The goal of treatment of chronic vulvovaginal disease is often control, not cure.
General measures
There are several general measures that are essential for the successful treatment of any vulvovaginal disease. Despite adequate diagnosis and treatment, patients may fail to improve if these fundamentals are not addressed. These include educating patients about the nature of their disease, addressing psychosexual issues, stopping irritants, using appropriate vehicles for medications, anticipating and treating iatrogenic disease, prescribing estrogen when appropriate, and having a rescue plan for acute symptoms.
Education
Symptoms of vulvovaginal disease are common, yet women are often unaware of this fact and feel isolated with their problems. Patients commonly feel embarrassed discussing their problems and, therefore, often have many concerns that are unaddressed. Many have fears that their symptoms represent cancer, sexually transmitted disease, or infidelity. These topics should be discussed as directly as possible, because patients may not volunteer their fears. It is a good idea to ask patients what they think their problem is, to get an idea of their concerns so that they can be addressed immediately. Vulvovaginal disease can significantly interfere with sexual function and intimacy as well as overall disposition. Frustration and depression are common and can contribute to a pain syndrome, if present. It is important to take the time to support patients. In addition, counseling is important for patients and their partners. Involving the partner from the first visit is ideal. Resources with accurate information are helpful because there are many myths on the Internet and elsewhere. Referring patients to the International Society for the Study of Vulvovaginal Disease ( www.ISSVD.org ) is suggested because there are educational resources available that are up to date, and may help women feel less alone in their disease. The National Vulvodynia Association ( www.NVA.org ) is another excellent resource for patients. In the author’s experience, referring patients to support groups is not helpful, because many of the people participating are unhappy and not supportive in a positive way. Handouts are a great idea, because there is often an enormous amount of information to absorb at the initial encounter, and patients are able to review the information again at home.
An important part of the educational process is management of patients’ expectations. Vulvovaginal disease is often chronic, and the aim of care is control, not cure, for most diseases. This needs to be explained clearly to patients, followed up by a comprehensive care plan of how patients will get better, but not necessarily cured of their disease.
Psychosexual Issues
It is well known that depression can occur in conjunction with almost all chronic pain syndromes. Depression can also alter pain perception. For successful treatment of vulvovaginal disorders, depression or any other psychological issues must be addressed. As discussed previously, counseling is imperative for most patients. Sex therapy or couples counseling is often helpful as well. In addition, the use of antidepressants is encouraged. Fortunately, the tricyclic class of antidepressants has the advantage of also treating chronic pain and producing sedation to prevent nighttime scratching. If tricyclics are ineffective at treating the depressive symptoms, however, other classes of antidepressants can be considered (discussed later).
Irritant and Allergic Contact Dermatitis
Vulvovaginal disease often has multiple concurrent etiologies, and it is imperative to consider allergic contact dermatitis in all patients. Irritant and allergic contact dermatitis are often not the primary problems but secondary complications. Irritant contact dermatitis is common, because vulvar skin is inherently more sensitive than other skin areas and has weak barrier function. Diseased vulvar skin is often even more prone to irritation. Irritants are substances or practices that would create irritation in most people if used often enough or left on the skin long enough. Irritant contact dermatitis is nonimmunologic. Alternatively, allergic contact dermatitis requires prior sensitization to an allergen and constitutes an immunologic memory T-cell response on re-exposure to that allergen. This can result in an inflammatory cutaneous reaction. In vulvar irritant and allergic contact dermatitis, some patients only have sensory irritation, with no detectable skin change.
Irritants include strong irritants, such as topical mediations for genital warts that cause an acute reaction, and weaker irritants that have a more cumulative effect ( Table 1 ). Weaker irritants include moisture, friction, vaginal discharge, urine feces, soaps/cleansers, feminine wipes or sprays, douches, sanitary pads, creams, semen, lubricants, and spermicides. Aggressive washing with wash cloths is another common cause of irritation, as is overly frequent washing, often out of fear of odor or concern that poor hygiene is the cause of the symptoms. In addition, use of a hair dryer to dry the vulva after bathing should be discouraged as this can cause chapping and irritation.
| Physical irritants | Excessive washing, wash cloths, hair dryers, sanitary pads, tight clothing |
| Hygiene products | Soaps and cleanser, powders, douches, perfumes, deodorants, bubble bath/oils/salts, depilatory creams, adult or baby wipes |
| Body fluids | Sweat, vaginal secretions (normal or abnormal), urine, feces, semen |
| Medicaments | Antifungal creams, topical antibacterial agents, over-the-counter anti-itch creams |
| Lubricants and contraceptives | Spermicides, condoms, diaphragms, lubricants |
Allergic contact dermatitis is less common than irritant contact dermatitis, but is still common ( Table 2 ). The incidence of vulvar contact dermatitis has been reported to vary from 20% to 30%. In a recent study of 50 women with vulvar pruritus, 8 patients (16%) had one or more relevant positive allergic reactions. The relevant allergens were usually cosmetics, preservatives, and medicaments. In another study, 47% of patients with lichen simplex chronicus had positive patch tests. Although it is not clear whether or not the allergic contact dermatitis triggered the lichen simplex chronicus or if the allergy was secondary to treatments used for the lichen simplex chronicus, it is important to recognize and treat both problems concurrently. If no dermatitis is present, it is unlikely that allergic contact dermatitis is playing a role.
| Topical anesthetics (eg, benzocaine) | Chlorhexidine (eg, in K-Y Jelly [Johnson & Johnson]) |
| Topical antibiotics (eg, neomycin) Perfumes | Latex (eg, latex condoms) |
| Preservatives (in creams, prescription creams, hygiene products, and nail polish) | Topical antifungal medications (eg, imidazoles and nystatin) |
| Topical steroids |
Some of the more significant allergens implicated in vulvar allergic contact dermatitis include topical anesthetics, ethylenediamine, topical antibiotics, fragrances, antifungal creams, and topical steroids. Benzocaine is a common allergen found in many over-the-counter anti-itch creams, including Vagisil, which is a specifically marketed for vaginal and vulvar symptoms and commonly tried by women before they present to a physician. Ethylenediamine is found in generic Mycolog or Kenacomb cream. Neomycin is another common culprit found in antibacterial creams. Fragrance is ubiquitous in hygiene products. Nystatin, imidiazoles, and corticosteroids are known sensitizers, as are the preservatives in their cream vehicles. Corticosteroid allergy should be considered in anyone not improving with a steroid-responsive disease.
Allergic contact dermatitis is diagnosed by patch testing. Patch testing should be considered in all patients presenting with vulvar dermatoses or pruritus. It should always be performed when a patient is not responding to therapy as expected. Most patients with vulvovaginal problems present to their physician only after trying several home remedies. They have often tried several over-the-counter creams, cleansers, and antifungal and antibacterial treatments. It is important to have a high index of suspicion for both irritant and allergic contact dermatitis. General measures suggested for all patients include only washing once a day with plain water and fingertips; stopping all products used on the vulva or vagina (including over-the-counter and prescription products); not using panty liners or pads; and avoiding spermicides, condoms, and some lubricants, such as K-Y Jelly, which has chlorhexidine and preservatives (Astroglide and vegetable oil are acceptable). Avoiding tight clothing, such as jeans, is helpful. If an emollient is needed, plain petrolatum used just after bathing is safe and effective. These instructions should be given to patients in a handout if possible. General instructions for patients to decrease irritant and allergen exposure include
Stop all products used on vulva and vagina
Avoid sanitary pads, use tampons
Avoid spermicides, condoms, and K-Y Jelly (vegetable oil or Astroglide are acceptable)
Wear loose clothing.
Vehicles
When at all possible, topical creams or gels should be avoided when treating vulvovaginal disease because they tend to sting and burn, causing further irritation to the area. In addition they contain more preservatives and additives than ointments do and therefore have more potential for causing irritant or allergic contact dermatitis. Ointments should be used for topical treatment, even if they require compounding. Sometimes oral treatment is preferred to avoid any manipulation or further irritation to the area or for severe disease.
Anticipate Adverse Events and Iatrogenic Disease
Vulvovaginal candidiasis and contact dermatitis are common complications when treating vulvovaginal disease. Many of the treatments used to treat vulvovaginal disease, such as antibiotics, corticosteroids, and estrogen, predispose patients to vulvovaginal candidiasis. A prudent approach is to use antifungal prophylaxis during treatment. Oral fluconazole (150 mg weekly) is a good choice rather than a topical antifungal to avoid the risk of irritant or allergic contact dermatitis. The presciber must be mindful of the risk of medication interactions with oral fluconazole.
It is impossible to completely remove the risk of allergic contact dermatitis, but using ointments rather than creams decreases the risk of preservative allergy, because creams contain more preservatives. Careful prescribing, asking patients to avoid self-treatment, and having a high index of suspicion when patients are recalcitrant or flaring help minimize the possibility of allergic contact dermatitis from complicating vulvovaginal disease.
Estrogen Replacement
Estrogen deficiency can make any vulvovaginal problem worse, and it can sometimes be the primary problem. Estrogen maintains the tissue of the vagina and introitus, and without it, these tissues become atrophied, dry, and fragile. There are many causes of low estrogen, including medications (oral contraceptive pills and tamoxifen), menopause, the postpartum period, and breastfeeding. Estrogen-deficient patients are particularly susceptible to trauma from normal activities, scratching, or irritants. All patients should be evaluated for estrogen deficiency and estrogen replaced in those who are deficient. This is essential for the successful treatment of their vulvovaginal condition (discussed later).
Rescue Medications
Most patients with vulvovaginal disease have acute exacerbations of their symptoms at times. It can alleviate patient anxiety to have a rescue plan with techniques/tools and medications that patients can turn to when they have acute worsening of their condition. Cold compresses kept in the refrigerator (not the freezer, to avoid frostbite) are ideal for patients to use to alleviate pain or pruritus. Cool water soaks act similarly by hydrating the tissue and, therefore, temporarily sealing small cracks and fissures in the skin. Patients can soak for 10 to 15 minutes up to 2 times a day, pat the area dry, and then gently cover the area with plain petrolatum to seal in the moisture and create some barrier protection. Petrolatum is irritant- and preservative-free, is inexpensive, and has minimal risk of causing any secondary problems. Patients should be cautioned that soaking too often may be counterproductive because it can dry out the tissues and cause irritation in itself.
Topical xylocaine is helpful relief for acute symptoms as well as to facilitate sexual intercourse or even micturition. It can be applied 30 minutes before intercourse. Unfortunately, a frequent side effect is burning and stinging from both the 2% xylocaine gel and 5% xylocaine ointment, which limits its use in many patients. In the authors’ recent experience, success was found with a dental formula of lidocaine powder 10%, prilocaine power 10%, and tetracaine power 4% compounded into a gel.
Nightime sedation is a key part of a rescue plan. Many vulvovaginal patients have poor sleep secondary to itch or pain. Patients who can sleep often have poor quality sleep because they are scratching in their sleep, and this also prevents the improvement of their condition. Lack of quality sleep can contribute to depression and difficulties coping with pain or itch. Dermatologists are often most comfortable using sedating antihistamines, such as diphenhydramine or hydroxyzine hydrochloride, to assist sleep. If these medications are not successful, or if patients are scratching in their sleep, tricyclic antidepressants, such as amitrityline or doxepin, are often more effective for sedation because they induce deeper sleep for a longer period of time. This may help decrease scratching during sleep and improve sleep quality.
Lastly, patients experiencing an exacerbation of their condition must be seen and evaluated for the cause of the flare. Infections and allergic contact dermatitis are common causes of flares; thus, a timely history, physical examination, appropriate cultures, and treatment often can truncate an acute flare quickly.
Specific medications
Corticosteroid Therapy
Topical corticosteroid therapy
Topical corticosteroids are the mainstay of treatment of many vulvovaginal diseases, including lichen sclerosus, lichen planus, and other pruritic diseases. The modified mucous membranes are relatively steroid resistant, and often potent or superpotent corticosteroids, such as clobetasol proprionate, are required for successful treatment. A common error in treating vulvar diseases is using a topical steroid that is not potent enough for too little period of time. It is rare to see atrophy of the modified mucous membranes of the vulva. It is important to demonstrate to patients exactly where the ointment is to be applied, so that the corticosteroid is not causing side effects on areas that are not steroid resistant, such as the hair-bearing labia majora, crural crease, perianal skin, and medial thighs. If topical steroid is needed in these nonresistant areas, a less potent steroid is considered and patients should be followed closely for side effects. Adverse effects from topical steroids applied to these nonsteroid-resistant areas include atrophy of the skin, striae (which are permanent), steroid rosacea/dermatitis, erythema, candidiasis, exacerbation of condylomata accuminata, epidermal cysts, and, rarely, systemic absorption. Although iatrogenic Cushing syndrome can develop with less than 50 g per week of topical clobetasol, far less than 1 g per week is used on the vulva. Systemic absorption has been reported from mucosal application as well, but this is generally not a clinical problem except in infants overtreated under diaper occlusion. This again emphasizes the importance of demonstrating the proper technique of application and the amount of topical ointment to be applied, which is typically far smaller than a pea. In most cases, 30 g of clobetasol propionate ointment should last longer than 6 months. In addition, all patients using potent or ultrapotent steroids on the vulva should be followed closely and examined at least monthly. If there are any concerns or adverse events, hypothalamus-pituitary-adrenal (HPA) axis testing can be performed.
Ointments are the preferred vehicle in the vulvovaginal area as creams and gels tend to sting and burn and have more preservatives in them. Anecdotally, it has been the authors’ experience that the Temovate brand (Dermovate in Canada) seems better tolerated on the vulva than the clobetasol propionate generic ointment; however, this has not been reported or published elsewhere.
Many studies have shown that once-a-day dosing of topical corticosteroids is adequate for most dermatologic diseases. Pharmokinetic studies have shown measurable plasma levels of clobetasol propionate 48 hours after a single application of ointment. Twice-daily dosing could be considered in resistant disease, however, because studies of severe resistant psoriasis show slight superiority of multiple daily applications compared with once-daily applications.
Once a patient’s condition has stabilized, the frequency of application can be decreased, or the potency of the steroid can be decreased. Many vulvovaginal diseases require chronic maintenance therapy. One option is to decrease the frequency to every other day and then, if the remission is sustained, continue to decrease the frequency. If patients’ disease returns at any point, they are titrated back up to the dose or frequency that was effective. Some diseases, such as lichen sclerosus, are not curable, and patients who have that disease must remain on minimal dosing for ongoing control. It has been the authors’ experience that ultrapotent steroids 3 times a week on the vulva for chronic maintenance therapy have minimal risk of side effects. Sometimes using plain petrolatum on the days steroid is not applied is helpful because of the emollient effect, and it also keeps the routine of applying topicals daily. It is often harder for patients to remember to apply medication 2 or 3 times a week rather than daily application.
Intravaginal corticosteroid therapy
Intravaginal topical corticosteroids are used for treatment of lichen planus or desquamative inflammatory vaginitis. There are no commercially available intravaginal corticosteroids available, but hydrocortisone acetate 25-mg rectal suppositories are used off label. Other options include compounding a 500-mg hydrocortisone suppository or using topical corticosteroid ointment with an applicator. These are typically used once daily before bed, and titrated down in frequency or potency as soon as possible. The absorption of topicals is greater in the vagina than on the vulva, but little is known about the optimal frequency or potency to limit systemic absorption. Patients must be monitored frequently for side effects and the signs and symptoms of Cushing disease, and physicians must have a low threshold for HPA testing. It is reasonable to consider HPA testing in patients who use potent intravaginal corticosteroids (clobetasol or hydrocortisone 500-mg suppositories) more than 3 times a week.
Intralesional corticosteroid therapy
Intralesional corticosteroids are especially helpful for thick plaques (eg, lichenification), which are not penetrated well by topical therapies; stubborn areas that are not responding to topicals; areas with deep inflammation (eg, hidradenitis suppurativa); patients with poorly controlled pruritus; or patients with questionable compliance. Depending on the problem, up to two 1-mL injections of triamcinolone acetonide (10 mg/mL) can be used, ideally with a 30-gauge needle. Generally the 10-mg/mL dosing is used if the desired effect is thinning of the lesion. Sometimes only 0.1 mL is needed, for example, in the case of a small but thickened scar. When the anti-inflammatory effect is more desired, as is the case of cysts, the triamcinolone can be diluted further to 3.3 mg/mL using injectable saline. If repeat injections are needed, these are generally done at 6-week intervals. The main side effects of intralesional corticosteroids can include atrophy and hypopigmentation.
Systemic corticosteroid therapy
Systemic corticosteroids are usually reserved for severe cases, for example, severe erosive lichen planus, and are used to get the condition under control so that patients can then tolerate topical agents. Often short courses, usually 2 to 4 weeks, are used using 40 to 60 mg per day of oral prednisone. There is no need to taper if the treatment is less than 2 weeks in duration. Topical corticosteroids should be started before the oral prednisone is stopped to prevent flaring during the transition time. An alternative to oral prednisone is intramuscular triamcinolone acetonide (60–80 mg). The effect of this lasts approximately 1 month. The side effects of systemic steroids make it an unacceptable treatment for long-term therapy of vulvovaginal conditions.
Topical Calcineurin Inhibitors
Pimecrolimus and tacrolimus are immunomodulators that block the release of inflammatory cytokines from T lymphocytes in the skin while promoting cutaneous innate host defenses. They are approved as second-line therapies for atopic dermatitis and are used off label for many other dermatologic disorders, including vulvovaginal disease. Tacrolimus comes as an ointment and pimecrolimus as a cream. They are approximately equivalent to a midpotency topical corticosteroid. The main advantage of topical calcineurin inhibitors is they do not have the side effects topical corticosteroids do, such as atrophy of the skin and HPA axis suppression. Several small studies suggest benefit in many vulvovaginal disorders; however, their use is limited on the vulva by their common side effect of stinging and burning, which is more pronounced on eroded skin. Keeping the tube of medication cool in the refrigerator sometimes helps alleviate some of the stinging, but it cannot be tolerated by many patients. In addition, there are concerns about calcineurin inhibitors increasing the risk of progression to cancer. Vulvovaginal diseases (eg, lichen sclerosus and erosive lichen planus) have a small but real risk of progression to squamous cell carcinoma (SCC). There is concern that calcineurin inhibitors may inhibit immunocompetent cells, which normally survey the skin and prevent premalignant cells from developing into cancers. There are case reports where there was likely a causal relationship between the use of topical tacrolimus and the development of SCC on the gentials.
Currently, topical pimecrolimus and tacrolimus are considered second-line agents for the treatment of many steroid-responsive vulvovaginal dermatoses when topical corticosteroids cause side effects or the area is steroid resistant. Patients should not use these agents if they have a compromised immune system or an active skin infection.
Antifungal Therapy
Topical antifungal therapy
Women with vulvovaginal diseases commonly experience vulvovaginal candidiasis as a complication of their treatment. Corticosteroids, estrogen, and antibiotics all predispose patients to vulvovaginal candidiasis.
Patients with chronic or unresponsive candidiasis should undergo culture, because management failure is more often due to misdiagnosis than medication failure. Before starting any antifungal treatment for vulvovaginal Candida infection, it is imperative to obtain a culture. Many patients with vulvar symptoms have been labeled as having vulvovaginal candidiasis for months and sometimes years, in the absence of documented infection. Often there is another diagnosis other than candidiasis to explain the vulvar symptoms. In addition, it is important to determine the species and sensitivities, because some species may be resistant to first-line treatments. In one study, more than 20% of Candida isolates were resistant to fluconazole.
Most topical antifungal preparations are available only as creams, which are inherently irritating to the vagina and vulva. When possible, oral treatment can be prescribed to avoid exposing the vulva to more irritants. An alternative to systemic treatment is nystatin ointment or vaginal tablets, the most soothing topical anticandidal agents. It can be used nightly for 2 weeks.
Candida albicans is the most frequently isolated yeast from the vagina and tends to be sensitive to all azoles and nystatin (a polyene). In recent studies, Candida glabrata is the second most common isolate from vaginal cultures and is known to have resistance to the entire class of azoles and polyene antifungal agents. Generally, nonalbicans Candida infections are asymptomatic, but when treatment is desired, intravaginal boric acid tablets (600 mg) can be compounded and used daily for 2 to 3 weeks. Patients should be advised to use this vaginally only, because it is toxic if ingested orally. Another treatment for nonalbicans Candida is flucytosine topically. It might be more efficacious than boric acid, but there are no randomized studies to show this. It is more expensive than boric acid. Flucytosine is compounded to form ointment in tube applicators. A 5-g dose is used nightly for 14 days.
Systemic antifungal therapy
Systemic treatment or prophylaxis for yeast infection is often preferred over topical treatment because it eliminates the potential for further irritation to the vulva. Prophylaxis to prevent vulvovaginal candidiasis is often needed when treating patients with vulvar disease. Antiyeast prophylaxis should be considered when an antibiotic is prescribed in patients with chronic vulvovaginal issues. In addition, antifungal medications can be prescribed for the first few weeks when estrogen replacement is instituted. There is a highly significant relationship between the use of estrogen and the occurrence of vulvovaginal candidaisis. Once the vagina is fully estrogenized, Candida becomes less of a problem. For antibiotic and corticosteroid therapy, the prophylaxis should be considered for the duration of the treatment, but this needs to be individualized for each patient.
If there is evidence of vaginal Candida infection, a single dose of oral fluconazole (150 mg) can be given. In more complicated or resistant cases, another option for treatment is fluconazole given in 3 doses of 150 mg at 72-hour intervals. If there is significant vulvar involvement, more doses may be needed, or a topical may be used concurrently on the vulva. In recurrent vulvovaginal candidiasis, defined as four or more symptomatic attacks in a 12-month period, fluconazole (150 mg) can be given weekly to maintain remission after the first 3 doses have been given to induce disease remission. One drawback of using oral fluconazole is its many interactions with other drugs. Fluconazole is the only medication with Food and Drug Administration approval for vulvovaginal candidiasis. Itraconazole and, less so, terbinafine, are useful orally as well.
Antibiotic Therapy
In dermatology, antibiotics are often used for their anti-inflammatory effects as well as their antimicrobial action.
Topical antibiotics
The most common topical antimicrobial agents used in vulvovaginal diseases are clindamycin (2% cream) and metronidazole gel. Both are useful to treat group B streptococcus (GBS), keeping in mind that these bacteria can be a normal colonizer of the vagina and only occasionally cause infections. A 5-g dose is inserted into the vagina nightly for 7 days. An alternative is clindamycin ovules (100 g for 3 days). Clindamycin is also used to treat desquamative inflammatory vaginitis, and in this case it is used more for its anti-inflammatory action. The treatment is more chronic in nature, and often several weeks are needed before improvement is noted. Close follow-up is warranted because relapse is not uncommon. Clostridrium difficile infection is a rare side effect.
In addition to its use in GBS, metronidazole (0.75% gel) is used to treat bacterial vaginosis at a dosage of 5 g daily (one applicator is inserted into the vagina nightly for 5 days).
In general, it is best for patients to avoid over-the-counter topical antibiotics, in particular those containing neomycin. Many of these antibiotics are known potent sensitizers and the risk of allergic contact dermatitis is high.
Systemic antibiotics
Systemic antimicrobials are preferred to topical therapy in patients with chronic vulvovaginal symptoms to limit irritants and allergens affecting the vulvovaginal area. Topical antibiotics tend to come as gels or creams, which are inherently more irritating to the vulva and vagina. The risk of allergic contact dermatitis can make the use of oral metronidazole and oral clindamycin more appealing. Metronidazole (500 mg twice daily for 7 days) or clindamycin (300 mg twice daily for 7 days) can be used for bacterial vaginosis. Metronidazole is also the treatment for trichomoniasis. Bacterial vaginitis should be cultured and the antibiotic chosen by sensitivities. GBS can often be treated with penicillin V potassium, amoxicillin, ampicillin, or clindamycin but often relapses immediately.
Estrogen Therapy
Estrogen deficiency can make any vulvovaginal problem worse and sometimes can be the primary cause of the disorder (discussed previously). There are several different methods of estrogen delivery, including topical intravaginal cream, intravaginal tablets, estrogen-releasing vaginal ring, and oral replacement therapy. It has been the author’s experience that estradiol-17β cream (Estrace) is better tolerated than conjugated equine estrogen cream (Premarin), although the latter is less expensive. Both are dosed 3 times a week intravaginally at night. Vaginal tablets (Vagifem) are sometimes more acceptable to patients who find the creams irritating and messy, and treatment with 17β-estradiol vaginal tablets has been shown equivalent to conjugated equine estrogen vaginal cream for atrophic vaginitis. Other trials have found that women seemed to favor the estradiol-releasing ring (Estring), followed by the vaginal tablets, and then the cream. Choosing a method of delivery that patients find acceptable may increase compliance and improve treatment outcomes. None of these methods resulted in appreciable systemic estradiol levels. Systemic estrogen is another option; however, some women may find they need topical estrogen as well.
There is a significant relationship between the use of estrogen and Candida infection. Oral fluconazole (150 mg weekly) for the first few 5 weeks of estrogen therapy or, alternatively, nystatin ointment or an azole cream coadministered in the same applicator as the estrogen helps ameliorate this risk.
Psychoactive Medications
Vulvovaginal dieases are often complicated by pain and itching, and often this results in poor sleep as well. Central nervous system medications that have been shown to help these symptoms, when caused by neuropathic pain or itching, include tricyclic antidepressants (eg, amitriptyline), neuroleptics (eg, gabapentin), analgesics for neuropathy (eg, pregabalin), and selective norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine. These medications can help with the sleep disorder, pain, and depressive symptoms that often accompany vulvovaginal disease. Tricyclic antidepressants, such as amitriptyline or doxepin, are often dosed at night because they are sedating and benefit patients who are up at night with pain of itch. They create a deeper level of sleep than antihistamines do, and, therefore, people are less likely to scratch in their sleep. They also help with depression, but if patients are depressed, counseling should be prescribed as well. Gabapentin and pregabalin are also indicated for neuropathic pain but are less sedating. SNRIs (eg, venlafaxime) can help with pain and depression as well. The medication choice should be based on patients’ predominant symptoms, whether or not pain, itch, sleep disturbance, depression, or a combination of these. All of these medications are best started at very low doses and titrated up slowly to effect.
Other Techniques/Tips
Pelvic floor muscle physiotherapy has been shown to help when vulvodynia is present as a primary or secondary condition. Physiotherapy has the added bonus of one-on-one time with a professional familiar with vulvovaginal problems. This provides an outlet for patients to discuss their problem outside of counseling and somewhat normalizes their situation so they do not feel as isolated because of their disease.
Constipation can complicate vulvovaginal symptoms. It can be helpful to ask if constipation is an issue, and if it is, address dietary changes, such as increasing fluids and fiber, and recommend and prescribe stool softeners when needed.
Smoking is a risk factor for cancer and has been shown a factor in vulvar intraepithelial neoplasia, also known as SCC in situ or Bowen disease. In one study, women who smoked had more extensive disease and were also more likely to have persistent disease after treatment. Patients who smoke and have vulvar disease should, therefore, be counseled to stop, because this may put them at higher risk for their disease to be complicated by cancer.
Recalcitrant Problems
If vulvovaginal patients fail to improve, several factors should be considered. The first is adherence. Studies of dermatology patients using topical therapies have shown that adherence is poor at best in most patients. It is easy to see how nonadherence could occur: for example, patients may be alarmed by warnings on the package of steroids or calcineurin inhibitors and not want to use them. Another barrier to adherence could be elderly or obese patients who may have difficulty with application of topical medications.
The second factor to be considered in recalcitrant vulvovaginal disease is the possibility of allergic contact dermatitis. This can be acute, subacute, chronic, or irritant contact dermatitis from the prescribed treatment or something a patient is using at home.
If a vulvovaginal problem is resistant to treatment, the general measures (discussed previously) should be addressed, such as educating patients about the nature of their disease, addressing psychosexual issues, stopping irritants, using appropriate vehicles for medications, anticipating and treating for iatrogenic disease, prescribing estrogen when appropriate, and having a rescue plan for acute symptoms. Associated symptoms, such as constipation, should be addressed. Patients do not improve unless these general measures are attended to simultaneously.
Lastly, always consider an incorrect initial diagnosis or that a new disease may have developed if there is lack of response to therapy. Have a low threshold for rebiopsy to rule out Paget disease or malignant transformation. Think about possible systemic disease that may have developed that may need systemic control, such as diabetes mellitus or Crohn disease, because local factors are less effective.
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