Vulvodynia is a complex chronic pain condition that requires an individualized self-directed treatment strategy. It is important to identify and take into account the following factors: contributing biopsychosocial factors, patient’s goals for treatment, patient’s motivation and self-efficacy.
This section will provide you with a way to frame your approach to treatment. Currently there is no standardized management for vulvodynia.
Placebo controlled RCTs are lacking in vulvodynia research. The following recommendations are derived from uncontrolled studies, observational research, case reports and expert opinions. A systematic review demonstrated that comparing clinical trial is difficult due to a lack of standardized treatment outcome measure (Sadownik et al., 2018).
A placebo effect of 35-50% has been reported in vulvodynia research. This may be consistent with a high rate of natural remission. One study reported a 40% improvement in sexual pain over a two-year period without intervention (Davis et al., 2013). Physicians should instill hope in patients that their pain will improve over time.
Davis, S. N, Bergeron, S, Binik, Y. M., & Lambert, B. (2013). Women with provoked vestibulodynia experience clinically significant reductions in pain regardless of treatment: results from a 2-year follow-up study. Journal of Sexual Medicine, 10(12), 30-80.
Sadownik, L., Yong, P., & Smith, K. (2018). Systematic review of treatment outcome measures for vulvodynia. Journal of Lower Genital Tract Disorders, 22, 251–259.
The following recommendations have been introduced on other pages but are reiterated here for importance:
Though pain-free vaginal insertion is one goal, some people may have other goals. It is important to ask the patient about their goals rather than making assumptions. Asking the patient what they would like to work on may lead to different responses than the physician would expect.
Click Tab 2 "Examples of Patient Goals" above for examples.
It is important to revisit the patient goals at each follow-up appointment as their goals may change over time.
The physician’s goal is to empower the patient to develop confidence to take control of their treatment experience. Whatever the patient’s goals are, collaboration is key to promoting treatment adherence.
Once the patient goals have been identified, use the resources below to develop a treatment plan in collaboration with the patient that aligns with their current goals. Initiating a treatment plan for vulvodynia will likely take place over several visits. It is important to manage expectations - treatment for vulvodynia is a long-term process. Unfortunately there is no “quick fix”.
Click the dropdown menus below to learn more about key areas that can be targeted in treatment planning:
- Is your patient experiencing atrophy of the vulvar vestibule causing pain?
- Atrophy of the vulvar vestibule can look like erythema, thinning and decreased elasticity.
- This can be seen in menopausal patients, as well as people who are breastfeeding or on anti-androgenic medications like the combined birth control pill or spironolactone
Menopause and Breastfeeding
- Using topical estrogen vaginally, such as with tablets, creams, or rings, will not treat the vulvar vestibule. The vestibule must be treated separately.
- Patients can apply topical estrogen cream to the vulvar vestibule daily.
Atrophy due to the birth control pill
- This is also called hormonally mediated vestibulodynia
- For any patient experiencing vulvar pain the use of the birth control pill or other anti-androgens should be explored.
- The vulvar vestibule is rich in estrogen and androgen receptors.
- Current hypothesis is that the effect is mediated through a defective or weaker androgen receptor on the vulvar vestibule that do not bind hormones well.
- Affected patients will have atrophy of the vulvar vestibule on physical exam and associated pain with touch (q-tip test)
- We currently don’t know a lot about this condition, such as prevalence, etiology, time course, or best treatment option
- The accepted treatment currently is a compounded estradiol 0.03% / testosterone 0.1% in hypoallergenic base such as glaxal. This should be applied to the vulvar vestibule daily. Resolution of symptoms may take several months.
- Patients may not experience complete resolution without discontinuation of the birth control pill.
Reference: Krapf JM, Goldstein AT. Combined estrogen-progestin oralcontraceptives and female sexuality: an updated review. Sex Med Rev. Published online March 21, 2024.
Some anxiety and distress will be alleviated just by having their symptoms validated and receiving a diagnosis.
By using this Toolkit, your patient will have already learned about the following:
1. Vulvar anatomy and pelvic floor
2. Vulvar skin care
3. Current understanding of etiology of vulvodynia
4. How to identify contributing factors
5. How pain is interpreted and processed
6. How the sexual response cycle is impacted by pain
See the Resources section for more information for patients. Some patients may realize that their knowledge about sexuality is minimal or is heavily influenced by negative attitudes toward sexuality, conservative upbringing, etc.
Pelvic floor physiotherapy is a key essential treatment for vulvodynia.
For many people with vulvodynia, there is increased tension in the pelvic floor muscles as part of a learned, protective guarding response against painful contact at the vaginal opening.
The goal of physiotherapy appointments is to help the patient learn more about their own pelvic floor muscles and answer questions such as:
- What is the pelvic floor?
- What does the pelvic floor do?
- How can I get it to do want I want it to do?
Pelvic floor physiotherapy is a cornerstone of treatment for vulvodynia. As an isolated modality, EMG biofeedback has shown the most promising results. However, many studies have employed multimodal techniques, which include pain education, EMG biofeedback, manual techniques and vaginal inserts. There is consistent evidence that the multimodal approach decreases pain and improve sexual function. Manual therapy has not been studied in isolation.
Morin, M., Carroll M. S., & Bergeron S. (2017). A Systematic Review of the Effectiveness of Physical Therapy Modalities in Women With Provoked Vestibulodynia. Sexual Medicine Review, 5, 295-322.
For many patients the thought of seeing a pelvic floor physiotherapist can be anxiety provoking. This video shows physiotherapist, Laura Werner, explaining what to expect at an appointment in her clinic.
Here is a list of physiotherapists recommended by the B.C. Centre for Vulvar Health:
Given the impact of pain on mental health and vice versa, it can be very helpful to screen for symptoms of depression and anxiety. At the B.C. Centre for Vulvar Health, we often use the GAD-7 to screen for symptoms of anxiety and the PHQ-9 to screen for symptoms of depression. You can find those measures here: 🔗 https://uhs.fsu.edu
Both doctors and patients may be skeptical about the possible utility of psychological skills in helping them to manage vulvodynia. This video shows Dr. Kaitlyn Goldsmith, Registered Psychologist, discussing the role of psychology as a tool in the treatment of vulvodynia.
People who experience vulvar pain will likely benefit from sex therapy. A referral to a sex therapist does not mean that the pain is “in your head”. Sex therapy can be helpful because vulvar pain can cause stress and anxiety, and vice versa. In addition, vulvar pain can cause additional difficulties such as low sexual desire, difficulties with sexual arousal, and relationship distress.
This video shows Dr. Kaitlyn Goldsmith, registered psychologist, discussing what to expect when seeing a sex therapist, psychologist, or counsellor for vulvodynia and other sexual difficulties.
List of BC-based vulvodynia aware sex therapists/psychologists:
★ Community-based resources can be found in the resource section.
★ Specific exercises that can be done in a family physician office can be found in the Going Beyond section tab to the left.
Both cognitive behavioural therapy (CBT) and/or mindfulness therapies are both evidence-based, effective treatment options for vulvodynia. CBT focuses on learning about the relationships between thoughts, emotions, physical sensations, and behaviours and how they can be impacted by pain and also maintain pain. Mindfulness strategies focus on cultivating the mind-body connection and acceptance . These interventions have been shown to decrease pain, decrease sexual distress, and improve anxiety.
Brotto, L. A., Bergeron, S., Zdaniuk, B., & Basson, R. (2020). Mindfulness and Cognitive Behavior Therapy for Provoked Vestibulodynia: Mediators of Treatment Outcome and Long-Term Effects. Journal of Consulting and Clinical Psychology, 88 (1), 48–64.
Dunkley, C. R. & Brotto, L. A. (2016). Psychological Treatments for Provoked Vestibulodynia: Integration of Mindfulness-Based and Cognitive Behavioral Therapies. Journal of Clinical Psychology, 72, 637–650.
1. It is important to acknowledge that communicating about sex, especially when sex is not going well, can be challenging for many people. Nonetheless, conversations with partner(s) about sex are important in the context of vulvodynia. It can be helpful to have the patient bring their partner(s) to appointments with physicians and other care providers who can provide reliable information and introduce these topics during the visits.
2. When beginning treatment, it is important that the patient have a discussion with their partner(s) to remove intercourse from the "sexual menu". Check out our tips for having these conversations in the next dropdown menu.
3. Encourage the patient to watch the videos with their partner/s – “What is Vulvodynia” and "The Impact of Pain on the Sexual Response Cycle", which can be found in the resources section of this website.
5 tips for initiating a discussion about removing vaginal insertion:
1. Schedule a time to talk (choose a time when you have the energy, you have privacy, and are not rushed)
2. Let partner(s) know agenda for discussion
3. Prepare what you want to say ahead of time
4. Discuss/agree on other options for intimacy
5. Set a time for a follow-up discussion
Resource Book: Let Me Count the Ways by Klein and Robbins
Given the potential impact of vulvodynia on sexual and romantic relationships, it is important to consider how partners can be a source of support. Here are a few ways in which partners can be supportive to individuals during treatment vulvodynia:
1. Partners can attend appointments (many healthcare providers such as psychologists, physiotherapists, family doctors, and gynaecologists will welcome having partners attend appointments).
2. Learn about vulvodynia. Education can be very helpful in increasing empathy, understanding, and communication about vulvodynia with your partner.
3. Avoid products and activities that cause pain. Put vaginal insertion on hold. Instead, focus on non-insertion based sexual activity. The book "Guide to Getting it On" by Dr. Paul Joannides includes several suggestions for non-insertion based sexual activity and techniques.
4. Avoid pressuring the individual with vulvodynia to engage in activities that involve vaginal insertion. Pressure can increase stress and anxiety and further entrench the sexual and pain difficulties.
5. Communication is key. Researchers have found important differences between ‘solicitous’, ‘facilitative’ and ‘negative’ partner responses to painful intercourse.
Resource Books:
The Chronic Pain Couple by Karra Eloff
Aches Pain and Love by Kira Lynne
See handout below for more information.
1. If patients are able to have occasional intercourse it is best to time intercourse around ovulation to maximize the chance of getting pregnant. Ovulation usually occurs mid-cycle, for example on day 14 for people with 28 day cycles. They can also choose to use an ovulation test kit to optimally time intercourse.
2. If insertional intercourse is not possible, patients can try self-insemination. This technique involves purchasing a syringe or turkey baster. The partner ejaculates into a sterile container and the semen is drawn up into the syringe/baster. The syringe with semen is inserted into the vagina to facilitate insemination. Ideally, insemination is carried out at the time of ovulation.
3. Another alternative is to seek out the assistance of a Fertility Clinic. These centers offer insemination under sedation or general anesthetic in British Columbia. Referrals are required.
Olive Fertility Centre 🔗oliverfertility.com
Contact Dr Beth Taylor at ✉ BTaylor@olivefertility.com
Pacific Coast Reproductive Medicine 🔗pacificfertility.ca
Contact Amanda at ✉ ACullen@pacificfertility.ca to arrange for a consult to discuss options.
What if they are on neuropathic medications?
Patients with spontaneous/unprovoked vulvodynia may benefit from systemic therapies. Commonly used medications include tricyclic antidepressants and gabapentin.
These medications are FDA risk category C.
If patients cannot discontinue these medications, they should discuss with their obstetrical care provider or maternal fetal medicine physician pre-conception to review risks and benefits.
Ensure your patient sees an obstetrical care provider who is vulvodynia-aware, or open to learning about the physical and psychological impact of vulvodynia on pregnancy, labour, and delivery. There are a few common concerns that patients with vulvodynia have during pregnancy.
1. Transvaginal ultrasounds. For patients with vulvodynia, the transvaginal ultrasound may be painful and traumatic. If a transvaginal ultrasound is required, it is important to have a discussion with the patient to answer questions and discuss options for reducing anxiety during the exam.
2. The Group B Streptococcus test at 35 weeks gestation. This test can be done via self-swab for patients with vulvodynia.
On its own, vulvodynia is not a reason to plan an elective cesarean section. There is no evidence that a vaginal delivery will worsen or improve vulvar pain longterm.
It can be helpful to review and emphasize pain relief options for vaginal delivery, including an early epidural. After an informed discussion, if a patient desires, they should be allowed to plan an elective C-section.
It is essential to remind the patient that they are empowered to make their own decisions throughout labour and delivery (e.g., decisions about pain management, c-section deliver, etc.).
Because patients with vulvodynia are likely particularly sensitive to vulvar and obstetrical pain, it can be helpful for patients with vulvodynia to work with their healthcare team to ensure a trauma-informed approach to labour and delivery.
Lactational amenorrhea can cause vulvovaginal atrophy due to estrogen suppression. During this time, patients may benefit from topical estrogen therapy applied to the vulvar vestibule to decrease provoked pain.
At the BC Centre for Vulvar Health we commonly see patients who have been prescribed prn topical lidocaine and given vaginal inserts by community physicians. For many patients, these strategies are ineffective and frustrating. Read below to find out what we recommend.
Downsides
Consider
PRN lidocaine
for insertional
intercourse
Vaginal Inserts
Other topical therapies, such as amitriptyline, baclofen, gabapentin, have limited data and their use is not recommended.
End of Psychosexual Impact. Handouts, videos and recommended readings for patients can be found in the 🔗 Resources section or visit Going Beyond below.
The Primary Care Toolkit was created by the Vulvodynia Working Group with support from a Partners in Care Grant allocated by the Shared Care Committee, a Joint Collaborative Committee (a partnership between Doctors of BC and the BC government). The Working Group is comprised of family physicians, specialists, physiotherapists, psychologists and patient partners who have expertise and/or lived experience with vulvodynia. The Toolkit has been developed, not as a standard of care, but rather as a guide to assist physicians and other providers who are involved in similar work. The Toolkit is intended for use by healthcare professionals. It is not a substitute for independent clinical judgment. Physicians and other providers using the toolkit should always exercise their own clinical judgment when making medical decisions. If you are not a medical professional then your use of the Toolkit is at your own risk.
Working Group Members: Dr. Melanie Altas, Dr. Marjon Blouw, Jennifer Diep, Dr. Kaitlyn Goldsmith, Hayley Leonovas, Dr. Jennifer Scarth, Dr. Samantha Stasiuk, Dr. Tracy Tresoor, Laura Werner, Dr. Greg Siren, and Dr. Ralitza Spassova.
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