Transcript of VPS Podcast 5 - Vulvodynia: a podcast lecture by David Nunns

Slide 21 (26:29) Management of women with vulvodynia: Medical treatments

I’m now going to start focusing on the first of four principles of treatment, the first one being medical treatments. By medical treatments, I mean usually prescription-based drugs or creams which you need to get from your doctor.

Slide 22 (26:46) Treatments – Unprovoked vulvodynia

There are a number of treatments available for women with unprovoked pain that are very effective. As I mentioned, unprovoked vulvodynia is like other chronic pain conditions where there is what we call neuropathic pain or nerve ending-type pain. The first-line treatment of neuropathic pain is tricyclic antidepressant drugs such as amitriptyline and nortriptyline. In fact Nice guidance is that amitriptyline is the drug of choice for neuropathic pain. We use this on a titrating regime, starting at 10 mg at night, increasing by 10 mg every four to five days, or even slower, depending on the patient. An upper dose would be around 75 to 100 mg a day. And just some advice really on amitriptyline and nortriptyline: it’s best taken at night; side-effects usually do settle after 10 to 14 days; the average dose is around 60 mg. So patients have to really be quite encouraged when they start taking these tablets, and warned especially of the side-effects. I find nortriptyline has a slightly better side-effect profile than amitriptyline, and I would use nortriptyline over amitriptyline because of less dry mouth and tiredness.

Second-line drugs as well include gabapentin and Lyrica – these drugs are used for neuropathic pain, and again, they’re used on an increasing dosage regime, a titrated dose. There is evidence, as I say, for tricyclics and gabapentin working in women with neuropathic pain and also vulvodynia, so I think it’s certainly worth trying these drugs as a first-line treatment. They can be combined: if there is an optimal dosage on one but not quite enough pain relief, the drugs can be combined together.

Third-line drugs are drugs such as tramadol and other antidepressant drugs, but these would really be beyond prescription for the average hospital doctor and GP and many patients with severe pain that need third-line treatment probably should be seen by the chronic pain team.

Acupuncture and anaesthetic gels are also there. Acupuncture is a good chronic pain strategy: there is some evidence that this works for vulvodynia, and anaesthetic gels can numb the skin, but one has to beware of irritancy on the skin because gels sometimes contain alcohol, so it can sting.

Generally all these treatments should be tried together at the same time to produce hopefully an overall reduction in pain levels. The evidence from trials today suggest that’s roughly about 30% to 50% reduction in pain levels, with the most benefit coming from the drugs, the tricyclics and gabapentin.

Slide 23 (30:22) Treatments - Vestibulodynia

When it comes to vestibulodynia, this is a problem of touch sensitivity, and patients can have purely sexual pain, or if they’re not sexually active, or even if they are sexually active, they can get a lot of pain just from, for example, tight clothing, and that triggers off the memory of pain and they get a flareup.

Generally the strategies used in the previous slide aren’t used first-line, and I would tend to favour a desensitising of the area. Desensitising literally means making less sensitive the area, usually through physical treatments, and that could be anything from massage with a finger, vaginal trainers such as the Amielle or Femmax, to help relax the pelvic floor muscles, pelvic floor exercises, a very simple soft vibrator just to produce some vibratory sensation in the area of pain. Biofeedback, which is not routinely available in the country, is another option, and we’ve had the most experience from the literature from Dr Glazer’s work in America. They all in essence do the same: they make the vulval area and the pelvic floor area less sensitive, less tight, less painful. Anaesthetic gels I put at the bottom because there may be some benefit from the regular use of 5% lidocaine ointment nightly - rather than using it as and when, use it on a regular basis nightly on a cotton wool ball when passed into the vagina/vulval area. Zolnoun’s work showed that this did actually reduce allodynia when patients were followed up with a nightly use of 5% lignocaine ointment on a cotton wool ball.

Slide 24 (32:30) Management of women with vulvodynia: Sexual therapy

Sexual therapy is incredibly important, because many patients who’ve got vulvodynia are quite phobic about touching the vulval area – there’s avoidance of intercourse, there’s avoidance of any intimacy, sometimes, and this can lead to reduced sex drive and vaginismus, poor lubrication – there’s a real knock-on effect. So, I think there is a great role for a sexual therapist in the management of women with provoked pain. I think a referral is very important at an early stage rather than a later stage. It’s really how we as doctors sell this to patients, and I do tell patients to try and invest a bit of time in seeing the therapist, and it’s really as an adjunct to all the other treatments we can offer patients, such as the drugs, the acupuncture, the anaesthetic gels etc. But sometimes for patients with pain, sexual pain and a number of problems, it’s the sexual pain that becomes the most important issue.

Slide 25 (33:41) Management of women with vulvodynia: Physical treatments

I’m not going to cover physical treatments in this lecture because there is a podcast attached to the website and Helen Forth from the Royal Free Hospital, who’s a physiotherapist, is going to talk about some of the physical treatments for vulval pain. When we talk about physical treatments, we’re really talking about physiotherapy-type interventions to try and make less hypertonic the pelvic floor. A lot of evidence does show that there is dysfunction in the levator muscles in women with vulvodynia: the muscles are tight and they’re poorly functioning and they’re not able to relax or contract like a normal muscle. Again, I think seeing a physiotherapist for this type of treatment is an adjunct to all the other treatments.

Holistic therapy – I think this is really just an acknowledgment that there are non-medical ways of managing chronic pain, and in an ideal world with time in the clinics, one would have a discussion with the patient about lifestyle changes, exercise, any form of stress-relieving strategy the patient wants to do. I think with chronic pain you do get a number of both social and behavioural changes. That might involve putting weight on, drinking too much alcohol, side-effects from the medications; chronic pain can give bad backs, it can give stiffness etc. This is what I mean by ‘holistic management’: just recognising these knock-on effects of chronic pain, and telling the patient to try and fit in some sort of way of addressing the problem.