Last month I hosted an event, “Ask Susan Anything”.  As part of this event, I asked attendees to write in with their questions for me to address during that call.  One question in particular got me thinking and I decided to take a deeper dive into its answer for this month’s article. 

 

The question I was asked was, “ What is the evidence to support various medical treatments for vulvodynia/vestibulodynia/vaginismus. In particular, is there evidence to support the use of lidocaine, either topically or on a cotton ball overnight, hormonal treatment (testosterone creams), diazepam suppositories, pain, and other medications? Also, what are the indications and success rates for surgical management?”

 

What are Genito pelvic pain/penetration disorders?

 

Genito pelvic pain/penetration disorders, GPPPD, are characterized by

1.  Difficulty with vaginal penetration during intercourse
2. Genito pelvic pain with intercourse or penetration 
3. Fear or anxiety related to genito-pelvic pain or penetration 
4. Tightening of the pelvic floor muscles during vaginal penetration

 

To be classified as GPPD, at least one or more of these symptoms must be present for at least 6 months and cause distress. 

 

Vulvodynia, vestibulodynia, and vaginismus are all classified as genito-pelvic pain/penetration disorders. 

 

As pelvic health therapists, when we work with these patients, we need to take into consideration the psychological impacts as well as the physiological underpinnings of these conditions. 60% of women who report GPPPD say it compromised their abilities to enjoy life. 

 

Once this cycle of pain begins,  fear and anxiety of the pain returning the next attempt at sexual relations with their partner feed back into itself.  Sexual arousal is as much of a mental response as a physical one, perhaps even more. When the cognitive or mental component is impaired with anxieties and fears,  the physical response is impacted as well. 

 

A biopsychosocial approach is a must. 

 

Taking a biopsychosocial approach with patients suffering from GPPPD is a must.  There are too many interrelated components that feed into these disorders.  

 

Relationship factors, cultural and personal beliefs, body image, other health problems, other mental health issues, and stress can all impact sexual health and GPPPDs. Only by diving deeper into other underlying social, emotional, and psychological factors can we really help our patients improve their pain.  

 

As I’ve said before, we can’t just treat the cracks at the top of the pyramid.  We need to find the underlying foundational problems that led to the cracks at the top. Utilizing the SAD CLLIFSS framework is a great way to get at the deeper underlying beliefs and emotional impacts of women suffering from GPPPDs. 

 

Evidence to support treatments of GPPPDs

 

Aside from physical therapy interventions for GPPDS, there are other treatment options out there in the form of creams and ointments, cognitive therapy, and even surgical interventions to treat these conditions. The following will be a review of the current literature on the effectiveness and indications of these treatment options. 

 

Tatiane Fernandes, Lucia Helena Costa-Paiva, Aarão Mendes Pinto-Neto, Efficacy of Vaginally Applied Estrogen, Testosterone, or Polyacrylic Acid on Sexual Function in Postmenopausal Women: A Randomized Controlled Trial, The Journal of Sexual Medicine, Volume 11, Issue 5, May 2014, Pages 1262–1270, https://doi.org/10.1111/jsm.12473

 

• This study found that treatment of postmenopausal women with symptoms of vaginal atrophy responded well with the use of topical polyacrylic acid, testosterone, and estrogen for 12 weeks.
• Polyacrylic acid is a calcium salt that can absorb 60 times its weight in water. It’s perfect for providing lubrication and hydration.
• Over this time, participants reported improved sexual function, including increased desire, lubrication, and reduced pain when compared with a placebo lubricant

 

Labus, Jennifer S., et al. “Reduced concentrations of vaginal metabolites involved in steroid hormone biosynthesis are associated with increased vulvar vestibular pain and vaginal muscle tenderness in provoked vestibulodynia: An exploratory metabolomics study.” Molecular Pain 17 (2021): 17448069211041853.

• This study found that women with provoked vestibulodynia (PVD) have a significant reduction of metabolites that produce steroid hormones in their vaginal fluids that help maintain tissue integrity and nociceptive processing. 
• Reduction in these hormones is related to increased vulvar vestibular pain and vaginal muscle tenderness

A Yee, A Dury, J Ouellet, B Komisaruk, S Goldstein, I Goldstein, (197) Hormone Receptor Distribution and Innervation in Neuroproliferative Vestibulodynia: Immunohistochemical Evidence, The Journal of Sexual Medicine, Volume 20, Issue Supplement_1, May 2023, qdad060.189, https://doi.org/10.1093/jsxmed/qdad060.189

• This study found evidence of androgen and estrogen receptors in the vestibule suggesting that entrance dyspareunia may be best treated at the vestibule 
• They also suggest that combined testosterone and estradiol cream may be more effective than estradiol alone
• They also saw success with DHEA applied intravaginally helping resolve entrance dyspareunia

 

Morin, Mélanie, et al. “Multimodal physical therapy versus topical lidocaine for provoked vestibulodynia: a multicenter, randomized trial.” American journal of obstetrics and gynecology 224.2 (2021): 189-e1.

• These researchers found that multimodal physical therapy was more effective at reducing pain during intercourse than the use of topical lidocaine. 

• Participants receiving physical therapy also reported improved pain quality, sexual function, sexual distress, satisfaction, and participant’s impression of change
• 79% of women in the physical therapy group reported being very much improved compared to 39% in the lidocaine group

 

Bergeron, Sophie, et al. “Cognitive-behavioral couple therapy versus lidocaine for provoked vestibulodynia: A randomized clinical trial.” Journal of Consulting and Clinical Psychology 89.4 (2021): 316.

• This study showed that Cognitive Behavioral Couple Therapy was more effective than lidocaine for vestibulodynia 
• Partners in this study improved their sexual function, sexual distress, and pain catastrophizing from pre to post-treatment and 6-month follow-up with CBCT over lidocaine treatment. 

 

Dahl, Denali K., et al. “A mucoadhesive biodissolvable thin film for localized and rapid delivery of lidocaine for the treatment of vestibulodynia.” International Journal of Pharmaceutics 612 (2022): 121288.

• This study discusses the temporary symptomatic relief of using topical lidocaine and the limitations of its use due to anatomy of the vestibule, poor retention, and dosage limitations due to leakage

• They found that using biodissolvable films saturated with lidocaine were well tolerated and had a better ability to stay localized to deliver the lidocaine to targeted tissues than creams or ointments.

 

Perez-Lopez, Faustino R., et al. “Systematic review and meta-analysis of the effects of treatment modalities for vestibulodynia in women.” The European Journal of Contraception & Reproductive Health Care 24.5 (2019): 337-346.

• This study looked at the use of surgery as an intervention for treating vestibulodynia. 
• Surgery is not indicated for people with generalized vulvar pain disorders and non-provoked vestibulodynia
• Surgery does have a high success rate for neuroproliferative vestibulodynia
• “In 2010, a meta-analysis of 33 published papers showed that 78.5% of women had significant relief, and 88.8% had at least some relief. (6) Additional studies have shown similar encouraging results: 80% pain-free at one year (7), 89% of women reporting comfortable intercourse (5), and 100% of women saying they would not change their choice to have the surgery (5).”

Murina, Filippo, et al. “Vaginal diazepam plus transcutaneous electrical nerve stimulation to treat vestibulodynia: a randomized controlled trial.” European Journal of Obstetrics & Gynecology and Reproductive Biology 228 (2018): 148-153.

 

• This study found that vaginal diazepam plus TENS is useful to improve pain and pelvic floor instability in women with vestibulodynia

 

Stone, Rebecca H., et al. “A systematic review of intravaginal diazepam for the treatment of pelvic floor hypertonic disorder.” The Journal of Clinical Pharmacology 60 (2020): S110-S120.

 

• This article found that TENS and vaginal diazepam provided more subjective relief and doesn’t offer any statistical changes in the outcome measures pre and post-treatment

 

Final thoughts

 

As women’s and pelvic health therapists treating women with GPPPD, we really need to consider the whole person when it comes to treatment approaches. There are many cognitive and behavioral influences to these conditions outside of just the physical realm that need to be considered. 

 

From the literature review, we know that topical estrogen, testosterone, and DHEA are great options for locally treating the pain associated with these conditions. Lidocaine is another great option but has its limitations due to the difficulty in keeping the medication localized to the appropriate tissues. 

 

Surgery is an option that has great success for women suffering from neuroproliferative vestibulodynia, but it is invasive.

 

Utilizing CBCT is another great option for bringing mindfulness and body awareness to the treatment approach.  Combining CBCT with physical therapy treatments is a great way to bring awareness to the body, relaxation to the pelvic floor muscles, and mindfulness to treatment sessions and sexual experiences to help to reduce symptoms of GPPPDs. 

 

As therapists, we need to work closely with MDs in treating these patients, especially if utilizing topical creams, to ensure they are working appropriately and adequately in conjunction with physical therapy interventions.

 

For more information on another complicated case that was discussed during this event, please listen to Tough To Treat episode number 184: Back Pain, Thoracic Outlet, Post Cancer Recovery – Where do I go from here?