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Center for Vulvar Medicine

Over the last decade, Greenville Health System gynecologist Laura Wang, M.D., has drawn on her long-standing interest in vulvar medicine to provide excellent care to a trickle of patients presenting with vulvar problems. But it was not until she received an influx of older patients from a retired colleague that the scale of this medical problem became apparent.

“I gave them a questionnaire that asked about pain during intercourse, and 30 to 40 women said yes,” she recalls, describing a central symptom of the condition.

As is typical, many had failed previous attempts at treatment and had given up hope. Dr. Wang feels this is likely the result of inadequacies in the medical curriculum, combined with patient diffidence.

“Vulvar medicine is rarely taught in most residencies, so gynecologists, internists, and family practitioners have limited exposure to it. Some patients are too embarrassed to discuss their problem with their medical provider. The combination of these issues is likely why the average time to diagnosis is 5-12 years. After diagnosis, many women who have the condition never receive appropriate treatment,” she says.

With a large pool of unserved patients and a staff physician knowledgeable and passionate about this area of gynecology, Greenville Health System felt the time was right to open a Vulvar Clinic. All services for the diagnosis and treatment of vulvar problems are now concentrated in a single convenient location on Halton Road in Greenville.

Pain symptoms
Patients with vulvar problems commonly present with one of two symptoms: pain or itching.

A burning pain may involve the entire vulva (vulvodynia), or is focused on the opening (vestibulodynia). Intercourse may be painful or impossible (dyspareunia). They may be unable to wear pants, ride a bicycle, or sit comfortably without a donut cushion.

“In the case of vulvodynia or vestibulodynia, pain is due to increased or inappropriate firing of neuroreceptors in response to minimal, non-painful stimuli, or, in some cases, in the absence of stimuli,” says Dr. Wang. “These patients are exquisitely sensitive to touch, and being brushed with a Q-tip feels like being burned with a lit matchstick.”

Physical examination often reveals a normal-appearing vulva.

“As a matter of fact, abnormalities such as inflammation and infection effectively rule out the diagnoses of vulvodynia and vestibulodynia,” says Dr. Wang.

She also sees many patients with chronic, severe pruritus, which leads to scratching, increased skin trauma and worse itching.

“Many of these patients suffer from dermatologic conditions that may affect other parts of their body, including lichen sclerosis, lichen simplex chronicus, hidradenitis suppurativa, psoriasis, and eczema. Because it affects the vulva, however, they do not think of it as a dermatologic issue.”

Treatment of pain
Treatment of vulvodynia and vestibuledenia require a multi-pronged approach that includes antidepressants, anticonvulsants, physical therapy, biofeedback, and treatment of pain-related depression.

“These patients do not have depression or seizure disorders, but antidepressants and anticonvulsants can be highly effective in regulating pain signals,” says Dr. Wang.

Treatment of itching
Because vulvar prutitus has multiple etiologies, treatment depends on correct diagnosis.

• Lichen sclerosis. This condition is characterized by white patches that are extremely pruritic and can develop into painful erosions and ulcerations. If left untreated, lichen sclerosis can scar the vulva, narrowing the vaginal opening. Extensive scarring can prevent intercourse, and may close the urethra, causing women to have trouble voiding. Fortunately, if treatment is instituted before anatomic distortion occurs, response is excellent. Close monitoring is recommended, since recurrence is common and these women are at increased risk of developing vulvar carinomai.

• Lichen simplex chronicus. This condition is caused by chronic exposure to irritants, leading to excessive scratching, which further traumatizes and irritates skin. Treatment is focused on eliminating potential irritants and preventing scratching. Patients are instructed to wear gloves to bed, and a sleeping medication may be given to reduce scratching at night. Patients are told to wash the vulva with water only, wear white cotton underwear, use white toilet paper, and to wash clothes with certain laundry detergents without fabric softeners. If patients have an allergy to menstrual pads, a source for organic cotton pads is provided.

• Hidradenitis suppurativa. This condition causes acne-like lesions to grow into the skin, resulting in chronic inflammation. Patient experience various degrees of pain, drainage, and scarring. It is more common in overweight women, African- Americans, and women with family history. Treatment begins with antibiotic wash, hormonal intervention, and weight loss. Advanced disease requires aggressive surgical management.