Q&A: Effective, accessible treatments for common vulvovaginal pain
Key takeaways:
- Vulvovaginal pain is common and can have many causes, including hormonal, nerve and muscular factors.
- Treatment can involve hormone therapy, pelvic floor physical therapy, or nerve blocks or medications.
About one in four women experience vulvovaginal pain that persists for 3 to 6 months or more, yet many delay seeking care or struggle to find a physician who can provide effective treatment.
Healio spoke with Sarah T. Cigna, MD, MS, FACOG, IF, assistant professor of obstetrics and gynecology and director of the Sexual Health and Gender Affirmation Center at George Washington University, about the causes of vulvovaginal pain, available treatments, and the importance of increasing education and training in sexual health for residents.
Healio: How common is vulvovaginal pain?
Cigna: Vulvovaginal pain is incredibly common, particularly chronic vulvovaginal pain, which is pain lasting more than 3 to 6 months. It happens in one of four people with vulvas. Those who are going to be more likely affected by this are people with other conditions that may contribute to pain. Patients with endometriosis, with difficult or even uncomplicated childbirths, may have higher risk of vulvovaginal pain than someone without a birth because they may not have had musculoskeletal stress on their body. People involved in competitive sports, particularly sports involving a lot of core strength and holding tension in the core chronically, like dancers, gymnasts and cyclists as well as equestrians, are more likely to experience vulvovaginal pain. A question we ask frequently is, “Were you involved in any of these types of activities, or any other competitive or extreme sports?” It is well understood that these activities can cause pain in your leg, knee or arm due to repetitive use, but what we do not recognize as openly is that it can affect your core, including the pelvis, so the muscles of the pelvic floor often are affected.
Healio: Which women are most likely to deal with the symptoms of vulvovaginal pain?
Cigna: People in menopause are affected more commonly and people of color or of lower socioeconomic status are more likely to be affected, in a large part because symptoms go ignored, unnoticed or they may be in denial that their symptoms are something that can be fixed. Many people are suffering in silence, not realizing that there are things to do to help them, and there’s a lot of shame associated with anything going on with the pelvis or genitals, which leads people to delay initiation of care.
It is common for people to go years without relief and finding a doctor who can help. When someone comes to me and says, “I started having pain 6 months ago,” I often say, “I’m so happy we could get in touch with you so easily.” But it is devastating for people because vulvovaginal pain affects their relationships, ability to engage and stay in a romantic relationship, to have children, to use tampons, have the freedom to go swimming during menses. There are all these pieces that are affected by these conditions and that impacts people’s mental health as well.
Healio: What are the available treatments for vulvovaginal pain?
Cigna: Vulvovaginal pain is a symptom. Vulvodynia and vestibulodynia are words that are commonly thrown around, even in the medical community, as diagnoses. But the truth is, unless you have some etiology attached to that word, it means nothing. The etiology is what is going to help me understand what is going to be the best treatment to help them. For example, a patient experiencing a decrease in estrogen and other hormones in their body due to menopause, or a person who is lactating and producing a lot of prolactin, could have pain in the vulva because of those decreased hormones. We would treat that with hormones.
Another example could be a person who has had a tailbone injury from horseback riding, for example, and have had pain ever since, or perhaps even other symptoms such as burning or irritation on the vulva because of nerve damage. Those issues can be associated with muscles or nerves, and we have to treat them with physical therapy, nerve blocks or nerve medications. Pelvic floor physical therapy is one of the most common approaches we recommend as treatment. The approach depends on the etiology, and you cannot know that unless you know to do the exam and get the history that is going to help lead you to the correct treatment.
Healio: What type of training or education do OB/GYNs receive about diagnosing and treating vulvovaginal pain? What are the consequences of any lack of training?
Cigna: There is a study that looks at 800 OB/GYN residents across the country. The researchers asked residents about sexual health education in their curriculum. The questions were centered on comfort and what the importance of sexual health was. Did they feel that their program leadership valued teaching about sexual health? The answer to that was largely yes. About two-thirds responded that their program felt that it was important. But, when you look at the knowledge questions asked in the second part of the survey about specific sexual health and vulvovaginal disorders, about 50% were able to answer correctly. That shows the failure of OB/GYN training in this field.
OB/GYNs are not the only ones who don’t get enough education on this. This lack of education spans every specialty. But OB/GYNs are the frontline people seeing these patients. Patients come to us for genital concerns, so we have to have knowledge about their anatomy, physiology and the pathophysiology, so that we can help them feel better. If you do not have a trained OB/GYN who has some experience from a mentor or curriculum, the patients will not get treated and then they suffer in pain and they may not have access to other specialists.
I got all my training from outside of my residency. I love my residency and had very good training. But it took a lot of overhauls to improve the training that we were giving to both residents and medical students. Now, we have many lectures, practical and clinical opportunities that do that.
Healio: What are some steps you have taken to help improve education and training in this area?
Cigna: We developed education spanning the whole length of the trainees’ time. For medical students, we spend time in the anatomy lab teaching the clinical correlation of clitoral and vulvar anatomy during anatomy labs. We give a couple of lectures during the preclinical years, and in one of them, I bring a patient with me, and we go through her experience going through menopause and how that affected sexual function. It is a powerful couple of hours that they spend learning about the impact of sexual health on a patient’s quality of life. During the third year, every med student must rotate through OB/GYN, it is a core rotation in clerkship. I take routine medical students in my clinic, as does Anita Mikkilineni, MD, Kathryn Dumas, MD, and Joey Bahng, MD. Mikkilineni is the director of our new 2-week resident curriculum that every third year resident completes. We give lectures to students during clerkship about sexual health, particularly about vulvovaginal disorders. As fourth years, they can do an elective with us for 2 weeks where they spend clinical time working with us. We have a routine built-in rotation for 2 weeks in their third year. Those of us who see patients will bring our patients into the resident clinic when we have overflow from our clinic, and residents get that exposure as first, second, third and fourth years. We are trying to make it so that it is through the whole continuum, because that is what is going to help make them better as clinicians to identify and be able to treat this in the future.
Healio: You launched a fellowship in sexual medicine. Can you walk us through the process of getting that off the ground, and the level of interest/applications?
Cigna: We are the first OB/GYN sexual medicine fellowship in the country. There was one before that took care of people with vulvas, led by Irwin Goldstein, MD, IF, and Sue Goldstein, CCRC, CSE, IF, but that was only for urologists. My dream was to start a fellowship and that involved getting the support of my chair, Nancy Gaba, MD, FACOG, who has been incredibly supportive, the support of my department and of the bigger George Washington University programming. I created objectives, expectations, and collaborated with other specialties, so that my fellow was going to get a well-rounded experience. It was important to me that they get exposure to gender affirmation care, which is important because the gender-diverse community has a very high rate of sexual dysfunction and, particularly, pain. We are trying to start a relationship here that is going to help support those patients as much as possible.
It’s always a little slow with new fellowships because word has to get out that it exists. But we already selected our fellow for next year and we had three applicants from three different universities that were all OB/GYN residents. I foresee this becoming much bigger over time.
Healio: Could you provide some background for the Sexual Health and Gender Affirmation Center? What services does the center provide?
Cigna: The center is sexual health and gender affirmation, but there is a lot of overlap. We have three providers that offer the full spectrum of sexual health. We focus on the biologic causes and collaborate with physical therapists and psychotherapists in the area. Then we have our gender affirmation provider who oversees most of the hormone therapy, gender-affirming hysterectomies and prenatal care for gender-diverse patients.
On the sexual medicine side, we mostly treat pain because that is the most prevalent thing and what the most demand is for, but we also treat arousal, orgasm and desire conditions. We do a lot of vulvar dermatosis and collaborate with our minimally invasive gynecologic surgery team and help treat a lot of patients with endometriosis who have other pain conditions. We take care of pregnant patients and offer consults for people outside of George Washington University who are pregnant, whose providers need help addressing their pain during pregnancy because some medications are safe or not safe, and we have a number of techniques to help patients advocate for ways to go through labor in a way that’s not going to exacerbate pain.
Healio: The center provides an “accessible insurance model.” What does that mean for patients?
Cigna: Sexual medicine as a specialty tends to live in the cash-pay boutique or concierge practice model. For practitioners who are interested in pursuing sexual medicine as part of their full spectrum of care, it can be hard to stay in business and take insurance because insurance companies do not reimburse and sometimes won’t cover it at all. Many sexual medicine diagnosis codes are psychiatry codes. It is a similar reason why many psychiatrists and psychologists cannot take insurance.
Our model is unique, and it means that we have a lot of demand. We have waitlists usually out at least a few months that we are scheduling because patients need care and many of them cannot afford to spend thousands for a visit. We work within insurance as much as we can. Some treatments are obviously not going to be covered by insurance, but at least when they come to see us, it is a copay or consult fee that is within their insurance plan that they have been paying for.
Healio: Is there anything else you’d like to add?
Cigna: The International Society for the Study of Women’s Sexual Health, the International Society for the Study of Vulvovaginal Disease and the International Society for Sexual Medicine are all great organizations. The International Society for the Study of Women’s Sexual Health, especially, which I am on the current education committee, has many educational programs, virtual programs and in-person courses.
There are also several advocacy organizations out there for patients with different genital pelvic pain issues, including one for vulvovaginal concerns called Tight Lipped. It is a great place to send patients for support, community and resources.
For more information:
Sarah T. Cigna, MD, MS, FACOG, IF, can be reached at scigna@mfa.gwu.edu; Instagram: @DrSarahCigna.