Locating Pain in Breast Cancer Survivors Experiencing Dyspareunia: A Randomized Controlled Trial

Goetsch, Martha F. MD, MPH; Lim, Jeong Y. PhD; Caughey, Aaron B. MD, PhD

doi: 10.1097/AOG.0000000000000283
Contents: Original Research

OBJECTIVE: To locate sites of genital tenderness in breast cancer survivors not using estrogen who experience dyspareunia and to test the hypothesis that tenderness is limited to the vulvar vestibule rather than the vagina and is reversed by topical anesthetic.

METHODS: Postmenopausal survivors of breast cancer with moderate and severe dyspareunia were recruited for an examination including randomization to a double-blind intervention using topical aqueous 4% lidocaine or normal saline for 3 minutes to the areas found to be tender. Comparisons of changes in patients' reported numerical rating scale values were made with the Wilcoxon rank-sum test with significance set at P<.05.

RESULTS: Forty-nine patients aged 37–69 years (mean 55.6±8.6 years) had a median coital pain score of 8 (interquartile range 7–9, scale 0–10). On examination, all women had tenderness in the vulvar vestibule (worst site 4 o'clock median 6, 4–7). In addition, one had significant vaginal mucosal tenderness and two had pelvic floor myalgia. All had vulvovaginal atrophy with 86% having no intravaginal discharge. Aqueous lidocaine 4% reduced the vestibular tenderness of all painful sites. For example, pain at the worst site changed from a median of 5 (4–7) to 0 (0–1) as compared with saline placebo, which changed the worst site score from 6 (4–7) to 4 (3–6) (P<.001). After lidocaine application, speculum placement was nontender in the 47 without either myalgia or vaginal mucosal tenderness.

CONCLUSION: In breast cancer survivors with dyspareunia, exquisite sensitivity was vestibular and reversible with aqueous lidocaine. Vaginal tenderness was rare despite severe atrophy.

CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01539317.

LEVEL OF EVIDENCE: I

In breast cancer survivors with dyspareunia, pain is located in the vulvar vestibule, is rarely in the vagina, and is reversible.

Departments of Obstetrics and Gynecology and Public Health & Preventative Medicine, Oregon Health & Science University, Portland, Oregon.

Corresponding author: Martha F. Goetsch, MD, MPH, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, UHN 50, Portland, OR 97239; e-mail: goetsch@ohsu.edu.

Funded by the Circle of Giving, Center for Women's Health, Oregon Health & Science University.

Presented to the Pacific Coast Obstetric and Gynecologic Society, Walla Walla, Washington, October 4, 2013.

Financial Disclosure The authors did not report any potential conflicts of interest.

© 2014 by The American College of Obstetricians and Gynecologists.