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Vulvodynia Interventions—Systematic Review and Evidence Grading

Andrews, Jeffrey C. MD, FRCSC

Obstetrical & Gynecological Survey: May 2011 - Volume 66 - Issue 5 - p 299-315
doi: 10.1097/OGX.0b013e3182277fb7
CME Program: CME REVIEW ARTICLE 14

Introduction: State of the art guidance exists for management of vulvodynia, but the scientific basis for interventions has not been well described. Although there are many interventional therapies, and their use is increasing, there is also uncertainty or controversy about their efficacy.

Objective: To systematically assess benefits and harms of interventional therapies for vulvodynia and vestibulodynia.

Methods: The following databases were searched, using MeSH terms for studies related to the treatment of vulvodynia or vulva pain/pruritus/dysesthesia/hyperesthesia/hypersensitivity: MEDLINE, PsycINFO, Scopus, Cochrane Library, EBSCO Academic, and Google Scholar. Using Medical Subject Reference sections of relevant original articles, reviews, and evidence-based guidelines were screened manually. Manual searching for indirect evidence supporting interventions was done whenever no direct evidence was found for a treatment described within a review or guideline. Each modality is assessed with a grading system similar to the Grades of Recommendation, Assessment, Development, and Evaluation system. The grading system assesses study quality, effect size, benefits, risks, burdens, and costs.

Results: For improvement of pain and/or function in women with vestibulodynia (provoked localized vulvodynia), there was fair evidence that vestibulectomy was of benefit, but the size of the effect cannot be determined with confidence. There was good evidence of a placebo effect from multiple studies of nonsurgical interventions. There was fair evidence of lack of efficacy for several nonsurgical interventions. There were several interventions for which there were insufficient evidence to reliably evaluate. There was insufficient evidence to judge harms or to judge long-term benefits.

For clinically meaningful improvement of pain in women with generalized unprovoked vulvodynia, there was insufficient evidence for benefit of any intervention. There was fair evidence of a placebo effect in people with neuropathic pain and functional pain syndromes, from multiple studies of interventions. Based on indirect evidences from studies of patients with other pain disorders, interventions may be selected for future research.

Conclusion: There is fair evidence for effectiveness of vestibulectomy for vestibulodynia; however, there is uncertainty about the size of the absolute effect, because of the risk of bias inherent in studies of pain interventions without a placebo control group. Providers and patients looking for evidence-based interventions for generalized unprovoked vulvodynia may need to rely on indirect evidences from studies of neuropathic pain and functional pain syndromes.

Target Audience: Obstetricians & Gynecologists, Family Physicians

Learning Objectives: After completion of this educational activity, the obstetrician/gynecologist should be better able to identify potential causes of vulvar pain to facilitate diagnosis of vulvodynia and vestibulodynia, distinguish between the symptoms of localized, provoked vulvodynia and generalized unprovoked vulvodynia to select the most appropriate therapies, evaluate the efficacy of surgical and nonsurgical interventions for the treatment of generalized unprovoked and localized, provoked vulvodynia. In addition, assess the benefits and risks of interventional therapies for vulvodynia and vestibulodynia to improve patient care.

Associate Professor, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN; and Vanderbilt Center for Evidence-Based Medicine, Vanderbilt Institute for Global Health, Nashville, TN

Chief Editor's Note: This article is part of a series of continuing education activities in this Journal through which a total of 36 AMA/PRA Category 1 Credits™ can be earned in 2011. Instructions for how CME credits can be earned appear on the last page of the Table of Contents.

The author, faculty, and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interest in, any commercial organizations pertaining to this educational activity.

Dr. Andrews has disclosed that the U.S. Food and Drug Administration has not approved the use of botulinum toxin, Interferon, Cromolyn, Nifedipine, Montelukast, TENS, Nitroglycerin, Photodynamic therapy, and Magnetic field therapy for the treatment of vestibulodynia as discussed in this article. Please consult the product's labeling for approved information.

The author is solely responsible for the content of this article and the decision to submit for publication. No statement in this article should be construed as an official position of the Vanderbilt Evidence Practice Center, the International Society for the Study of Vulvovaginal Disease, nor the GRADE Working Group.

Correspondence requests to: Jeff Andrews, MD, 719 Thompson Lane, Suite 27166, Nashville, TN 37204–3195. E-mail: jeff.andrews@vanderbilt.edu.

© 2011 Lippincott Williams & Wilkins, Inc.