March 2006 · Vol. 18, No. 3Vulvovaginal disorders: 4 challenging conditions
How to identify and treat candidiasis, contact dermatitis, lichen sclerosus, and vestibulodynia
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Fast Track
The wet mount is only 40% specific for Candida
Teach the patient self-examination, because carcinoma can arise quickly, between annual or semi-annual follow-up visits
Vestibulodynia is the leading cause of dyspareunia in women under 50
As a last resort for vestibulodynia, vestibulectomy with vaginal advancement yields excellent long-term results
Start a tricyclic antidepressant at a dose of 10 mg daily, increasing by 10 mg per week until the total dose is 100–150 mg
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Elizabeth
G.
Stewart,
MDDirector, Vulvovaginal Service, Harvard Vanguard Medical Associates, and Assistant Professor of Obstetrics and Gynecology, Harvard Medical School,
Boston
Dr. Stewart is the author (with Paula Spencer) of the bestselling book,
The V Book: A Doctor's Guide to Complete Vulvovaginal Health,
New York: Bantam Books; 2002
The symptoms are recited every day in gynecologists’ offices around the world: itching, irritation, burning, rawness, pain, dyspareunia. The challenge is tracing these general symptoms to a specific pathology, a task harder than one might expect, because vulvovaginal conditions often represent a complex mix of several problems. Candida and bacterial invasion frequently complicate genital dermatologic conditions. Atrophy and loss of the epithelial barrier worsen the problem. Over-the-counter (OTC) and prescription remedies can lead to contact dermatitis. Vulvodynia may be the ultimate outcome, possibly from central sensitization after chronic inflammation, which in turn can mislead the clinician into thinking appropriate therapy “doesn’t work.” And it is important to remember that any genital complaint has the potential to dampen a woman’s self-esteem and hamper sexual function.
This article covers the fine points of diagnosis and treatment of 4 common vulvovaginal problems:
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