An Update from The Journal for Nurse Practitioners
Volume 12, Issue 8, September 2016
This article by the Journal for Nurse Practitioners focused on the holistic treatment approach to provoked vulvodynia, highlighting several recent research findings that we’d like to share. According to the International Society for the Study of Vulvovaginal Disease, provoked vulvodynia is pain localized to the vaginal vestibule when provoked (touched) that has been present for at least 3 months and does not have a clear identifiable cause. Provoked vulvodynia (PVD) you may have heard also referred to as vestibulitis or vestibulodynia.
How PVD begins isn’t known, but likely it is a complex combination of factors involving genetics, musculoskeletal and neurologic mechanisms, and psychological factors, including the interplay between chronic stress and pain, leading to a sustained pain response. Research has also shown that low confidence about how to manage and cope with the pain is related to higher pain intensity. Depression and anxiety further complicate PVD. As we are already aware, providers are generally unfamiliar with this disorder. Women see up to 6 providers before being accurately diagnosed and treated.
Current recommendations call for the least invasive treatment options available. This article focused on two treatment options which are noninvasive and comprehensive, yet often only recommended as alternative options: Cognitive Behavioral Therapy (CBT) and Mindfulness. CBT is a multi-session practice that includes relaxation, self-management techniques, and restructuring thoughts and emotions that are maladaptive. While CBT is a change-oriented strategy, mindfulness seeks to create awareness of the body, thoughts, and emotions by simply noticing them rather than judging them.
In one study, CBT was found to be superior to surgical procedures in pain relief with intercourse at a 2 ½ year follow up. And CBT has been shown to be more effective in reducing pain and improving sexual function than topical steroids. CBT was also found to improve patient confidence in being able to manage and cope with the pain, along with significantly reducing depression and pain anxiety. At the 1 year follow up these findings had either been maintained or improved.
Current studies also suggest that women with PVD benefit from the practice of mindfulness. Women were found to have significant improvements in their own confidence to manage and cope with their pain, along with decreases in pain hypersensitivity and feelings of hopelessness. Women who participated in a mindfulness-based CBT program experienced decreased depression, anxiety, and fear. These findings were maintained at the 6 month follow up.
CBT and mindfulness are noninvasive, effective long term, and provide an approach that factors in both mind and body, not just physical pain. Current research would suggest these options be recommended as a first-line treatment instead of an alternative therapy. More evidence-based guidelines are needed for PVD in tandem with increased provider awareness.
In addition, we at paindownthere.com would add that further research is needed in the multidisciplinary approach to treating PVD. We believe highly in “top-down” approaches such as mindfulness but also recognize the need for simultaneous “bottom-up” approaches that take into consideration biological/medical factors that may call for medication, physical therapy, and nutrition intervention as well.