Treatment for both diseases consists of ultrapotent topical steroids to arrest the inflammatory process. Vaginal lichen planus is treated with hydrocortisone suppositories (25 mg at bedtime), with the length of treatment dependent on severity.5 More potent steroids may be necessary.
CAUSE 3Candida
This infection can be extremely difficult to diagnose for a variety of reasons. Patients come in partially treated with over-the-counter antifungals. Many have taken a fluconazole tablet with a long half-life of action. Others have a cyclical candidiasis that is seen only in the luteal phase of the cycle. In these cases, fissuring is often attributed to other causes.
Complicating matters further, a wet mount will be negative in the presence of Candida approximately 50% of the time.6 For these reasons, a culture is essential when there is an index of clinical suspicion and white blood cells are present on the wet mount.
Uncomplicated Candida is treated by topical -azole creams for 3 or 7 days or a single fluconazole 150-mg tablet.
Complicated Candida (that is, more than 3 infections in a year or infection in a pregnant or immune-compromised host) will require longer courses of therapy.7
CAUSE 4Desquamative inflammatory vaginitis
Because the intense inflammation produced by the 2 diseases are similar, some people believe desquamative inflammatory vaginitis is a form of lichen planus8—in fact, it is sometimes called lichenoid vaginitis. However, desquamative inflammatory vaginitis does not scar the vagina, suggesting a different cause. Its profusely irritative discharge—microscopically characterized by sheets of white blood cells—resembles Trichomonas and Candida. Sheets of white blood cells and parabasal cells also resemble Trichomonas, Candida, or severe atrophy.
Discussing dyspareunia: Questions crucial to a thorough exam1
Questions such as “Are you sexually active?” and “Do you have any concerns about your sex life?” can begin a discussion of dyspareunia. Other vital questions include the following:
When did the pain begin? Primary complete dys-pareunia may result from a congenital anomaly or psychosocial issues, but the leading cause is vulvar vestibulitis.2 Acquired dyspareunia has many causes.
When and where does the pain or discomfort occur? Ask the patient to describe its severity, character, duration, location, and time during the menstrual cycle. Superficial dyspareunia usually is due to vestibulitis, inadequate lubrication, or an anatomic abnormality of the introitus.3 Other causes include vulvar atrophy, infection, urethral disorders, and vulvar dermatitis or dermatosis. Pain associated with deep penetration or thrusting may be related to a retroverted uterus or to impaired mobility of the pelvic organs due to scarring from endometriosis or pelvic inflammatory disease.4 Cystitis and interstitial cystitis may cause deep midline dyspareunia, as well as dysuria and other urinary tract symptoms. Deep dyspareunia can also be due to vaginal dryness or atrophy. Consider adnexal or bowel pathology when the pain occurs laterally.
Are there other sexual problems? Pain during intercourse often causes sexual dysfunction, which needs to be addressed before the pain can resolve.
What have you tried to treat or prevent the pain? Successful aids can offer diagnostic clues.
Is there any vaginal discharge, itching, burning, odor, or bleeding? These may be present with vaginitis or a neoplasm. Increased discharge may be due to vestibulitis.
Do you have any gynecologic problems, such as endometriosis, fibroids, or chronic pelvic pain? These conditions have well-known associations with deep dyspareunia. Endometriosis and vulvar vestibulitis occur together.
Have you had vulvovaginal or pelvic infections, such as candidiasis, herpes, gonorrhea, or chlamydia?Recurrent herpes or Candidal infection can be painful and difficult to diagnose; pelvic inflammatory disease can cause scarring and decreased mobility of pelvic organs.
What gynecologic surgery or other procedures have you undergone? Childbirth, radiation or chemotherapy, or incontinence procedures may lead to dyspareunia. Female circumcision is practiced in some cultures and should be considered when appropriate. Scarring and fibrosis can distort anatomy, narrow the vagina/introitus, and decrease tissue mobility, thereby causing pain during thrusting. Chemotherapy and radiation may result in premature ovarian failure (hypoestrogenism). Radiation vulvitis contributes to superficial pain.
What is your natural lubrication like? If it is low, have you tried commercially available lubricants? Natural lubrication may be reduced from hypoestrogenism, certain drugs, or difficulty with arousal.
What do you use for contraception? Latex allergy from condoms or a diaphragm, or an irritant reaction to spermicides may be at the root of the pain. Lowestrogen oral contraceptives or depot medroxyprogesterone acetate contribute to poor lubrication. The intrauterine device is a risk factor for recurrent Candida.
What medical or psychiatric problems are you currently being treated for? Skin disorders such as eczema and lichen planus may be associated with vulvar dermatitis. Inflammatory bowel disease may be related to pelvic adhesions. Interstitial cystitis can cause both dyspareunia and dysuria.
What drugs are you taking? Many medications are associated with dyspareunia due to side effects such as decreased sexual arousal, vaginal lubrication, or serum estrogen levels.
Have you ever been sexually abused or had a traumatic injury involving your genitals? Did you receive counseling or help for this? Many women have worked through their trauma, but unresolved issues can contribute to ongoing pain. Sexual abuse is a risk factor for chronic pelvic pain but is not associated with vestibulitis.5
What do you think may be causing this problem? Often, the patient will provide the answer.
REFERENCES
1. Stewart EG. Approach to the woman with dyspareunia. UpToDate. Available at: www.uptodate.com. In press.
2. Meana M, Binik YM, Khalife S, Cohen DR. Biopsychosocial profile of women with dyspareunia. Obstet Gynecol. 1997;90:583-589.
3. Heim LJ. Evaluation and differential diagnosis of dyspareunia. Am Fam Physician. 2001;63:1535-1544.
4. Steege JF, Ling FW. Dyspareunia: A special type of chronic pelvic pain. Obstet Gynecol Clin North Am. 1993;20:779-793.
5. Edwards L, Mason M, Phillip M, et al. Childhood sexual and physical abuse: incidence in patients with vulvodynia. J Reprod Med. 1997;42:135-139.