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Vulvodynia And Acupuncture

France Guevin, BS, Marc Steben, MD, Yves Lepage, PhD, Bernard Lambert, MD

Original article from http://www.medicalacupuncture.org/aama_marf/journal/vol17_1/article3.html

ABSTRACT
Background
 Vulvodynia, characterized by burning sensation, pain, and pruritus, is often treated with antidepressants. Recent studies indicate that acupuncture may be an effective modality.
Objective To evaluate the short-term effect of acupuncture on vulvodynia.
Design, Setting, and Patients A convenience sample of 13 patients in a private clinic setting.
Intervention Acupuncture at 3 main points for all patients: BL 22, SP 6, and LV 5, alternatively on the left and right meridians, in 4 weekly
treatments.
Main Outcome Measure Pain measured on a 10-point visual analog scale (VAS) before and at the end of treatment, and 3 months later (at 4 months).
Results Significant differences (at P<.001) were observed between pretreatment, and 1 and 4 months later, from a VAS mean of 8.69 to 4.38 and 2.31, respectively.
Conclusions Acupuncture appears to be a possible alternative to antidepressant treatment for vulvodynia. A longer surveillance period is
needed to verify our results.
KEY WORDS
Vulvodynia, Acupuncture, Vulvar Dysesthesia, Vulvar Pain, Visual Analog Scale (VAS)

INTRODUCTION
The prevalence of vulvodynia, or generalized vulvar dysesthesia, is largely unknown in the general population.1 It was described by Tovell and Young in 19782 as an undetermined disorder in 26 patients (2.6%) in a series of 877 consecutive cases. The diagnosis was founded on an eliminatory basis for skin lesions. Patients were distressed by a burning sensation, pain, and pruritus, and the term “pudendagra” was used. The concept of vulvodynia or chronic vulvar discomfort was accepted in 1984.McKay4 differentiated pruritic symptoms, as associated with skin changes, thus confirming vulvodynia as an exclusion syndrome associated to a disorder of unmyelinated C fibers. Tricyclic antidepressants amitriptyline and desipramine are typically first-line therapies5 but recently, new avenues have been evoked in 2 pilot studies on acupuncture for the simplicity of use and rapid clinical response.6,7

Danielsson et al,6 using a visual analog scale (VAS), noted significant changes (P=.01) for negative quality of life at 3 months following treatment: from a score of 7.2 to 3.2 in a series of 14 women. Pain at coitus was included in the sample of vulvar vestibulitis. Powell and Wojnarowska7 reported in 1999 a clinical response in 12 patients: 2 of the cases were stratified as cured, 3 cases with partial improvement, and 4 slightly improved.

In order to verify the possible action of acupuncture on vulvodynia, we reviewed 13 cases of generalized vulvar dysesthesia, without any coital pain or sexual interference.

METHODS
Thirteen patients with general vulvar dysesthesia filled out the Stanford pain visual questionnaire (VAS, 1-10) in an office setting with us.8 Verbal consent was obtained from all patients. No double-blind intervention or controls were used; this pilot study was strictly an evaluation of acupuncture effectiveness on vulvodynia patients. Patients were seen by their physician before and after acupuncture; they were informed about the technique and mechanisms on all spheres of their body, nervous system, Qi/xue, body, and mind. Our inquiry included patient age, duration of disease, and pain score before acupuncture, at 1 month, at the end of 4 weekly treatments, and at 4 months, or 3 months after the end of the treatment. All patients were screened by us and screening included a negative Q-Tip test, wet smears, vaginal cultures, and a negative clinical vulvar examination. An acupuncturist performed all the treatments. Dermatological lesions such as eczema, psoriasis, lichen simplex sclerosis and atrophicus, and planus were excluded. Cyclic yeast vaginitis, human papillomavirus, vulvar intraepithelial neoplasia, and localized dysesthesia (vestibulodynia) were also excluded. Patients did not receive antidepressive or antiepileptic medication at the acupuncture treatment or for 4 months thereafter.

Acupuncture is defined as an insertion of a needle on precise points of the body.9 The rationale is based on Traditional Chinese Medicine (TCM), covering Yin-Yang, Five Elements, Baguang, Meridians theories, and reflexology. According to the age of the patient and the duration of the problem, we referred to Liver (Shu Jueyin) and Bladder (Shu Taiyang) meridians (young persons, few months to a year of discomfort). Also, the Chong and Tae Mo (Curious Meridians) were considered. If symptoms were present for longer than a year, the diagnosis of Liver and Kidney Yin deficiency was considered, with apparent Fire or false Fire. In reference to the nervous system, neuralgia appeared stronger at the T2-T5 levels and lighter on L1-L5, including sacral holes painful pressure points. Literature sources are the confluence of French, Chinese, and American studies.9
Stainless steel needles from 2-6 cm and 0.25 mm diameter (#32), and 6 cm and 0.25 mm diameter (#32) were used (Suzhou Shenlong Medical Apparatus Co Ltd, China). They were individually packed in an aluminum and plastic plate of thin needles, then sterilized and discarded after a single use.

Needles were placed according to the chosen locations and the person’s size, at a depth of 2-10 mm, perpendicularly or longitudinally, with different angles. Needles remained in place for 20-30 minutes in a comfortable position. We use needles without any manual or electric stimulation. Treatment was repeated weekly for 4 sessions. (Patients may indicate a pinch when skin is pierced. A feeling of numbness may be experienced near the site of puncture but it disappears with the removal of the needle, with some variations to the patient’s pain threshold.) Three main points were used for all patients: BL 22, SP 6, and LV 5, alternatively on the left and right meridians (Figure 1). No Qi response or T-witch response was used . Other interventions were: moxibustion below the navel segment level, according to the season, age, and general condition of the patient, and recommendation to avoid cold at all levels of food, clothing, and space. This study was undertaken in a private clinic setting.

A single-factor analysis of variance with repeated measures followed by a contrast analysis using paired t test with Bonferroni correction was used to study the pain level before the treatment, after 1 month, and after 4 months. The association between the ages of the patients, the duration of pain, and the pain level was studied with Pearson correlation.

RESULTS
Patients’ mean (SD) age was 47.5 (15.3) years (range, 23-70 years) (Table 1). Mean symptom duration was 38.2 (18.6) months in 10 completed questionnaires. Mean pain score levels varied from 8.69 (1.75) in the pretreatment period to 4.38 (2.93) at 1 month to 2.31(2.66) at 4 months. These mean levels were significantly different (F=37.49, P<.001). Significant mean differences were observed between pretreatment and at 1 month (P<.001), and pretreatment and the end of the survey at 4 months (P<.001), and at 1 and 4 months (P=.02). One patient did not achieve any improvement, and another had a partial response (pain score reduced from 9 to 5). There were no treatment complications.

 

Table 1. Patient Information and Pain Outcomes

Pain on Visual Analog Scale (1-10)

Patient
No.

Age,
y

Duration,
mo

Before
Treatment

At
1 mo

At
4 mo

1

36

60

10

7

1

2

25

36

8

2

2

3

61

48

10

3

1

4

50

24

7

3

1

5

62

20

10

10

10

6

67

41

4

2

3

7

23

9

9

9

3

8

39

9

7

5

9

43

72

10

5

1

10

58

10

1

1

11

45

36

10

3

1

12

70

8

2

1

13

39

36

8

3

0

Mean

47.5

38.2

8.69

4.38

2.31

(SD)

(15.3)

(18.62)

(2.93)

(1.75)

(2.66)

Median
(range)

45
(23-70)

36
(9-72)

9

3

1

 

There wasn’t any significant linear relationship observed between age and duration (r=0.108, P=.77), age and pain levels at pretreatment (r=–0.230, P=.45), age and pain levels at 1 month (r=–0.327, P=.28) age and pain levels at 4 months (r=0.147, P=.63), duration and pain levels at pretreatment (r=0.195, P=.59), duration and pain levels at 1 month (r=–0.301, P=.40), and duration and pain levels at 4 months (r=-0.450, P=.19). The difference between the pain levels at 4 months and pretreatment was also not linearly related to age (r=0.259, P=.39) and duration (r=–0.502, P=.14).

Figure 1. BL 22 is located in the lumbar region and SP 6 and LV are on the antero-internal and mid-lower side of the leg

DISCUSSION
We are unaware of any controlled trials of acupuncture treatment for vulvodynia.10 A controlled trial comparing acupuncture with amitriptyline would be challenging, especially with medium and long-term follow-up. Neuropathic pain mechanisms in vulvodynia remain unclear.11Recently, quantitative sensory testing showed increased vulvar pain presence and peripheral body regions12 with the evocation of a possible central control mechanism. Reed et al13emphasized minimal differences between general vulvar dysesthesia and vestibulodynia, with no significant differences between both groups. They could be the variant of the same pathophysiological mechanism.

Sexual activities appeared similar between vulvodynic patients and controls,14 although frequency of intercourse or orgasm was less frequent in the affected group. Our study could be extended to vestibulodynia without the aid of physiotherapy or sexual therapy. A longer period of evaluation of up to 12 months is deemed optimal with inclusion of amitriptyline as control. However, our study raises hopes in the short-term management of a challenging and often undetected syndrome.

CONCLUSIONS
Acupuncture may be a possible alternative to antidepressant treatment for vulvodynia. A longer surveillance period is needed to verify our results.

ACKNOWLEDGEMENT
Many thanks to Bruno St-Pierre for Figure 1.

REFERENCES

  1. Harlow BL, Wisc LA, Stewart EG. Prevalence and predictors of chronic lower genital tract discomfort. Am J Obstet Gynecol. 2001;185:545-550.
  2. Tovell HMM, Young AW. Classification of vulvar diseases. Clin Obstet Gynecol. 1978;21:955-961
  3. Burning vulva syndrome: report of the ISSVD Task Force. J Reprod Med. 1984;29:457.
  4. McKay M. Vulvodynia versus pruritus vulvae. Clin Obstet Gynecol. 1985; 28:123-133.
  5. McKay M. Dysesthetic (“Essential”) vulvodynia treatment with amitriptyline. J Reprod Med. 1993;38:9-13.
  6. Danielsson I, Sjöberg I, Östman C. Acupuncture for the treatment of vulvar vestibulitis: a pilot study. Acta Obstet Gynecol Scand. 2001;80:437-441.
  7. Powell J, Wojnarowska F. Acupuncture for vulvodynia. J R Soc Med. 1999; 92:579-581.
  8. Stanford Patient Education Research Center Web site. URL: http://patienteducation.stanford.edu/research/painseverity.html. Accessibility verified June 25, 2005.
  9. Guevin F, Bossy J, Yasui H. Nosologie traditionnelle chinoise et acupuncture. Paris, France: Masson; 1990.
  10. White AR. A review of controlled trials of acupuncture for women’s reproductive health care. J Fam Plann Reprod Health Care. 2003;29(4):233-236.
  11. Wesselmann U, Brunett AL, Heinberg LJ. The urogenital and rectal pain syndromes. Pain. 1997;73(3):269-294.
  12. Gisecke J, Reed BD, Haefner HK, Giesecke T, Clauw, DJ, Gracely RH. Quantitative sensory testing in vulvodynia patients and increased peripheral pressure pain sensitivity. Obstet Gynecol. 2004;104(1):126-133.
  13. Reed B, Gorenflo DW, Haefner HK. Generalized vulvar dysesthesia vs. vestibulodynia: are they distinct diagnoses? J Reprod Med. 2003;48(11):858-864.
  14. Reed B, Advincula AP, Fonde KR, Gorenflo DW, Haefner HK. Sexual activities and attitudes of women with vulvar dysesthesia. J Obstet Gynecol. 2003;102(2):325-331.

AUTHORS’ INFORMATION
Ms France Guevin is an Acupuncturist in Montreal.
France Guevin, BS, d’Ac, MOAQ
415 Blvd Saint-Joseph East
Montreal QC H2J 1J6
Canada
E-mail: f.guevin@bellnet.ca

Dr Marc Steben is a Physician at the Vulvar Diseases Clinic at the Notre Dame Hospital Chum Montreal.
Marc Steben, MD
Vulvar diseases clinic, Hôspital Notre-Dame CHUM Montreal
1560 Sherbrooke E.
Montreal QC H2L 4M1
Canada
Fax: 514-528-2452 • E-mail: marc.steben@sympatico.ca

Yves Lepage, PhD, is a Professor of Mathematics at the University of Montreal.
Yves Lepage, PhD
Department of Mathematics and Statistics
C.P. 6128, Succursale Centreville University of Montreal
Montreal QC H3C 3J7
Canada
Fax: 514-343-5700 • E-mail: yves.lepage@umontreal.ca

Dr Bernard Lambert is an Obstetrician-Gynecologist, and Associate Professor of Obstetrics and Gynecology at the University of Montreal.
Bernard Lambert, MD, FRCSC, FACOG*
Dept of Gynecology, Hôtel-Dieu CHUM, University of Montreal
3840 St-Urbain
Montreal QC H2W 1T8
Canada
Phone: 514-890-8000, #12685 • Fax: 514-412-7213
E-mail: bernardlambert@vif.com

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Recently, I treated the third patient with Vulvodynia with acupuncture. The result is very encouraging.

Ms. D.  a middle age Caucasus woman came to see me because she has been frustrated with various treatments for her IC (Interstitial cystitis), she heard I had treated a IC patient very successfully with acupuncture. She had urinary tract bacteria infection, which was recovered after the extensive antibiotic treatments, however, after that, she still has urinary frequency and strong burning pain when urination. She has been diagnosed as Interstitial cystitis, and then secondary developed Vulvodynia and pelvic bottom dysfunction.

When Ms.D. started to see me, she told me her physical therapist had treated her for several months. She had many trigger points and knots around the tail bone, anus and both sides of vulva(esp. right), both  inner sides of thighs.

After six sessions’ acupuncture, included in local A’shi / trigger point treatments and adjusting liver, spleen, kidney meridians, patient’s pain has been improved 60%, most of trigger points and knots at both thigh and around tail bone disappeared. The urinary frequency still there, but the burning pain decreased. Patient is very happy and still under our treatment, twice a week.

Notes on 08/20/2012: patient’s overall health condition has been improved, the thighs’ pain no longer exist. The pain around tail-bone, anus, and vaginal only 5-10% left. Most of days seem no a lot of pain. The uncomfortable in bladder area, and urine urgency better, but there has not been improved much. This means: her IC issue didn’t get big improvement, but the vulvodynia and leg pain, pain around anus close to clinically cured.

Here is another article from online, for your information.

Vulvodynia and Acupuncture Treatments

By Maryann Child, Acupuncture Physician
www.coralspringsacupuncture.com 

http://www.vulvodyniasupport.com/acupuncture.html

Vulvodynia is a condition, which few in the medical profession have yet to resolve or even understand. Little research exists and little is known about its origins or how best to treat it. What does seem apparent is that for those women who do have it, it is a constant daily dis-ease. Characteristics of Vulvodynia may vary from woman to the next, what is very certain is that there is usually pain and possible burning of the vulva. The level of pain can change from mild to severe. The etiology behind the condition may vary from one woman to the next, so differential diagnosis is essential for individual patient care. This differential diagnosis is what sets Chinese Medicine aside from Western Medical approach. Two women with the same diagnosis may have completely different disharmonies, so treatment is very unique to the patient’s personal body care.

Acupuncture may be a treatment option for Vulvodynia and Vestibulitis. In the proceedings workshop sponsored by the US Dept of Health in collaboration with the National Institutes of Health, National Institute of Child Health and Human Development, Office of Research on Women’s Health, and the National Office of Rare Diseases on April 14-15, 2003, discussion on the lack of understanding and research on the subject of vulvodynia was addressed. Dr. Elizabeth Stewart, of Harvard University had stated that physical therapy might alleviate the vulvar pain that was referred from the ligaments and joints in the spine and pelvis. One study did confirm that patients that used acupuncture to alleviate the pain showed improvement, and over all quality of life. She also did state that surgery for Vestibulitis was highly controversial because of the lack of clear pathophysiology for vulvar pain. There was great concern over cosmetic results. The overall consensus is that there is a relationship to the pudendal nerve being pinched. In Europe and in pain centers in the US, decompression of the nerve is attempted. Acupuncture is a great alternative to relieve compression of this nerve, and to strengthen overall system health.

Acupuncture is part of an ancient system of healing which incorporates all aspects of the physical and non-physical bodies. It is part of a larger doctrine called Oriental Medicine or Traditional Chinese Medicine. The belief is there is a vital energy that surrounds all living things. We call this “qi” or “prana”. It seems that just about every ancient culture has a name for it. We all recognize it as being real and existing. Even allopathic, western medicine has a name for it “vitality”. It is within this energy that the practitioner works his or her art. Constantly changing and creating harmony where there is disharmony, tonifiying what has been depleted and rectifying what has been in exuberance. The I ching states that all things are constantly changing and that nothing stays the same. This is the beauty of life. Every practitioner counts on this change to occur. After every treatment one anticipates the positive change in the body, hoping to rectify its disharmony. Acupuncture points are small areas of energy that spiral round, each with a different action and indication. These small energy spirals travel a pathway, which for the most part connect to an internal body organ. However there are other pathways that do not connect to any organ, these are referred to as extra ordinary pathways. Then lastly there are smaller pathways that diverge from the larger ones and cross the body. These smaller pathways allow for even the smallest communication between energy and body. The insertion of a needle into an acupuncture point creates communication between the function of the point and the body’s energetics. The formulation of points creates a reaction in the body. The body accepts the information and begins a cycle of change. Cycles of change can vary from one body to the next. Gradual improvement of symptoms is what is expected.

In Traditional Chinese Medicine the body is viewed as having patterns of harmony and disharmony. A practitioner pays very careful attention to what the condition of the body is. One examines closely what the blood is doing, what the “qi” is doing, and what it is not. The practitioner further seeks to determine where the patterns of disharmony exist. Differential diagnosis is attained and treatment to restore the body is begins. Women’s bodies are so diverse, that there are no two bodies alike. With treating Vulvodynia, I have noticed that even though there may be some similarities between patient’s symptoms, their etiologies or rather the root cause of the disorder is very different.

I first became aware of this disharmony about five years ago around the year 2000. I began treating a young patient who complained of sheer fire burning of her external genitalia. I remember feeling a bit puzzled because I had not heard of such a condition, so naturally I began to do some research. Very few of my colleagues had even heard of it. No one in my area had ever treated it. With this I began her treatment protocol.

The response that I have seen from my patients, lead me to believe that VV is completely treatable and I will explain why. I will cite two examples of patients that were treated with Acupuncture. What follows are two brief patient cases that were treated with Acupuncture. I’d like to mention that both patient’s are still receiving treatment, and are still obtaining very favorable results.

Mrs. P is a 35-year-old non-smoking married woman who was recently given a name to her burning and stinging of the vulva. For the past two years she has been treated for urinary tract infections. She has a history of low back pain and migraines. Although her migraines were a big concern for treatment, even more so was the constant irritation of the vulva. Mrs. P had a total of four treatments over the course of one month before significant results were obtained. Currently Mrs. P still comes in for treatment one time a month occasionally twice a month. Mrs. P is still undergoing treatment and is about 60 to 70 percent improved. There are many days where she is free from burning and stinging. She can remain free of discomfort for many weeks at a time.

Miss. M is a 49 year old, non-smoking non-married woman who was diagnosed
with Vulvodynia over the summer of 2004. The pain started in 2003, but was recently given a diagnosis. Her major complaint is pain of the vulva. The pain is drawing in nature. The pain is worse while sitting and better lying down. Mrs. was initially treated with Chinese herbal formulas that were modified specifically for her disharmony. Three weeks into treatment she began to feel improvement of her symptoms. Initially her improvement was minimal, then gradually began to feel better. Currently Mrs. M is treated every 4 to 6 weeks.

I wish to express my very concern for the lack of study on VV and treatment. Many women that I have seen have informed me of different experimental procedures that their Dermatologist, Gynecologist and Neurologists have mentioned. I say experimental because there is no significant data to show proof of success. I have even heard of a new use for botox. Injecting botox was the latest that I have heard this week. This is a desperate attempt in the medical world. Although there is no concrete evidence of a cure, in any medical model, all physicians would like to see a resolution of Vulvodynia. I hope if nothing else to bridge the gap between a woman and her options for treatment.

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