Is Chronic Vulvar Pain Being Missed, Undertreated in Black and Hispanic Patients?

WASHINGTON — Racial and ethnic disparities persist in the management of vulvodynia, a retrospective cohort study found.

Black and Hispanic patients were more frequently prescribed general pain relievers for chronic vulvar pain while white and non-Hispanic patients were more likely to receive more targeted therapies, reported Mitali Sharma, BS, of the Case Western Reserve University School of Medicine in Cleveland, at the American College of Obstetricians and Gynecologists (ACOG) annual meeting.

“Pain may be managed differently across racial and ethnic groups given historical disparities in healthcare, and [this study] aims to identify how this impacts the treatment of vulvar pain in particular,” Sharma said.

Vulvodynia is chronic pain or discomfort of the vulva lasting for more than 3 months without a clear, identifiable cause. It is generally diagnosed by ruling out other causes of vulvar pain and using a cotton swab to palpate various regions of the pelvis to characterize pain. Sharma noted that vulvodynia has a prolonged diagnostic journey with most women attending many appointments over the course of years before getting a diagnosis.

A 2015 study found that Black women were more likely to describe their vulvodynia as “aching” whereas white women used more classical descriptions like “burning.” This could lead to delayed diagnoses, Sharma said, though the burden of diagnostic accuracy should not be placed on patients.

“Before we even began to run analyses, we noticed that patients who identify as white or non-Hispanic make up the vast majority of those who hold a documented diagnosis code for vulvodynia,” Sharma said. “Rather than true disease prevalence, we wondered whether this might be due to a number of different factors, such as symptom reporting, symptom description, recognition, or treatment.”

For this analysis, Sharma and team searched the TriNetX Clinical Research Database to identify 48,262 instances of the ICD-10 code for vulvodynia. They stratified the results by race and ethnicity — but not age or menopausal status — and compared treatments and outcomes across these cohorts. The majority of patients were white (33,566) and non-Hispanic (32,433) while 3,037 patients were Black and 3,049 were Hispanic.

White patients were more likely to receive vulvar excision procedures and treatment with vaginal estrogens, antidepressants, and benzodiazepines (P<0.0001). Conversely, Black patients were significantly more likely to receive general pain relievers, including nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and aspirin, as well as topical analgesics, muscle relaxants, and hydroxyzine (P<0.0001).

When comparing ethnicities, Hispanic patients were more likely to receive NSAIDs and acetaminophen (P<0.0001). Their non-Hispanic counterparts more often received physical medicine and rehabilitation, aspirin, topical triamcinolone, topical estrogens, antidepressants, and benzodiazepines (P<0.0001).

“While there’s no clear consensus on the optimal management of this condition, treatment options range from conservative vulvar care all the way up to surgical management,” Sharma explained.

Conservative care focuses on reducing irritants, like wearing 100% cotton underwear, and on treating symptoms with cool gel packs, mild soaps, lubrication, and medication. Surgical management could go as far as vestibulectomy to remove some tissue from the vaginal opening.

Pelvic floor physical therapy, cognitive behavioral therapy, and mindfulness-based cognitive therapy are also utilized to assist patients with coping with pain and in addressing the fear-avoidance cycle that can perpetuate pain and sexual dysfunction, Sharma said.

Researchers looked at three relevant procedure codes: psychotherapy, physical medicine and rehabilitation, and excision of the vulva, perineum, and introitus. For prescriptions, they looked at multiple NSAIDS, topical analgesics, gabapentin, local anesthetics, antidepressants, benzodiazepines, botulinum toxin (Botox), skeletal muscle relaxants, neuromuscular blocking agents, topical estradiol, and triamcinolone.

Sharma noted a limitation was the overrepresentation of white and non-Hispanic people and the underrepresentation of people of color in the data.

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