What is cyclic vulvovaginitis?
Cyclic vulvovaginitis refers to recurrent burning and itching sensation that occurs at the same stage of every menstrual cycle. The pain specifically worsens just before or during the menstrual bleeding, or may settle during bleeding.
Cyclic vulvovaginitis occurs in women of all ages that are still menstruating.
What are the symptoms of cyclic vulvovaginitis?
- Between cyclical flare-ups the patient may have no symptoms
- Intense burning, irritation, stinging and itching just before or during menstrual bleeding
- Pain can be aggravated by sexual activity and is usually worse the day after intercourse
Cyclic vulvovaginitis can lead to localised or generalised vulvodynia.
What causes cyclic vulvovaginitis?
Cyclic vulvovaginitis is due to recurrent thrush (candida infection). Vaginal smears and cultures should be performed to confirm this. If a culture taken during a symptomatic phase comes back negative, a swab and a scraping during the asymptomatic phase should be taken and cultured.
The laboratory should report the specific strain of candida and its drug sensitivities so that the most appropriate treatment may be selected.
When candida is not cultured, symptoms may be due to dermatitis associated with oestrogen hypersensitivity, which is thought to be due to the higher levels of circulating oestrogen present premenstrually. It is treated by progesterone.
Management of cyclic vulvovaginitis
The main goal of treatment is to remove the cause.
When candida is responsible, topical and oral antifungal agents are used to treat the flare-ups. The oral agents ketoconazole, itraconazole and fluconazole may also be prescribed to prevent further candidal infection, taken intermittently (there are various regimes). Boric acid intravaginal capsules or pessaries may also be prescribed.
If candida is not cultured, all antifungal agents should be discontinued. To reduce contact with irritants, it may be helpful to use pads instead of tampons during menstruation, and to take baking soda sitz baths. Non-soap cleanser should be used for washing.
Irritation due to dermatitis may settle with hydrocortisone cream; it is not usually helpful or desirable to use more potent topical steroids.
Some patients find the tricyclic antidepressant drug amitriptyline helpful.