Transcript of VPS Podcast 5 - Vulvodynia: a podcast lecture by David Nunns

This is a transcript of the soundtrack from VPS Podcast 5, which is a slide presentation. You can view the presentation at Podcast 5 - Vulvodynia: a podcast lecture by David Nunns. Timings of each slide are provided in order to aid quick location.

 

Slide 1 (00:00) Introduction

This is a podcast lecture, focusing on vulvodynia. It’s designed mainly for health professionals, but some patients might find it of interest. My name’s David Nunns, and I work in Nottingham in the Gynaecology Department there. I have a vulval clinic once a fortnight and see many women with vulval disease, including vulvodynia.

 

Slide 2 (00:28) Topics to be covered

In this lecture, I wanted to cover the following topics: a little bit about the causes of vulval pain; how to assess a woman with vulvodynia; a bit about management of vulvodynia; covering a little bit about the framework of care for health professionals when it comes to managing patients with vulvodynia; and to finally focus on the work of the Vulval Pain Society.

 

Slide 3 (01:04) Photo of a normal vulva in a postmenopausal woman

This picture shows a normal vulva in a post-menopausal woman. When we talk about the vulva, we talk about the external female genitalia. As you can see, laterally there’s the hair-bearing labia majora, the inner folds of the skin are the labia minora, clitoris, clitoris hood at the top and the perineum between the anus and the vagina. Centrally, in this patient it’s quite obvious to see the vestibule area – this is the area of skin between the lower part of the vagina and the labia minora, and this patient looks quite red. This doesn’t imply any evidence of inflammation, but it’s quite normal because the skin in this area is thinner. The vulva’s richly innervated by nerve endings and it’s the site of a number of primary skin conditions such as lichen sclerosus and lichen planus, but it can also be involved as a skin surface with skin disease elsewhere such as psoriasis and eczema.

Things can get complicated on the vulva because it’s the sexual organs, so there can be a number of knock-on effects on an individual’s sex life, but also the skin comes into contact with a lot of potential irritants, such as over the counter products, topical treatments and even urine. So things can get complicated, and sometimes there can be more than two things going on on the vulva at once, particularly with chronic patients.

 

Slide 4 (02:48) Framework for assessing vulval problems

This is the framework that I use when I see a patient with a difficult vulval problem. As was mentioned before, sometimes patients might have a couple of problems going on at the same time. I divide the framework up into infection, inflammation of the vulva, i.e. skin conditions, neoplastic problems and pain syndrome problems. I think this is helpful because some patients, for example with lichen planus, might need a vulvodynia-type strategy, because many of these patients present with pain. Also, some patients, for example with lichen sclerosus, can have a secondary candidal infection.

 

Slide 5 (03:39) Vulval eczema

I’m not going to talk about infection or the cancerous/precancerous conditions of the vulva because I think those problems are quite easily diagnosed by most doctors, but I just wanted to briefly mention vulval eczema. This is the commonest condition that we would see within a vulval clinic. There are different types of vulval eczema, which is essentially itchy, inflamed skin. Most eczema is fairly obvious after taking a history and examining the patient, but sometimes very subtle eczema can produce very small fissures or splits in the skin that present with a vulval pain problem, and these can easily be missed and overlooked. These are often like very small paper cuts and the vulva needs to be examined closely to detect them.

 

Slide 6 (04:36) Management of vulval eczema

The management of vulval eczema is to essentially look for a potential irritant on the skin: an over the counter product, a topical treatment, or it may be something like urine or even sanitary pads. This should be withdrawn. A moisturiser is essential, and the moisturiser of choice would be something such as Cetraben. This can be used regularly and liberally. Sometimes patients itch with their vulval eczema at night time, and therefore an antihistamine can be helpful, and the treatment for eczema, the mainstay of treatment is going to be a steroid ointment in a reducing regime for around three months. It’s very important to give the patient written information.

 

Slide 7 (05:30) Lichen planus

I wanted to mention lichen planus because this can also present with vulval pain, and these patients often have an overlap with lichen sclerosus, which is another itchy, inflammatory skin condition, but in lichen planus soreness is the main presenting complaint rather than itch. Sometimes there’s a profuse vaginal discharge and the appearance can be very subtle. So it’s very important to look at not only the vulva but also the vagina in all patients who present with pain to not overlook some subtle lichen planus. When this is involving the vagina, it’s called erosive lichen planus.

 

Slide 8 (06:21) Management of lichen planus

When managing lichen planus, the treatment is going to be similar to our treatment for lichen sclerosus: a very potent topical corticosteroid such as Dermovate on a reducing regime. Scarring and narrowing of the vagina can happen, particularly with vaginal involvement, and sometimes for vaginal disease we use intravaginal steroids such as the Predfoam enemas that we use for inflammatory bowel disease. These patients do need long term follow-up, and occasionally systemic treatment under a specialist dermatologist interested in lichen planus.

 

Slide 9 (07:09) Vulval fissures

Vulval fissures are the final skin disease I wanted to mention before moving on to vulvodynia, because these very small fine paper cuts in the skin can be a cause of vulval pain. They can occur as a part of another skin problem such as eczema or even lichen sclerosus, but they can just develop in isolation. The treatment of this problem is difficult, but the general approaches are to treat the underlying skin problem if there is one with the steroids and the emollients mentioned before, massage the area, or any other desensitisation technique is helpful, and surgery, really as a last resort, to cut out the area of the fissure.

 

Slide 10 (08:04) Photo of a vulva with a posterior fourchette fissure

This picture shows a patient who’s got a posterior fourchette fissure. These patients are often quite phobic about touch, and quite apprehensive about intercourse, so it’s important to ask about any psychosexual problems - in particular vaginismus.

 

Slide 11 (08:23) Vulvodynia – an overdiagnosis?

I think it’s important to cover the skin problems before moving on to vulvodynia because sometimes a diagnosis of vulvodynia can be given to a patient and a subtle skin problem can be overlooked. This paper was published in 2008 by Bowen et al from an American clinic where vulval biopsy was carried out on most of the patients attending the clinic who had vulval pain. They found that in 61 per cent of women who were diagnosed by the referring clinician with vulvodynia, there was a clinically relevant skin problem, and this was often eczema, lichen sclerosus or irritant dermatitis. So I think it’s very important before a diagnosis of vulvodynia is given to do a proper assessment of the patient with a full history and examination.

 

Slide 12 (09:21) Vulvodynia

Vulvodynia is the term that we use to describe women who experience vulval pain in the absence of any skin disease or infection. These are not women who’ve got fissuring, or with lichen sclerosus, these are not women who’ve got evidence of vaginal infections. This is essentially a problem of the nerve endings, the nociceptors in the skin. This can produce an unprovoked pain picture, or a provoked pain picture, and in our up to date classification on this slide, we are going to want to try to identify where the patient feels pain. Is it clitoral pain, one-sided pain, or is it localised to the vestibule area? The term we used to use, ‘vestibulitis’, has now been replaced with a term called ‘vestibulodynia’, where there is pain on touch localised to the vestibule. Dynia means ‘burning’, and allodynia is the phenomenon when light touch produces a pain sensation.

 

Slide 13 (10:32) A spectrum of problems

I think there are good and bad things about having a diagnosis of vulvodynia. No doubt for the patient, this is a good thing, because it gives the woman a diagnosis, it allows her to focus perhaps on an appropriate treatment strategy related to the pain, and it would encourage doctors not to prescribe repeat antifungals to any women who’ve got chronic vulval pain. The disadvantages, however, of having a diagnosis of vulvodynia, are that you have a wide spectrum of pain perception in the women that we see, so that we have in one extreme, one woman with constant pain who is unable to move because of a vulval pain, perhaps needing strong pain relief. At the other extreme, you might get a woman who has a variable, even minimal amount of pain on touch in the vestibule, and this might just be during intercourse, but it is something that she can self-manage, and doesn’t require any medical intervention for. In the middle, you’ve got a wide variety of women who are coming towards health professionals wanting treatment for a pain problem. What I think may be happening is that when we see patients as doctors with vulvodynia, we give the diagnosis too soon, and launch into a treatment strategy, without really appreciating what is the individual impact on the woman of the pain. I think this is very important, because it’s that individual experience of pain that’s going to determine what sort of strategy you give to the patient for pain relief.

 

Slide 14 (12:34) Why does it develop?

We’re still not clear as to the cause of vulvodynia. We know that there is no subtle underlying infection in these patients; there is no hidden skin disease on biopsies, and there’s no evidence of a back problem that might be referring pain to the vulva, which is why we don’t do as a matter of routine vulval biopsies and MRI scans on patients who present with pain. What we do see in the histories of these women very regularly is a story of recurrent attacks of vulvovaginal thrush or cystitis-type problems. What we also know on biopsies taken from women with vulvodynia is that there is an increased number of nerve endings in the skin. So, the question is: does a past history of inflammation of the vulva lead to a chronic pain problem as seen in vulvodynia?

 

Slide 15 (13:48) Why does it develop? (continued)

There seems to be evidence now that a history of inflammation through recurrent thrush can lead to the problem of vulvodynia, at least in experimental animal studies. This is a study published in September 2011 and it involved giving mice recurrent attacks of vulvovaginal thrush, and treating them with Diflucan and antifungal. The aim of the experiment was to try and show whether an allodynia response or a vulvodynia-type picture would develop in mice with repeated attacks of thrush. The assessment of the mice to the recurrent attacks of thrush in terms of pain was using small monofilament von Frey fibres, which are used on the vulvas and, as a control, on the hind feet of mice, to try and demonstrate a response to pain by gentle pressure. What they found was that when the mice had two attacks of thrush treated by Diflucan, there was no allodynia response after these two infections subsided, but after a third attack of thrush and treatment, 40 per cent of the mice continued with a sustained allodynia response.

In addition, in another experiment, there was a prolonged attack of thrush without treatment in the mice, which produced a sustained allodynia response in the mice. This suggests that recurrent attacks of thrush despite treatment can produce sustained changes in nerve ending function, i.e. allodynia. When the histology of the vulva was looked at, there was no evidence of inflammation, so this pain that was experienced was not related to inflammation, but they did find that there was an increase in nerve endings, i.e. a proliferation of nerve fibres in the skin.

When they tried to look at the allodynia response in another experiment in the mice by producing a similar reaction to the fungus and assessing the allodynia response, it was very variable and the question really is this: are there genetic reasons amongst the different mice to account for the variable response to allodynia? These are unknown questions, but it certainly seems from this study that inflammation is linked to producing an allodynia-type chronic pain problem that we see in vulvodynia in humans.

 

Slide 16 (17:09) Assessment of women with vulvodynia

I think it’s very important to take a proper pain history from patients because what we really want to do is develop a profile of this individual’s level of pain, and its impact on function. The site of the pain is important. To me, patients who’ve got one-sided vulval pain may have a problem with a low coccyx or a low back problem to account for their pain, for example. Patients who have radiation of the pain from their vulva down their thigh even into the leg and up into the back, that may indicate not so much vulvodynia, but a referred pain typical for a low back problem. What are the aggravating and relieving factors? Well, an example would be pudendal neuralgia, which is a nerve entrapment syndrome where the pudendal nerve is squeezed in its sheath in the pudendal canal when the patient sits. The classical history of the patients with pudendal neuralgia complain of is pain on sitting, but relieved by standing and lying flat, and they also experience the feeling of a lump or a pressure inside the vagina. I think this is important because these patients may need to be seen for a discussion, for example, with a pain management team about a pudendal block, which is one of many treatments that those patients can receive.

Also, the severity of the pain, I think, is very important. This can be just a very subjective assessment of pain, using a simple ‘How bad is your pain?’ question to the patient or it can be objective, using a pain scale and there are a number of questionnaires patients can fill in for this. But this is important, because a patient whose pain may be very minimal may be unaccepting of drugs such as the tricyclics or gabapentin because of their potentially sedative effects, whereas a patient whose pain is very maximal, 8 or 9 out of 10 on a pain scale, would be very keen to take some of these drugs, despite the side effects. So it’s important to gauge the severity of pain to decide on which treatment options the patient wishes to pursue.

I also ask about sexual pain - very important, particularly with patients with provoked pain, because sometimes it becomes the elephant in the room: when the patient is complaining of pain and painful sex, it’s the sexual pain that becomes the most important problem if the patient’s directly asked.

Back problems, coccyx injuries – again, very important because some patients with vulval pain have referred pain to the vulva from back problems or coccygeal injuiries.

 

Slide 17 (20:27) Topics to be covered: Management of women with vulvodynia

If we look at management of women with vulvodynia, then we have some evidence produced guidelines on the management of vulvodynia, from the British Society for the Study of Vulval Disease. Their website is www.bssvd.org, and this website has the guidelines available online. This organisation draws in a number of specialities, from gynaecology, dermatology and GU medicine, and they produce these guidelines to look at all the available high-quality evidence relating to the management of vulvodynia. I’m briefly going to touch on some of those points in the next few slides.

 

Slide 18 (21:22) Management of women with vulvodynia: Psychoeducation

When it comes to management, I’ve divided the categories into medical treatments, sexual therapy, physical treatments and holistic. Medical treatments - we’re referring to treatments that are generally available from doctors: drugs on prescription, for example, injections or surgery. Sexual therapy would be delivered by, perhaps, a psychosexual therapist. Physical treatments - now this is mainly going to focus on desensitising the vulval area, and this would generally be given by a physiotherapist. And then, the holistic treatments - this could be anything from exercise, breathing exercises, relaxation, meditation, yoga etc – anything that suits the patient, but it’s just really an acknowledgement that those are for her to look into. Perhaps the most important initial part of managing vulvodynia is this issue of psychoeducation: explaining to the patient what the condition is.

 

Slide 19 (22:34) Psychoeducation!

Psychoeducation is crucially important. Usually the patients, when they’ve had vulval pain for an average of one to two years, get stuck in a void of not only symptoms but an inadequate treatment plan, an absent diagnosis. In that void they can fill their minds with all sorts of worries about fertility, spreading to other parts of the body, cancer etc. So, generally when we give vulvodynia diagnosis, we explain what the condition is, give them reassurance on all the different issues, such as fertility, infection passing on to partners, and that.

But I don’t think that’s enough: I think there needs to be a discussion with the patient about chronic pain and setting this ground is very important, I think, because it will give the foundation for the patient to then try some of the treatment strategies that will on the face of it not be very attractive, i.e. the antidepressant drugs.

I tend to talk about, with chronic pain, this issue of function within the nerve endings - the nociceptors in the skin, this issue of allodynia, the reprogramming of nerve endings from a touch pressure to a pain sensation; how this passes up through the spinal cord into the pain centre of the brain and returns down to the vulva, where the pain is felt - and to stress the importance of what is essentially the chronic pain process, the chronic pain cycle that inherently involves the pain centre in the brain. I would perhaps draw as an analogy those patients with phantom limb pain to illustrate this. Diabetics who have amputations because of leg ulcers still feel pain in the amputation, and this is because over a period of time, usually more than six months, sometimes three months, a chronic pain process has developed which involves the brain, and therefore it is not just the vulva, it’s the brain as well.

I cover two things: amplification and memory of pain. Amplification of pain is essentially this issue of allodynia, of touch of the vulva leading to an exaggerated sense of pain because of the nerve endings malfunctioning. The strategies we need to help reduce pain involve reducing this level of amplification, reducing the level of touch sensitivity in the vulva, and there are a number of ways we can do that: an example would be drugs. The other issue I talk about is memory of pain. No doubt a lot of patients have chronic background pain with acute flareups, and it’s these acute flareups that patients find incredibly distressing. So, what we try and teach patients is to try and focus on triggers, triggers that will cause a memory of pain to show itself: what are those triggers, how can the patient deal with them? The most obvious thing is sex to cause a trigger of pain. But it’s just acknowledging that ampllfication and memory are important characteristics of chronic pain and those are going to be the strategies to deal with it: reduce amplification and to identify triggers in pain.

 

Slide 20 (26:44) Education is crucial!

I think education is crucial. This is a paper carried out in Canada, where patients with provoked vestibulodynia underwent educational led seminars – group therapy, essentially – run by gynaecologists, and there was basic information on vulval anatomy, physiology, pain management, skin care and sexual function, i.e. psychoeducation. This paper shows a sustained benefit to the patients when these seminars were carried out.

 

Slide 21 (27:27) Management of women with vulvodynia: Medical treatments

I’m now going to start focusing on the first of four principles of treatment, the first one being medical treatments. By medical treatments, I mean usually prescription-based drugs or creams which you need to get from your doctor.

 

Slide 22 (27:48) Treatments – Unprovoked vulvodynia

There are a number of treatments available for women with unprovoked pain that are very effective. As I mentioned, unprovoked vulvodynia is like other chronic pain conditions where there is what we call neuropathic pain or nerve ending-type pain. The first-line treatment of neuropathic pain is tricyclic antidepressant drugs such as amitriptyline and nortriptyline. In fact Nice guidance is that amitriptyline is the drug of choice for neuropathic pain. We use this on a titrating regime, starting at 10 mg at night, increasing by 10 mg every four to five days, or even slower, depending on the patient. An upper dose would be around 75 to 100 mg a day. And just some advice really on amitriptyline and nortriptyline: it’s best taken at night; side-effects usually do settle after 10 to 14 days; the average dose is around 60 mg. So patients have to really be quite encouraged when they start taking these tablets, and warned especially of the side-effects. I find nortriptyline has a slightly better side-effect profile than amitriptyline, and I would use nortriptyline over amitriptyline because of less dry mouth and tiredness.

Second-line drugs as well include gabapentin and Lyrica – these drugs are used for neuropathic pain, and again, they’re used on an increasing dosage regime, a titrated dose. There is evidence, as I say, for tricyclics and gabapentin working in women with neuropathic pain and also vulvodynia, so I think it’s certainly worth trying these drugs as a first-line treatment. They can be combined: if there is an optimal dosage on one but not quite enough pain relief, the drugs can be combined together.

Third-line drugs are drugs such as tramadol and other antidepressant drugs, but these would really be beyond prescription for the average hospital doctor and GP and many patients with severe pain that need third-line treatment probably should be seen by the chronic pain team.

Acupuncture and anaesthetic gels are also there. Acupuncture is a good chronic pain strategy: there is some evidence that this works for vulvodynia, and anaesthetic gels can numb the skin, but one has to beware of irritancy on the skin because gels sometimes contain alcohol, so it can sting.

Generally all these treatments should be tried together at the same time to produce hopefully an overall reduction in pain levels. The evidence from trials today suggest that’s roughly about 30 to 50 per cent reduction in pain levels, with the most benefit coming from the drugs, the tricyclics and gabapentin.

 

Slide 23 (31:28) Treatments - Vestibulodynia

When it comes to vestibulodynia, this is a problem of touch sensitivity, and patients can have purely sexual pain, or if they’re not sexually active, or even if they are sexually active, they can get a lot of pain just from, for example, tight clothing, and that triggers off the memory of pain and they get a flareup.

Generally the strategies used in the previous slide aren’t used first-line, and I would tend to favour a desensitising of the area. Desensitising literally means making less sensitive the area, usually through physical treatments, and that could be anything from massage with a finger, vaginal trainers such as the Amielle or Femmax, to help relax the pelvic floor muscles, pelvic floor exercises, a very simple soft vibrator just to produce some vibratory sensation in the area of pain. Biofeedback, which is not routinely available in the country, is another option, and we’ve had the most experience from the literature from Dr Glazer’s work in America. They all in essence do the same: they make the vulval area and the pelvic floor area less sensitive, less tight, less painful. Anaesthetic gels I put at the bottom because there may be some benefit from the regular use of 5 per cent lidocaine ointment nightly - rather than using it as and when, use it on a regular basis nightly on a cotton wool ball when passed into the vagina/vulval area. Zolnoun’s work showed that this did actually reduce allodynia when patients were followed up with a nightly use of 5 per cent lignocaine ointment on a cotton wool ball.

 

Slide 24 (33:39) Management of women with vulvodynia: Sexual therapy

Sexual therapy is incredibly important, because many patients who’ve got vulvodynia are quite phobic about touching the vulval area – there’s avoidance of intercourse, there’s avoidance of any intimacy, sometimes, and this can lead to reduced sex drive and vaginismus, poor lubrication – there’s a real knock-on effect. So, I think there is a great role for a sexual therapist in the management of women with provoked pain. I think a referral is very important at an early stage rather than a later stage. It’s really how we as doctors sell this to patients, and I do tell patients to try and invest a bit of time in seeing the therapist, and it’s really as an adjunct to all the other treatments we can offer patients, such as the drugs, the acupuncture, the anaesthetic gels etc. But sometimes for patients with pain, sexual pain and a number of problems, it’s the sexual pain that becomes the most important issue.

 

Slide 25 (34:53) Management of women with vulvodynia: Physical treatments

I’m not going to cover physical treatments in this lecture because there is a podcast attached to the website and Helen Forth from the Royal Free Hospital, who’s a physiotherapist, is going to talk about some of the physical treatments for vulval pain. When we talk about physical treatments, we’re really talking about physiotherapy-type interventions to try and make less hypertonic the pelvic floor. A lot of evidence does show that there is dysfunction in the levator muscles in women with vulvodynia: the muscles are tight and they’re poorly functioning and they’re not able to relax or contract like a normal muscle. Again, I think seeing a physiotherapist for this type of treatment is an adjunct to all the other treatments.

Holistic therapy – I think this is really just an acknowledgment that there are non-medical ways of managing chronic pain, and in an ideal world with time in the clinics, one would have a discussion with the patient about lifestyle changes, exercise, any form of stress-relieving strategy the patient wants to do. I think with chronic pain you do get a number of both social and behavioural changes. That might involve putting weight on, drinking too much alcohol, side-effects from the medications; chronic pain can give bad backs, it can give stiffness etc. This is what I mean by ‘holistic management’: just recognising these knock-on effects of chronic pain, and telling the patient to try and fit in some sort of way of addressing the problem.

 

Slide 26 (37:07) Vulvodynia - some tips

In summary, and some tips, I think it’s important to spend some time explaining to the patient a bit about chronic pain, talking about pain memory and amplification. I think treatments should be combined as much as possible. Patients do need encouragement, particularly with some of the drugs. Patients need time to think things through. They need to do their homework and I usually direct them to the VPS website and tell them to self-manage. This issue of self-management for chronic pain is incredibly important, really - we have to move away slightly from this medical model of prescription given to these patients. Individually, I think we have to look at our own skills when it comes to these patients, because vulval pain encompasses so many different facets, from chronic pain, sexual therapy, vulval examination to the whole host of different treatments, and I guess as doctors we have limited numbers of skills, limited numbers of things we can give patients - our toolkit, as it were. We might have to define in our own minds what we want to treat patients with before asking other health professionals to come in. A very clear example would be things like sexual therapy and physiotherapy – those are patients we generally refer on. Something not so clear might be the prescription of drugs for vulval pain. Many doctors are happy giving amitriptyline and nortriptyline, but they’re not happy about giving gabapentin or pregabalin. So it may be that these sorts of patients who are needing more advanced pain management strategies need to be referred onwards.

 

Slide 27 (39:21) Topics to be covered: Framework for care of women with vulvodynia

This leads on to a framework of care for women with vulvodynia. I usually divide these women up into ‘complicated’ and ‘uncomplicated’. An uncomplicated patient is one that responds quite well to basic treatment: when I say ‘basic treatment’, the psychoeducation, the nortriptyline drugs, acupuncture -  somebody who’s responding, managing well, has the information and is quite happy to be left on an open appointment. But sometimes individual patients will need more than that, and this is where I think a team can be very important.

 

Slide 28 (40:09) Management

If we look at a team, then we’re looking at perhaps a lead person, a lead clinician to take charge of the overall package of care for the patient, and that lead is going to be making the diagnosis, starting basic treatment, and then, importantly, referring patients out to physio, psychosexual therapy, even pain management clinics. So patients might have quite a number of hospital visits to make for their treatment, but as long as patients are signed up for that, I think it’s worth it. When patients aren’t really engaged in treatment, they’re not really wanting to come to the hospital for treatment, they’re halfheartedly taking their treatment, they’re not attending clinics, then I think you’ve got probably a patient that’s not going to respond well. Our other colleagues, for example, Pain Management, have access to a whole host of other things in their toolkit: nerve blocks, pain management courses, sometimes access to clinical psychologists that in our speciality we can find difficulty getting. It’s essentially a multidisciplinary team. I’m not arguing for more new clinics to be established, but it might be styles of working within a hospital.

 

Slide 29 (41:43) Topics to be covered: Vulval Pain Society

Just finally, a little bit about the Vulval Pain Society, which we set up in 1996 as an information and support network to women with vulval pain. Most of our work is focused on the website, and also workshops, which are carried out twice a year around the country.

 

Slide 30 (42:09) The doctor-patient relationship

This is my last slide: the doctor-patient relationship. I think as doctors there is a perception that women with vulvodynia can be difficult to deal with: they’re angry, they’re complicated, complex, and they take a lot of time. Well, that’s one point of view. However, if you look at it from the patient’s point of view, and this is feedback I’ve had from patients, patients say not infrequently that they’re not taken seriously, there’s never enough time to discuss their problems, they always see different doctors when they come to the clinic, there’s rarely a cause given or basic information, there’s no instruction on treatment, for example, tricyclics, there never seems to be a plan and there’s no access if there is a problem. An example of that would be a tricyclic given to a patient without instruction and the patient gets dryness, dizziness soon after taking the tablet and then has to stop because of symptoms. There’s no way into the system to see a doctor, and the patient’s left in limbo until the next appointment, which is in three months’ time. It’s quite interesting to get this patient perspective, and on the basis of this, what I try and do is, I myself see the patient the same time she comes; I’ve got a whole array of factsheets; for difficult patients I might make a double slot; I always send the patient a copy of the GP letter; at the top of the letter there is access to the clinic should there be a problem – it’s always better to know there’s a problem rather than see the patient three or six months later and the treatment’s not been tried.

So I hope this lecture has been of help. If you would like more information, then please contact me at the Vulval Pain Society. Thank you for listening.