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Dr. Andrew Rynne

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Is Capsaicin cream effective in treating Vulvar Vestibulitis Syndrome?

Answered by
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Dr. Madhuri N Bagde

OBGYN

Practicing since :2001

Answered : 1390 Questions

Question
Dear Doctor,

There are some studies that suggest treatment of Vulvar Vestibulitis Syndrome using Capsaicin cream. What is your take on this treatment? Do you have any experience with patients using this method?

Regards
Mon, 4 Aug 2014 in Pregnancy
 
 
Answered by Dr. Madhuri N Bagde 4 days later
Brief Answer:
Detailed answer below.

Detailed Answer:
Dear XXXXXX, Thanks a lot for the query and I am sorry for a delayed response.

I understand that you want information regarding capsaicin cream for vulval pain syndrome.

Capsaicin is a drug that has ingredients present in chillies. The exact mechanism by which it acts is still not known to us. However it does help in reducing pain by numbing the nerves carrying pain. This is present in most of the over the counter analgesic creams. We also prescribe capsaicin containing creams to provide pain relief. It is usually present in combination with other pain killers like diclofenac.

From my observation, after application it produces a warmth in the applied area due to maybe dilatation of the blood vessels there. Also a mild stinging sensation occurs due to its counter irritant properties. These help in masking the pain to some extent. So it does help. But the effects are mostly short lasting and the pain tends to recur after variable interval. The warmth also has caused some patients to get a sort of addiction to it as it produces a feeling of well being at the pain site. But again the effects are short lasting.

So it may be used for short period of time when the pain is severe and it does decrease the intensity of the pain to some extent. Combining with other analgesics helps produce a more lasting effect in some women.

However a word of caution with its use is that it may cause an allergic reaction in some cases or produce excessive redness and burning. So must be used with caution and in small quantities only. Avoid rubbing the area after its application as this leads to burning sensation.

It must not be applied on mucus membrane like inside the vagina or inner surface of labia as may lead to excessive burning sensation.

I hope this helps with the query.

I am again sorry for the delay.

I will not be able to log in regularly for a few more days as I have a few other committments but will try to answer any further queries as soon as possible. So please excuse me for this.

Take care and feel free to ask any further queries.

Dr Madhuri Bagde
Above answer was peer-reviewed by
 
Follow-up: Is Capsaicin cream effective in treating Vulvar Vestibulitis Syndrome? 3 days later
Dear Doctor,

Thank you for the response.

Is there any other treatment you would recommend that has a more long lasting effect? What is the best treatment according to you?

Regards
 
 
Answered by Dr. Madhuri N Bagde 22 hours later
Brief Answer:
Management explained.

Detailed Answer:
Dear XXXXXX,

I would like to explain a few things before I suggest a treatment. There are many reasons for painful vulva. The pain may be due to low hormone levels seen commonly in older women, infections, allergic reactions that may be due to anything ranging from talcum powder to soap or hygiene products, skin conditions affecting the vulva and problems due to nerve abnormalities. Since the causes are different the management differs and hence it is important to know the cause.

Infections can be easily detected by various tests as well as local examination and managed with approporiate antibiotics. Problem is seen in managing older women with low estrogen and also women with nerve issues. In these cases hormone replacement as well as local hormones and lubricants are helpful.

Allergies can be managed by avaoiding the irritant.

Nerve damage and the resultant pain can be managed by drugs acting on the nervous system, local capasaicin or local anesthetic drugs. Sometimes if the pain is very severe the vulvectomy [ surgical removal of the vulva]may be needed.

So it is best to get examined and evaluated as to the cause and then go for treatment.

Hope this helps to clarify things a bit.
I am always here for any further queries.

Take care.
Dr Madhuri
Above answer was peer-reviewed by
 
Follow-up: Is Capsaicin cream effective in treating Vulvar Vestibulitis Syndrome? 2 days later
Dear Doctor,

Thank you for your response.

Let me then give you some more info.

Patient had a vaginal yaest infection a few years ago and was prescribed klotrimazol. It was after this that the burning in the vulva came. During this time, patient was also on contraceptive pills. Patient was advised to get off the pills and start using perfume free products. Nothing really helped. Patient was also advised to apply cortisone locally but without any luck. Estriol cream was also tried. Some 2-3 years later the pain was somewhat relieved but still there. Sitting in certain positions is still painful and using tampon is impossible. Examination by gynecologyst showed that the hymen is sore. No signs of infection. Possibly also vaginism.

Based on the above, what treatment would you recommend?

Regards
 
 
Answered by Dr. Madhuri N Bagde 3 hours later
Brief Answer:
Hi Kalle.

Detailed Answer:
Hello XXXXX and welcome back,

This seems to be a chronic case. Please do not use capasaicin in this case as the hymen is sore. If the cream acidentally touches the hymen there will be severe burning sensation.

As of now, please do not douch or use sitz bath. All of these actually suck up water from the cells if the osmolality of the fluids is not correct and so the sore XXXXXXX increases.

I suggest use a soothing ointment containig benzalkonium and choline salicylate. If this is not available just do not apply anything, leave the area undisturbed as far as possible and do not scratch or touch it as more irritation will lead to more swelling.

I would advise the use of oral drugs like etodolac and serratiopeptidase to help ease the inflammation to be taken with milk [ as they may cause acidity]. Also oral anti allergic preparations like cetrizine for a few days can be taken after prescription to help relieve the inflammation.

A topical ointment called zytee [ choline salicylate 9% and benzalkonium chloride 0.02%] can be applied locally after testing a small bit on the oral mucosa for sensitivity. This will help decrease the soreness and also the pain by local effect.

Avoid sexual intercourse for a few days.

Once the soreness subsides then she may simply use a lubricant jelly like glycerine to prevent exposure of that area to irritants.

If the above regimen fails then a surgical option may be sought after discussion with her gynec. However since there is soreness, I feel that the pain will subside with the above treatment. If she responds the treatment may be extended for a few more days until complete relief is achieved.

Hope this helps her. Let me know if any more help is needed.

Take care.
Dr Madhuri
Above answer was peer-reviewed by
 
Follow-up: Is Capsaicin cream effective in treating Vulvar Vestibulitis Syndrome? 3 days later
Dear Doctor,

Thank you for your answer.

I think I may have been a bit unclear regarding the current condition. The gynecologyst at that time (2 years ago) indicated that the hymen was sore, but today the patient is not feeling soreness, the correct characteristics of the pain today would be a burning feeling in the lower half part of the hymen, not soreness. So in some ways the condition has improved but its not improving any longer.

Based on the additional information, could you please let me know how patient can be helped?

Regards
 
 
Answered by Dr. Madhuri N Bagde 25 minutes later
Brief Answer:
Answer below.

Detailed Answer:
Hello and welcome back,

I was under the impression that a recent gynec examination had indicated soreness. If it was 2 years ago please get her re evaluated as it may simply be an infection or recurrence of infection.

In a few previous queries there was some mention about problems with the pelvic muscles and also about chances of nerve compression.

I had already suggested evaluation by a physical therapist as well as a neurlogist to rule out neurological origin to the pain.

She did have an examination by a physical therapist and some muscle spasm as well as tightness was detected and relaxation exercises were prescribed.

I also suggest that you see a neurologist to rule out nerve pain as she constantly has a burning sensation. Drugs like SSRI and SNRI are used in such pain and have shown good results.

As of now, step one is to get a re examination by a gynecologist if it has not been done in the recent past. If it is not conclusive, it may be nerve pain and so physiotherapy as well as a neurological evaluation may be needed.

Hope this helps.

Dr Madhuri
Above answer was peer-reviewed by
 
Follow-up: Is Capsaicin cream effective in treating Vulvar Vestibulitis Syndrome? 2 days later
Dear Doctor,

Thank you for your response.

Patient saw a gynecologyst yesterday but as usual the Doctor could not propose any usuful help or treatment that has not already been tried so right now we are desperate to get your help.

There is no sign of infection nor any neurological damage. SSRI was tried 2 years ago and did not help at all.

Muscle relaxation excercise was previously (2years ago) proposed since there was a sign of vaginism, but I believe that this treatment does not have to do anything with the burning feeling in the hymen, which is the main problem. Do you agree?

Operation is not an option.

Also, do you still think Capsaicin cream is a bad idea?

Best regards
 
 
Answered by Dr. Madhuri N Bagde 5 hours later
Brief Answer:
capsaicin can be tried

Detailed Answer:
Hello and welcome back,

I understand the issue well now.

Since surgery is not an option and there is no inflammation so use of local drugs is the only possible solution.

Capsaicin cream can be used but it must not touch the mucosa as it causes a burning sensation in most [ not all ] cases when it touches a mucosal surface like vagina. There is no harm in applying it on the vulva.

If the burning is severe and hindering with work then lignocaine ointment in small amounts on hymen will help to relieve the burning. Placentrex or zytee ointment can also be tried and can be applied directly on the mucosa to help decrease the burning. They are very effective.

Nerve involvement may be an issue if the muscles are tight and may compress a nerve. So combine the above with relaxation exercises. SSRI must be used for atleast 2-3 months to show benefit as they take time to become effective and dose adjustment is also needed. So please check how long they had been taken.

As of now the possible solutions are capsaicin on vulva, lignocaine on hymen and a bit in vagina and zytee or placentrex alternating with lignocaine along with exercises.

Hope this answers the query.
Take care and I am always here to help.

Dr Madhuri
Above answer was peer-reviewed by
 
Follow-up: Is Capsaicin cream effective in treating Vulvar Vestibulitis Syndrome? 45 hours later
Dear Doctor,

Thank you for your valuable answer.

-How often should capsaicin be applied?
-Should lignocaine be applied before capsaicin, and in that case, how long before?
-For how long should capsaicin be used?
-Is the use of capsaicin for treatment and to get rid of the pain, or is it only for temporary pain relief?

Regards
 
 
Answered by Dr. Madhuri N Bagde 2 hours later
Brief Answer:
detailed answer below.

Detailed Answer:
Hello XXXXXX,

Both capasaicin and lignocaine will provide temporary relief from the pain. They do not offer a long term solution in most cases. However as they are used locally they can be used for a longer term than oral drugs. Also sometimes they help to tide over the soreness phase and women get relief from their symptoms even after discontinuing the drugs.

An initial course of 3-4 months can be tried for capsaicin and 1-2 months for lignocaine and try to taper lignocaine as soon as possible. Use lignocaine when the pain is severe and unbearable in small amounts [ pea sized or less]. Please do not apply excessive amounts of lignocaine in an attempt to get relief as it has adverse effects on the heart in high doses. Small doses are very safe.

Capasaicin can be used twice daily every 12 hours on the vulva and I recommend a sensitivity test on the leg before using both the drugs.

Lignocaine can be used on the hymen and will provide a short term relief when the pain is severe. Do not use it immediately after capsaicin. An interval of 4-6 hours between the two is enough.

As surgery is not an option, please try the above regimen. Also prevent repeated contact with water or soaps as they cause soreness. Washing twice daily with a Ph balanced soap or wipe is enough until the burning subsides.

If the pain persists or recurs after therapy then neurological evaluation can be done.

I hope this provides some relief.

Dr Madhuri
Above answer was peer-reviewed by
 
Follow-up: Is Capsaicin cream effective in treating Vulvar Vestibulitis Syndrome? 32 hours later
Dear Doctor,

Thank you for your answer.

We are a bit confused regarding the use of lignocaine and capsaicin. Patient is experiencing a burning feeling when touching the hymen and this is the only part that is burning and hurting. Here you recommend the use of lignocaine, but you recommend the use of capsaicin on the vulva. Could you explain why capsaicin is to be applied on the vulva and not for example on the hymen? Could this really help the burning in the hymen?

Best regards
 
 
Answered by Dr. Madhuri N Bagde 7 hours later
Brief Answer:
It will help

Detailed Answer:
Hello and welcome,

Capasaicin is made from extracts from chiilies. It acts mainly as a counter irritant and also stimulates the nerves in such a manner so that pain perception is decreased. It also decreases the production of a substance responsible for pain. Most of the capsaicin creams [ as they come from chillies] produce an irritant sensation or a mild burning sensation after application on skin for a short while. If applied on mucosal surfaces like mouth, vagina this stinging may increase and even burning may result.

So most preparations are not recommended for use on mucosa. They are to be applied on skin. Application on the skin will counteract the nerves or mask nervous signals from the hymen and so interfere with their signals and provide relief.
I would also recommend a very low strength cream first like a 0.035% or 0.075% initially and see if she is able to tolerate it. Please do a sensitivity test with tiny amount on the leg area and wash the hands immediately after application. I would also recommend to read the leaflet suppiled with the cream before use.

Lignocaine ointment can be used on mucosal surfaces safely so she may use it in small amounts when the burning is severe.

Hope this clears the picture.

I am always here.

Dr Madhuri
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