Unprovoked vestibular burning in late estrogen-deprived menopause: A case series

OBJECTIVE: This study aimed to document cases of severe menopausal vulvar burning localized to the vestibule. MATERIALS AND METHODS: Seven postmenopausal women presented to a vulvar clinic between 2007 and 2011 complaining of debilitating constant vulvar burning pain. They were treated according to the vulvar findings. Statistical tools were descriptive. RESULTS: The women's ages ranged from 56 to 79 years (mean age = 67 years). Pain had begun 1 to 4 years before presentation (mean = 1.8 years) and was vestibular. Five had contraindications to estrogen supplements. Only 1 patient was using estrogen; the mean number of years from menopause to onset of burning was16 years (range = 4-27 years). Three patients developed pain during or after aromatase inhibitor therapy for breast cancer. Pelvic floor myalgia was present in 3 patients. Of the patients, 3 improved on systemic estrogen, 3 improved using topical vestibular estrogen therapy, and 1 was managed with reassurance alone. Vestibulodynia regressed in those using estrogen supplementation. One patient noted resolution after localized removal of vestibular mucosa. CONCLUSIONS: Severe unprovoked vestibulodynia can present as unprovoked generalized pain in late menopause, and topical lidocaine can aid the diagnosis. Constant pain can arise after years of only provoked pain or in association with further lowering of estrogen from antiestrogen therapy for breast cancer. Therapy to the vestibule can provide relief. Lidocaine and local application of estrogen cream to the vestibule are effective therapies, and physical therapy can be important. With encouragement to avoid estrogen during menopause and with the increasing use of aromatase inhibitors for breast cancer, menopausal unprovoked vestibulodynia may be increasing and can be challenging to diagnose and treat.