This month, we talk with Dr. Jill Krapf about vulvodynia, one of several sexual pain disorders she treats at The Centers for Vulvovaginal Disorders. Dr. Krapf shares expertise on the history of vulvodynia, the standard of care for treating vulvar pain, and similar conditions that need to be ruled out such as vulvar dermatoses.
Dr. Jill Krapf is a board-certified OB/GYN specializing in female sexual pain disorders at The Centers for Vulvovaginal Disorders in Washington, D.C. She is a Fellow of the International Society for the Study of Women’s Sexual Health (ISSWSH). Dr. Krapf earned her MD from Jefferson Medical College in Philadelphia, Pennsylvania. She completed a residency in Obstetrics and Gynecology at The George Washington University in Washington, D.C. She practiced and taught general Obstetrics and Gynecology in the academic setting at the George Washington University and then at University of Texas San Antonio while running specialty clinics in female sexual health for 8 years prior to dedicating her practice entirely to sexual pain conditions. Dr. Krapf is active in research and has published chapters and peer-reviewed articles on vulvodynia, vulvar dermatoses, and hypoactive sexual desire disorder. She is Associate Editor for the Journal of Sexual Medicine Online Access, as well as for the textbook Female Sexual Pain Disorders: Diagnosis and Treatment, 2nd Edition. SHWI: How did you become interested in vulvovaginal care for women?
Jill Krapf: In my final year of residency training to become an Obstetrician Gynecologist (OB/GYN), I had the good fortune of being assigned to one of Dr. Andrew Goldstein’s vulvar vestibulectomy surgeries. At that time in residency training (over 10 years ago), we had limited exposure to vulvar pain conditions. I was so interested that I spent a day a week with him in his office for almost a year. Vulvar conditions are often not openly discussed and may not be addressed by many physicians. With my additional training in vulvovaginal conditions, I started a clinic for female sexual health as a junior faculty member at my academic institution. It was as if the floodgates opened. I had so many women who felt comfortable coming to me for vulvar conditions and sexual pain. I love being able to provide a true diagnosis, basing the cause of the pain on how the body works. After practicing general OB/GYN for many years with a day a week devoted to sexual pain, I decided to transition my practice to treating women with vulvovaginal conditions full-time. I joined my mentor, Dr. Goldstein, at the Center for Vulvovaginal Disorders (CVVD) in Washington, DC, in the summer of 2019.
SHWI: As a specialist and researched writer on the topic of vulvodynia, tell us about how vulvodynia is diagnosed and treated and how big a problem it is for women at large.
JK: Up to 28% of women ages 18 to 40 years old report a history of chronic vulvar pain (lasting greater than three months). This means as many as 14 million women in the U.S. may experience chronic vulvar pain in their lifetime. However, up to 48% of these women do not seek care. And of those that do seek care, 60% of women saw three or more health care providers. In addition, greater than half of women who sought care did not receive a diagnosis. Vulva is the anatomical term for the external female genitalia. Odyne was the lesser-known Greek goddess of pain. So, the term “vulvodynia” literally translates to “vulvar pain.” The joint ISSVD, ISSWSH, and IPPS guidelines define vulvodynia as “vulvar pain lasting at least 3 months’ duration without a clear identifiable cause, which may have potential associated factors.” Although these “potential associated factors” may not be clearly defined or universally accepted at this time, research in the past 15 years is increasing our understanding and bringing us closer to determining the true causes of vulvodynia. SHWI: Knowing that vulvodynia is defined as chronic vulvar pain without identifiable cause, what is the standard of care and what other things do you do with your patients to help them live with this condition?
JK: The key to evaluating vulvodynia is to determine the specific location and cause(s) of the vulvar pain. In general, causes are related to hormones, muscles, nerves, or inflammation. Through a focused history and physical examination, I can localize the pain and determine the cause of the pain. Treatment is based on the specific cause of the pain. For example, for hypertonic or overactive pelvic floor muscles leading to pain, the standard treatment is pelvic floor physical therapy. For women who have pain with sex due to vaginal atrophy, treatment involves application of a local low-dose hormone topically to the area.
SHWI: How is vulvodynia different from vulvar vestibulitis and does this change the treatment modalities?
JK: “Vulvar vestibulitis” was a term used from the late 1980s until 2003 to describe severe pain of the vulvar vestibule (vaginal entrance) upon touch or attempted vaginal entry, such as pain with insertion during sexual activity. This term was changed because “-itis” implies an inflammatory etiology and this is not often the case. Now, the accepted term for this condition is “provoked vestibulodynia.” Vulvodynia may be generalized to the entire vulva (called generalized vulvodynia), localized to the vestibule (called vestibulodynia) or clitoris (called clitorodynia), or mixed, and may be provoked, spontaneous, or mixed. So, “provoked vestibulodynia” refers to pain localized to the vulvar vestibule that is provoked by contact or insertion. Determining the location of pain helps determine the cause of the pain, and so this often guides a treatment approach.
SHWI: Do you often work with pelvic floor therapists in your treatment plan and how have you seen this be successful?
JK: I work hand-in-hand with pelvic floor physical therapists when the pain is related to the pelvic floor muscles. Pelvic floor physical therapy employs a number of techniques to treat vulvodynia, including education, internal manual therapy, external therapy, biofeedback, desensitization, and home programs. Pelvic floor physical therapy is very effective and recognized as a first-line approach to treating vulvodynia.
SHWI: Many women suffer from a variety of vulvar dermatoses. How does this relate to these other diagnoses, and what kinds of treatment options support a woman’s healing?
JK: Identifying and ruling out vulvar dermatoses is an essential component in the evaluation of vulvodynia. The vulvar dermatosis I see most often is vulvar lichen sclerosus, which is a likely autoimmune condition that affects the genitals and around the anus. Women with a vulvar dermatosis may have vulvar scarring leading to narrowing of the vaginal opening or covering of the clitoris. This may result in painful intercourse or decreased orgasm. Treatment of vulvar dermatoses generally involves application of an ultra-potent topical corticosteroid. However, it is important to see a specialist to determine the appropriate treatment regimen.