Cyclic vulvovaginitis

What is cyclic vulvovaginitis?

Cyclic vulvovaginitis is a descriptive term referring to recurrent burning and itching of the vulva and/or vagina that recurs at the same phase of the menstrual cycle.

The three major causes of cyclic vulvovaginitis are:

• Cyclic vulvovaginal candidiasis [see Vulvovaginal candidiasis]
• Cytolytic vaginosis
• Autoimmune progesterone dermatitis.

Who gets cyclic vulvovaginitis?

Cyclic vulvovaginitis can affect menstruating women of all ages and races.

What causes cyclic vulvovaginitis?

The aetiopathogenesis of cyclic vulvovaginitis depends on the specific cause and may include:

• Candida infection and abnormal host response
• Bacterial (lactobacilli) overgrowth eg, cytolytic vaginosis
• Reaction to progesterone produced during the luteal phase of the menstrual cycle.

What are the clinical features of cyclic vulvovaginitis?

• Intense burning, irritation, stinging, or itching just before (luteal phase) or during menstrual bleeding.
• Patients may be symptom-free during the rest of the menstrual cycle.
• Pain can be aggravated by sexual activity and is usually worse after intercourse.
• Vaginal discharge can be minimal.
• Examination may show vulval erythema, oedema, and/or fissuring.

What are the complications of cyclic vulvovaginitis?

• Localised provoked vestibulodynia or generalised vulvodynia
• Vaginal discharge can cause a secondary irritant contact dermatitis
• Impact on quality of life.

How is cyclic vulvovaginitis diagnosed?

Cyclic vulvovaginitis is a clinical diagnosis based on history and examination. The Q-tip test should be performed to check for provoked vulvodynia.

Vaginal swabs and scrapings for smear and culture should be performed during the symptomatic phase and, if negative, again in the asymptomatic phase. If a Candida sp. is cultured, the specific strain and drug sensitivities should be reported.

What is the differential diagnosis for cyclic vulvovaginitis?

Cyclic vulvovaginal symptoms can also be due to:

• Fixed drug eruption due to medications taken for period pain
• Contact dermatitis to sanitary/hygiene products eg, methylisothiazolinone in wipes
• Sebaceous adenitis
• Genital herpes.

What is the treatment for cyclic vulvovaginitis?

General measures

• Avoid bubble bath and spermicides
• Use a non-soap cleanser and moisturiser
• Avoid nylon underwear and tight-fitting clothing
• Use tampons instead of pads

Specific measures

For vulvovaginal candidiasis:

• Topical antifungals, antifungal vaginal pessaries, oral fluconazole.

For cytolytic vaginosis:

• Stop use of antifungals
• Sodium bicarbonate (baking soda) douche or sitz bath to increase vaginal pH.

For autoimmune progesterone dermatitis:

• Avoid progesterone-containing medications such as the combined oral contraceptive pill
• Systemic conjugated oestrogen, ethinyloestradiol.

For dermatitis:

• Moderate potency topical steroid such as clobetasone butyrate.

Vulvodynia is best managed by a specialist vulval clinic.

What is the outcome for cyclic vulvovaginitis?

The outcome of cyclic vulvovaginitis depends on the cause. Correct identification and treatment can result in resolution of symptoms but may require long-term intermittent or continuous treatment.