Our data showed a high number of women who had years of lasting of vulvar pain, mostly who sought three or more doctors and either remained without diagnosis or received diagnosis different to vulvodynia. As a consequence of the probable inappropriate diagnosis received for the vulvar pain complaint, these women were frequently treated with inappropriate therapies for the management of vulvodynia, such as antifungal and topical hormones.
Some of these findings are in line with the results showed by Harlow & Stewart’s , that two-thirds of North-American women with chronic vulvar pain who sought medical care visited three or more physicians, many of whom failed to provide a diagnosis. Scientific literature suggests lack of awareness of the condition by both practitioners and patients as the main reason for the low rates of correct diagnosis and appropriate treatment [1, 15]. The present study also points to the fact that, in addition to typical vulvar pain, other vulvar signs (fissure, vaginal discharge, foul odor, erythema) and symptoms (burning, itching) were frequent. All those characteristics can make the diagnosis unclear, leading to a wrong interpretation of vaginal infection, for instance.
In fact, our data showed that many of the participants who sought medical care had been repeatedly treated for vulvovaginitis, obtaining poor or no symptom relief. This finding is consistent with Reed et al , who found that more than one-third of women diagnosed with vulvodynia were treated for candidiasis before receiving the final diagnosis and presented no improvement in vulvar symptoms. A possible explanation for the large number of women treated for candidiasis before reaching the final diagnosis also relies on the pathogenesis of vulvodynia that associates a high prevalence of yeast infections preceding VVD diagnosis . However, it is important to consider that a large number of women might be diagnosed with candidiasis when complaining of vulvodynia symptoms. This concept has been previously suggested by Harlow et al , who affirmed that the diagnosis of vulvodynia and recurrent yeast infection probably have a bidirectional association. In the present study, most participants treated for candidiasis after seeking medical care for the complaint of vulvar pain, reported they had no laboratory tests to confirm the suspicion of infection, and remained with the main symptoms. This finding also suggests that patients are overdiagnosed with vaginal infections when seeking a diagnosis for vulvodynia, supporting the bidirectional association.
Indeed, the opposite might also occur. Our study found that only one-third of the volunteers diagnosed with vulvovaginal disorders at the eligibility screening process still fitted the diagnosis of vulvodynia after treatment. This reinforces the need to follow recommendations for the exclusion of different diagnoses in order to increase accuracy in the diagnosis of vulvodynia . Laboratory tests confirming the hypothesized diagnosis of vaginal infection, for instance, should be encouraged as an objective measure to avoid misdiagnosis.
Furthermore, our data showed that the self-reported average pain score during the last sexual intercourse according to NRS was two points higher than the mean obtained in the CST. Although our sample was made up of both provoked and unprovoked vulvodynia, the first subtype was highly predominant. Diagnosis criteria for vulvodynia usually follows the ones proposed by Friedrich  that include 1) severe pain on vestibular touch or attempted vaginal entry, 2) tenderness to pressure localized within the vulvar vestibule, and 3) physical findings confined to vestibular erythema of various degrees. However, it is important to highlight that although the CST has been broadly used as a reliable tool to confirm the 2nd criteria, it only predicts provoked vulvodynia subtype. Therefore, self-reported complaints of high intensity of vulvar and/or sexual pain, should enrich clinical guidance for vulvodynia diagnosis as much as CST. Furthermore, Bergeron et al increased generality of vulvodynia diagnosis by showing the reliability of these criteria, modifying Friedrich criteria by limiting it to the 1st and 2nd criteria only, excluding the need to confirm erythema findings on the vulva vestibule . However, more than half of the present studied population was evaluated with vulvar erythema. These findings suggest that although, as proposed by Bergeron et al , not all women with vulvodynia may present this clinical sign, it is indeed important that practitioners pay attention to the fact that the presence of vulvar erythema is an expected finding in women with this condition.
In addition to diagnostic issues, a consensus also exists over the difficulty in treating vulvodynia . The most commonly prescribed medication for the treatment of vulvodynia is tricyclic antidepressants, selective norepinephrine reuptake inhibitors and anticonvulsants. Nevertheless, there is no general agreement that any of these drugs is highly effective in relieving vulvar symptoms . While some studies suggest that the use of these medications can only benefit women with generalized, unprovoked vulvodynia subtype [22, 23], others have shown similar effects of oral medication comparing the different subtypes of vulvodynia [7, 8, 24, 25]. Our data showed that the tricyclic antidepressant was the most widely prescribed drug, but only a small portion of women reported having strong vulvar pain relief. However, further studies are needed to suggest this finding as related to the predominant characteristic of the sample that had the provoked vulvodynia subtype.
A recent meta-analysis comparing medication versus placebo for treatment of vulvodynia showed that both improve sexual function, although medication has a minimally superior effect .The same study highlights the importance of adding a more efficacious treatment for female sexual dysfunction. Our data showed that, unfortunately, only a minimum amount of the women assessed received appropriate treatment for the management of vulvodynia. Nevertheless, the most commonly reported measures were either oral or topical medication (antifungal, hormone, gabapentin, steroids, amitriptyline), followed by lubricants, topical anesthetics and specific hygiene or vulvar care techniques, described as resulting only in a low symptom relief. Very few women reported having tried other efficacious treatment modes, such as physical therapy, even though it has been recommended by many guidelines as a first-line treatment for vulvodynia [7, 14, 27]. Although only a few women underwent physical therapy to treat vulvodynia in this study, the high percentage of those that reported achieving a high relief of vulvar pain with this approach supports its effectiveness.
Due to the study design, it was not possible to assess whether previous treatment improved sexual function. It is assumed, however, that they would also be characterized as having sexual dysfunction at that time, as this is an expected aspect of women with vulvodynia [4, 9]. Only 10% of our volunteers scored above the cut-off point, which is indicative of normal sexual function. It is clear that sexual dysfunction in this population is a consequence of vulvar pain, especially during intercourse [11, 28]. Nevertheless, whether the volunteers assessed in this study maintained or worsened their sexual function index over time remains unclear. The fact that this study depicts white, highly educated women, which may not be highly representative of our country, is also a limitation of our study. It is possible that increasing the number of women with vulvodynia, the numbers of delays in achieving a correct diagnosis and appropriate treatment would have increased even more in a population with lower levels of education. In addition, the self-reported characteristic of the study was the basis for the main variables assessed including: number of physicians sought, previous diagnosis and prescribed treatment, level of vulvar discomfort relief, among others. However, previous research has demonstrated a broad agreement between self-reported and medical record data among highly educated women . All women were clinically examined to confirm the diagnosis of vulvodynia, which also provides support to the goals analyzed.
Our findings highlight the importance of developing strategies to increase awareness about the diagnosis of vulvodynia and develop suitable treatment for the condition. These data emphasize the lack of a clear diagnosis of vulvodynia, confirmed by few appropriate treatment modes and a wide use of inefficient methods to deal with persistent vulvar pain.
In summary, a prolonged duration of vulvar pain, multiple visits to healthcare professionals and poor relief of pain with previously undergone treatments are common aspects in the clinical history of women with vulvodynia. Vulvovaginal signs and symptoms other than pain are common, and highlight the importance of having a better clinical and/or laboratorial tests supporting its diagnosis.