A 67-year-old Caucasian female presented for evaluation of persistent burning pain and itching in the vulvar region accompanied by marked erythema and warmth to the touch (). Her symptoms first appeared in childhood but increased in frequency and severity after menopause. During her reproductive years, she had experienced a myriad of urologic and gynecological symptoms. In her 20s, the preponderance of her symptoms involved her bladder, and she was subsequently diagnosed with interstitial cystitis. In her 30s, her gynecologic symptoms became more prominent and she was ultimately diagnosed with endometriosis for which she underwent a hysterectomy and bilateral oophorectomy at age 33. Throughout this time, her unexplained episodic vulvar symptoms were present; however, it was not until menopause that her vulvar symptoms became persistent and the frequency and severity of her flares dramatically increased. She found that the application of cold water and minimizing humidity and warmth in the perineal region were the only ameliorative modalities consistently effective in decreasing the frequency and severity of her “flares.” It is interesting to note that her mother and a maternal aunt had similar lifelong symptoms which they had attributed to horse back riding.
After treatment with beta-blocker (a). Acute flare (b).
On initial evaluation, the patient had normal appearing vulvar skin and vulvar mucosal changes consistent with the diagnosis of menopausal atrophy. On examination, she experienced diffuse burning and pain when the vulvar skin was gently stroked with a cotton swab. For the purpose of the symptomatic management of worsening burning and dyspareunia, we prescribed a trial of topical estrogen (0.05%) and lidocaine (5%) compounded in hydrophilic petrolatum. While this regimen provided some relief, she continued to experience “flares.” Consequently, the patient was asked to return upon recurrence of a “flare” for evaluation and photographic documentation (). In the absence of a known diagnosis, we empirically prescribed bedtime clonazepam (0.5
mg) which improved her overall sense of well being and decreased the intensity of the flares.
While her symptoms were manageable on clonazepam for 3 months, a marked improvement occurred only after a serendipitous change in her antihypertensive regimen. Within 2 weeks of her primary care provider adding a beta blocker (nebivolol) to her medical regimen, she noted a drastic improvement in her symptoms of vulvar burning and accompanying erythema (). To date, more than six months after the start of beta-blocker, the redness of her vulvar region has subsided, and her quality of life has dramatically improved.