University of Michigan Medical Center

1500 E. Medical Center Drive

Taubman Center, Reception E

Ann Arbor, Michigan 48109-0384

(734) 763-6295

The University of Michigan Center for Vulvar Diseases was founded in 1993 as a consultation and referral center for complex vulvar problems. All of our physicians are certified obstetricians and gynecologists.

The Center for Vulvar Diseases provides a comprehensive set of services to each individual. Members of our multidisciplinary staff attend each patient during a visit. The team approach has been created as the basic structure in recognition of the necessity to provide this intensity of care and expertise to patients who have already demonstrated that they are afflicted by a resistant and chronic illness, or an unusual vulvar condition.

The following people are actively involved in your care at the Center for Vulvar Diseases:

Dr. Haefner, an Assistant Professor in the Department of Obstetrics and Gynecology, received her medical degree and completed her obstetrics and gynecology residency and a fellowship in gynecologic pathology at the University of Michigan Medical Center. Dr. Haefner is board-certified in obstetrics and gynecology. She is interested in vulvar diseases and is a specialist in colposcopy and vulvoscopy. She is a member of the International Society for the Study of Vulvovaginal Diseases (ISSVD). Dr. Haefner is active in gynecologic pathology research. She offers skilled, perceptive support and detailed instruction to her patients.

Ann E. Cook is a registered nurse with a Masters Degree in Maternal-Child Health Care. She has a special interest in women’s health; thus, she has become certified as a Women’s Health Nurse Practitioner. She has always been interested in problems that have an impact on quality of life. She enjoys working in a team atmosphere with people who have the same goals of quality patient care for all women.

Cheryl Sorg is a Clinical Nurse III at the University of Michigan Medical Center. She graduated in 1980 from Oakland Community College with an A.D. in Nursing. She has a NCC Certification in Women’s Health Care. She is a member of the Michigan Nurse’s Association (MNA), the American Nurses Association (ANA). She coordinates nursing services for the Center for Vulvar Diseases.

Claudia Kraus Piper, M.S.W., is a clinical social worker at University of Michigan Medical Center’s Sexual Health Counseling Services. She is a certified sex therapist. She is also a licensed marriage and family therapist. She has specific interest in working with women who experience pain with intercourse. She is a clinical team member of the Center for Vulvar Diseases.

Other members of the Center for Vulvar Diseases and their areas of interest:

Infectious Diseases

Urogynecology

Reconstructive Surgery

Chronic Pain Consultant

Vulvar Malignancies

The University of Michigan is a teaching institution where resident physicians are an important part of patient care. Senior residents may be participating in your evaluation and treatment.

The staff recognizes the importance of open lines of communication with our patients. However, health care and the decisions relevant to each patient’s health problems cannot effectively be carried out over the telephone. Several circumstances exist in which phone calls to the Clinic regarding health care issues are important: (1) to request an earlier appointment than scheduled because of a change in vulvar condition, (2) to obtain advice regarding the development of side effects from treatment, or (3) to provide information that was requested by your provider at your last visit.

All clinical calls are documented and processed by a registered nurse. The nurse will take one of the following courses of action: (1) provide you with advice, (2) schedule an earlier or urgent visit for you at the Clinic, or (3) consult with the physician as soon as possible and arrange further communication with you.

Clinic phone lines are open from 8:00 a.m. to 5:00 p.m. to schedule an appointment. Please bear in mind that during non-clinic hours your medical records will not be available to the physician and nurse, and treatment options are therefore limited.

Because of the volume of calls that reach the Clinic daily, we request that your calls be kept brief. A useful suggestion is to outline your problem before calling and know your medications and dosages and pharmacy number if your call involves these. In your best interest, complex clinical dilemmas must be evaluated in person.

Under special circumstances, you may be asked to report progress between visits. This is not in place of regular follow-up evaluations. If you feel your condition has worsened and you require modification of your therapy, it is appropriate to call the Clinic and set up an earlier return visit.

Your provider will determine whether a return visit to the Center for Vulva Diseases is necessary. All referring care providers will receive a detailed letter about your visit. In certain circumstances, follow-up visits and medication management will be handled by your referring care provider.

Prescriptions are carefully calculated so that your medication will last until your next appointmenrt at the University of Michigan Center for Vulvar Diseases or with your primary care provider. In the event that you need medication prior to your next return visit, it is essential that you communicate with the appropriate service regarding this matter prior to running out.

Just as you would examine your breasts or skin for changes, you should examine your vulva. Many different diseases of the vulva have similar symptoms. The vulvar self-exam will help you to be aware of any changes in the vulvar area that may need ongoing evaluation. Some changes in the vulva may mean cancer. Tell your physician if you see any changes or have symptoms that don’t go away, such as itching, bleeding or discomfort. If a problem does occur, catching it at an early stage--when treatment is most successful--is in your best interest. Learning how to do a vulvar self-exam can best accomplish this.

The vulva is the external genitalia in the female. The skin of the vulva can be quite sensitive. Because it is moist and frequently subjected to friction while sitting and moving, this area can be easily injured. There are various strategies that can be used to prevent irritation and allow the vulva to heal. Skin that is moist becomes soft and is easily injured; therefore, keeping this area dry can accelerate healing. Chemicals found in toilet tissues, laundry soaps and detergents that contact the vulva can cause irritation. Avoiding contact with potential irritants that contain chemicals will be important. Fabric softeners in undergarments, chemicals in deodorant soaps, bubble baths, feminine hygiene spray and panty liners etc., can all cause irritation. The following recommendations are specific measures that can help in this regard.

Wear white 100% cotton underwear, and do not wear pantyhose, tights, or other close-fitting clothes. Enclosing this area with synthetic fibers holds both heat and moisture in the skin, conditions which potentiate the development of secondary infections. Tight-fitting clothes may also increase your symptoms of discomfort.

After washing underwear, put it through at least one whole cycle with water only. Some women have suffered needlessly from irritants in detergents whose residue was left in clothes by incomplete rinsing. Rinsing clothes thoroughly is more important than which detergent is used although to be on the safe side, the milder the soap, the better. Wash new underwear before wearing. Fabric softeners and drying sheets should not be used.

Rinse skin off with plain water frequently. Use tap water, distilled water, sitz baths, squirt bottles, or bidets. Pat the skin dry gently, or dry with a cool hair dryer if you prefer.

Use very mild soap for bathing. Neutrogena, Basis, Pears (made in England), and castile soap with

olive oil (Conti) are good soaps. They are found at pharmacies or health food stores. Remember that frequent baths with soaps may increase the irritation. You cannot wash away your symptoms. It may be best to not use soaps on the vulva; instead, rinse only with water.

A compress of oiled Aveeno (a powdered oatmeal bath treatment) has been recommended by some. It is placed over the vulva three to four times a day. Put two tablespoons of Aveeno in one quart of water. Mix in a jar and refrigerate. This is often helpful after intercourse or when symptoms are flaring.

Use lubricants suggested by your physician to make intercourse more comfortable. Astroglide is a product with a natural lubricating action. Other water-soluable lubricants include Lubrin, Moistur-el, Replens and KY Jelly.

Use 100% cotton menstrual pads and tampons. Many women with vulvar pain experience a significant increase in irritation and pain every month when they use commercial paper pads or tampons. This monthly increase in pain can often be reduced by using 100% washable and reusable cotton menstrual pads. Some disposable cotton pads are availavle. Pure cotton tampons are also available.

Don’t sit or remain in a wet bathing suit.

Avoid contraceptive devices and creams that can irritate sensitive tissues.

Additionally, it is often recommended that the vulva is left uncovered at night (i.e. no underwear) to allow adequate exposure to the air.

A large proportion of the patients seen at the University of Michigan Center for Vulvar Diseases have vulvodynia. The following information is a comprehensive review of the different aspects of vulvodynia.

Definition: Vulvodynia is defined as chronic (long standing) vulvar discomfort, that is characterized by the complaint of burning, stinging, irritation or rawness (International Society for the Study of Vulvar Disease, 1984). It may occur at any range. A number of different uncomfortable sensations are associated with vulvodynia. Other common terms to describe vulvar discomfort include: itching, aching, painful, stretching and throbbing.

Causes: Vulvodynia can be divided into two major categories: organic vulvodynia (those with a known cause) and "essential" vulvodynia (where a cause cannot be identified).

Vulvar pain can be associated with simple chemical irritation, so-called contact dermatitis. Common irritants include soaps, shampoos, scented toilet paper, douches, fabric softeners and scented menstrual pads. It can also be caused by certain medications which have been used to treat vulvar problems. Various infections can also be causes of vulvodynia. Women with chronic vulvar and vaginal yeast infection can frequently have vulvar itching and burning. Often symptoms worsen before menses as the changes in ovarian hormone production and the local vaginal environment can favor yeast growth during that time. Recurrent herpes simplex virus infection can also cause vulvodynia. These infections wax and wane, often starting at stressful times and lasting anywhere from a couple of days to a week or more. Irritation of the nerves which supply the vulva can also cause vulvodynia. This type of vulvodynia may radiate from the vulva to the perineum and into the groin and thigh. Some patients have lower back problems which may be associated with this pain also. Vulvar pain also results from injury (i.e. childbirth, vaginal/vulvar trauma).

"Essential" vulvodynia tends to affect an older population of women (average age in 60’s). Physical examination of this group of patients often does not demonstrate any visible abnormalities. It is important to understand that essential vulvodynia does not mean that there is not a cause of the vulvar discomfort, rather a cause cannot be identified. Despire the fact that a cause of vulvodynia cannot ve established in all cases, two things are important to keep in mind: 1. Frequently the discomfort associated with essential vulvodynia can be controlled, and 2. It is clear that there is generally no relationship between vulvodynia and the subsequent development of vulvar cancer.

Vulvar Vestibulitis: Some women present with distinct tenderness and at times erythema (redness) in the vestibule. Intercourse is painful and, in some cases, impossible due to the severe pain. Typically, women with vulvar vestibulitis present with a varying duration of symptoms from weeks to several years. Symptoms often begin after experiencing some type of infection or trauma followed by difficulty with intercourse. Burning, stinging, irritation or rawness at the vaginal opening (vestibule) with intercourse are the most common complaints. This same sensation is also experienced when placing tampons or touching in the area of the vestibule. Women with severe symptoms may also feel this same sensation when riding a bicycle, horseback riding or jogging. In more extensive cases, some patients experience these symptoms while sitting, walking or even without any movement. Typically, these women have seen a number of health care practitioners and have had numerous attempts at therapy with topical or oral antifungals, topical steroids, and antibiotics. Usually, these provide no long term relief.

The cause of vulvar vestibulitis is not known. Early studies implicated the human papilloma virus as a cause, but this is no longer considered to be associated with vulvar vestibulitis. There appears to be a small subset of women who have chronic yeast infection as a cause of their vestibulitis, and long term yeast suppression has met with promising results in these women. There is also another group of women who appear to have both vulvar vestibulitis and interstitial cystitis (a condition of the bladder which causes urinary frequency and burning). Because the vestibule and a portion of the bladder are the only two tissues in the body derived from the same embryologic tissue, investigators have begun to look for an irritant which might affect both of these structures. To date, no causative agent has been proven. Some patients relate the onset of their pain to a gynecological or obstetric event. It is important to recognize that there is absolutely no evidence that vestibulitis is a sexually transmitted disease, therefore, it cannot be contracted from or given to your sexual partner.

Treatment: Treatment of vulvar pain conditions is confounded by the fact that the cause is unknown in a great majority of cases, and the best treatment will likely come only when the cause has been identified. Where chronic yeast infection can be identified, suppression of yeast growth can be gratifying. Other topical therapies such as steroids and antibiotics have not met with success. Topical anesthetic agents (e.g., viscous or liquid xylocaine) can sometimes help with temporary relief. The greatest success in treating vulvar pain conditions comes from using a group of medications called antidepressants. This group of drugs (e.g., Elavil™, Pamelor™, Norpramin™) has been used to treat many chronic pain conditions where a cause cannot be. The TCA (tricyclic antidepressant) may work by inhibiting certain pain fibers which supply (innervate) the vulva. This in turn can prevent these specific nerves from transmitting the message to the brain where it is processed and pain is perceived. Another group of drugs, anticonvulsants, are used as treatment for other chronic pain conditions and may be used for vulvar pain. The use of the CO2 laser has not been successful, and in some cases, the results of treating vestibulitis with the CO2 laser have worsened the pain.

There is no standard treatment for patients with vulvar pain since there are likely multiple causes. Treatment suggested will depend on your individual case. Modifications of treatments and medication dosages may need to be altered if your symptoms vary. The doctors and nurses at the Center for Vulvar Diseases will discuss your individual case with you and develop an individual treatment plan based on your history, prior treatments and severity of symptoms.

Vulvar pain can be a difficult process to treat. Improvement may take weeks to months (even years) of long-term treatment. Spontaneous remission of symptoms has occurred in some women, while with others multiple attempts with medical management has proven unsuccessful in relieving 100% of symptoms.

• Vulvodynia is not generally associated with malignancy

• Vulvodynia is not due to poor hygiene, and the use of strong soaps and detergents can worsen the condition. Use gentle soaps or none at all, allowing water alone to cleanse the perineum. Dry the perineum with a hair dryer on a cool setting.

• Although the cause of vulvodynia cannot always be determined, it has been characterized well enough to allow treatment of the pain with a reasonable expectation of significant improvement, if not complete alleviation of pain.

• We understand that chronic pain is exhausting and can be demoralizing.

• There is nothing wrong with you as a person, the problem is your pain.

• Don’t feel that because this is genital pain that you can’t talk to other people. People with chronic problems need others for support. Family and friends can help.
• If you are in a relationship, both of you are affected by this problem. Appropriate couple counseling may be needed.

• It is OK to seek information on your own. The more you know about this disease, the more control you have over your situation.
• Sometimes patients become depressed if new treatments fail. Remember this as we work through this problem.

Over the last few years, there has been an emphasis on using a low oxalate diet with calcium supplementation to treat vulvar pain. The following information was prepared by a dietitian at the University of Michigan Hospitals.

® To alleviate and control pain associated with vulvar pain.

® This diet should be considered a "trial" for 3 months to 1 year. It may alleviate the pain for some individuals

® If symptoms decrease, ask your doctor about how long to continue.

® Eliminate all foods in the high oxalate column.

® Limit foods in the moderate oxalate list to 3 times a week.

® Drink at least 12-14 cups of water each day.

SUPPLEMENT:

® Take calcium citrate without Vitamin D.

® Two Citracal tablets, three times a day is recommended.

® Take calcium citrate without food on an "empty stomach" approximately forty-five minutes before eating.

® Take no more than 250 mg of Vitamin C per day. It is a precursor of calcium citrate.

Additional resources:

The Low Oxalate Diet Book. General Clinical Research Center, University of California, San Diego;
225 Dickinson Street, 8203; San Diego, California 92103-8203.

The Vulvar Pain Foundation, 433 Ward Street, Graham, NC 27253.

Various conditions are caused or made worse by high levels of tension. Biofeedback allows you to learn effective ways to reduce tension by relaxation. It has been used successfully in the treatment of a number of disorders, including migraine and tension headaches, asthma, chronic pain and anxiety disorders.

Biofeedback aids in developing self-regulation strategies for confronting and reducing pain. Sensitive detectors can be used on the vulva to tell you what is happening in your vulvar sensory neural environment. With the aid of an electronic measurement and amplification system or biofeedback machine, an individual can view a display of numbers on a meter, or colored lights to assess nerve and muscle tension. In this way it is possible to develop voluntary control over those biological systems involved in pain, discomfort, and disease.

The body has a protective muscle spasm to protect painful areas. The muscles react by tightening up. The detectors measure and amplify biological processes which you may not normally be aware of, so that this information can be returned or "fed back" to you. After exercise therapy, the muscles return to a stronger, more relaxed and more stable state. Women are taught to isolate and exercise their pelvic-floor muscles.

As a result of biofeedback it is possible to bring these biological processes under voluntary control. You can become an active participant in your own treatment. It gives you immediate information about whether you are becoming more relaxed or more tense. This is really the most important thing in any kind of learning--to know quickly whether you are going in the right direction. The time required for biofeedback and the frequencies of visits will vary with each person.

Another form of treatment that may be helpful that is used instead of or in addition to biofeedback is physical therapy. Treatment should be individualized and comprehensive. It is important to make the patient an active participant in their care and to establish goals at the outset of treatment. Muscle re-education has an important role in the treatment of vulvodynia.

Adapted from "Biofeedback at Michigan Head-Pain and Neurological Institute" Alvin Lake, PhD.

Glazer, HI, Godke G, Swencionis C, Hertz, R, Young AW. Treatment of Vulvar Vestibulitis Syndrome with Electromyographic Biofeedback of Pelvic Floor Musculature. The Journal of Reproductive Medicine 1995;40:283-290.

A sexual therapist may be involved in providing recommended counseling for patients seen at the University of Michigan Center for Vulvar Diseases. The following information may be helpful in understanding some of the sexual issues encountered in patients with vulvar diseases.

There are some conditions which can cause women to experience pain with sex, whether the activity is heterosexual intercourse, masturbation, partner attempting to penetrate the vagina with fingers, or other sexually stimulating activity. Many times numerous treatments have been tried, with little success. The pattern of experiencing pain with sex, sometimes for a long period of time, can be very challenging for women and for their partners. Sometimes the pain comes and goes, but the fact that the women cannot predict when they may or may not experience pain means that they are always vigilant that pain could happen. This can set up a cycle of women and partners anticipating pain, which, in itself, is distracting.

The sexual response cycle is generally separated into three categories. These are the desire phase, the excitement phase, and the orgasm phase. Seeing sexual response in phases can be helpful, because women can begin to understand where their problem is occurring. This can be beneficial, if only to help women and their partners understand the impact of attempting to maintain a healthy sex life while coping with chronic pain.

The desire phase refers to a woman’s interest in engaging in sexually arousing activity. We know that how a woman feels about herself and her body, what she expects from sexual experience in general and her partner in specific, and her experience with intimate relationships, whether sexual or not, all come together to influence sexual desire. Chronic pain can be a secondary cause of low sexual desire. For example, in the Vulvar Disorders Clinic women frequently tell us that the quality of their sexual interest and desire before they had pain was just fine. In other cases, some women state that they have always had some difficulty with sexual interest. This can vary from feeling they aren’t nearly as interested in sex as their partners to feeling that they would like to avoid sex forever if it was possible. In cases where sexual desire has always been problematic, this issue should be addressed. If this issue isn’t dealt with, for some women resolving pain could mean that there is no longer an acceptable reason to avoid sexual contact. We hesitate to include this as an example about what can happen, because many women have been told that their vulvar pain is not real, and we know that the pain is real. We can’t leave this factor out of a discussion about sexual desire.

The excitement phase describes what is happening in a woman’s body during sexually stimulating activity. She usually feels focused on the activity. Her vagina becomes moist with lubrication, and her genital region feels "full" because of blood flow into the area. This is similar to a man having an erection during sexual arousal. Pain is not supposed to be a part of sexual arousal, and so when it occurs we call it an excitement phase difficulty. This refers more or less to the "mechanics" of sexual functioning. By itself a pain problem means only that something isn’t functioning as it should. It is a symptom, and does not tell us anything about the woman’s desire to be sexual or to experience sexual attraction. Of course pain with sex is a catch 22 for women, and their sexual partners. Anticipating that sex might hurt can certainly affect sexual desire.

The orgasm phase is the discharge of pent-up sexual tension. Some women have orgasms regularly with sexual intercourse, and some women do not. This is normal, and is not a dysfunction. If a woman can have an orgasm with her sexual partner in some manner, the orgasm phase is intact. Vulvar or vaginal pain does not in itself lead to difficulties with orgasm. However, pleasure can be substantially blunted if pain or anxiety about pain is a part of the sexual experience. Distraction because of pain or fear of pain can also affect whether or not a woman is orgasmic.

1. Establish a working alliance with a health care provider. This should include a working relationship with a provider or team who validates the pain you are experiencing. Of course this does not mean false reassurance on the part of the team to you, or blind faith on your part that this provider will completely eradicate pain you have had, perhaps for a long time. This alliance should include:

1. Medical evaluation and treatment recommendations. Your part will be to provide clear background information and medical records.
2. An acknowledgment of the pain you are experiencing. The clinician will understand that you have pain, and that pain is interfering with your sexual pleasure and sense of well being. You will understand that even pain that is 100% physical in origin will have some psychological effects, because sexuality is a part of primary identity, and when you repeatedly experience pain with sex that identity is also injured.
3. The provider or team can help "normalize" the experience of frustration you may be having. This can help with a feeling of isolation. Couples dealing with painful sex often feel they are quite alone in the experience.
4. Honest exchange and communication.

2.Expand your sexual repertoire.

1. Focus on sensual as well as sexual. When sex begins to be associated with pain, the experience of sensual pleasure can be lost as well. Sensuality can be re-introduced with "non-demand" massage, cradling, backrubs or other activities. Some couples become touch avoidant when they have experienced the cycle of pain.
2. Avoid sex that hurts. This may seem obvious, but we have found conversely, some women may grit their teeth through uncomfortable sex because they feel that they are unfairly depriving their partner of the partner’s satisfaction. We have noted, however, that partners are distressed when they sense that the woman is not being straightforward about the fact that she is in pain. They don’t want to cause hurt or harm, and generally do not find sex pleasurable that causes pain.
3. Experiment with sexually stimulating activity that does not involve penetration. Oral sex, sex using a vibrator, massage, kissing, fondling, have all been found to be pleasurable alternatives to intercourse. If some of these ideas are objectionable to one or both partners, this should be frankly discussed. We have found that many couples have gradually become interested in alternative activities by slow exposure and experimentation. Again, clear communication is important, including paying attention to what is experienced as unpleasant.
4. Sexual activity not outcome (orgasm) oriented. Our culture tends to reduce sex to the idea of orgasm and ejaculation. Incorporating sexual and sensual play where the goal is simply to experience the moment has been liberating to many couples. Couples tell us that—if anything can be considered positive about vulvar pain—they have greatly expanded their definition of sex by concentrating on the pleasure of the moment and to greatly de-emphasize orgasm.

3. When other problems occur, secondary to vulvar pain

1. Muscle spasm (vaginismus). Sometimes muscles spasm involuntarily as a response to fear of pain. This is much like involuntary blinking will happen if there is a threat that something is flying straight for your eye. Sometimes it is difficult to sort out the origin of the pain. We will work with you to carefully determine whether you may be experiencing a muscle tightening in addition to vulvar pain. Fortunately there are techniques which work to overcome this symptom. You will work with your clinician or team to determine a treatment.
2. Partner sexual difficulty. Your partner could develop a sexual difficulty in response to your vulvar pain. This is understandable when you consider how frustrating the cycle of pain with sex can be for both of you. Sometimes partners withdraw from initiating sexual contact, or even touch contact, because of the fear of causing pain. Some men have developed erection difficulties. Perhaps they don’t see the connection between not being able to get an erection and the fear of causing their partner pain. Couples who are experiencing more than one sexual problem at once may benefit from discussing this with a therapist who understands sexual functioning.
3. Low interest in sex. This bears repeating. If your experience with sexual activity before the onset of vulvar pain was positive, and your energy for sex was fairly high, the fact that you don’t have interest in sex now is probably because of the frustrating challenge of the presence of pain. If you never had interest in sex and primarily engaged in sex for your partner’s sake, you may want to examine for yourself what you want your sexual life to be and what it would take (besides being without pain) for this to happen. If you have always wanted to avoid sexual contact because you find it unpleasant or fearful, discussing this with a therapist or trusted advisor may provide you with some insight about this problem.

At times, the use of vaginal dilators for your vulvar condition may be recommended. The following is a discussion on the use of vaginal dilators.

Pain with sexual activity can cause some reflexive tension in pelvic muscles. Anticipating that an activity may be painful can cause muscles to tense voluntarily or involuntarily, as a way to be self-protective. Sometimes a woman can benefit from learning more about how to gain voluntary control over the pelvic muscles. At times, vaginal dilators may be recommended. Vaginal dilators are smooth plastic cylinders in graduated sizes. They are rounded at the end. The smallest dilator is about the diameter of a tampon. Dilators will be provided for you in the recommended sizes, with discussion about how to use them. These instructions can be used for reference in between clinic visits. You may want to keep this handout with you when you are first using dilators.

Getting ready to use dilators. Select a time and place when you can have privacy to do dilator therapy. Many women elect to use their bedroom, and to use dilators while lying down. Plan for about 10 to 15 minutes a day, four to five times a week. Although this doesn’t seem like much time, it will require planning and consistency. We want you to be successful, and this will require repetition.

What you’ll need. At first you may benefit from using a mirror in order to see the vulva and vaginal opening. Locate the labia and clitoris as well as the opening to your vagina. You will need the dilator, and lubrication. Lubrication can be purchased in any drug store. Lubrication products are located in the same area as birth control items and condoms. Use a water based product rather than petroleum jelly. Many women like Astroglide. KY Jelly and Surgilube are also preferred products.

Beginning with dilators. Use a small amount of lubrication on the dilator. Tense and relax the pelvic floor muscles a few times. When you are in the "relax" phase of the exercise, insert the prescribed dilator. Some women find it helpful to push against the dilator, as if they were attempting to expel it. Notice your breathing. If you are tense and breathing is shallow, stop and attend to the tension before you proceed. Insert the dilator about two inches or so. You may be able to insert the dilator further. The pelvic muscles which tend to tense up are about an inch or so inside the vaginal opening, so the goal of this therapy is not how far you can insert the dilator, but what is happening to the muscles when you insert.

If you have pain, stop. Dilator therapy won’t be effective if you are in pain. Check with the health care provider supervising your dilator therapy. If you are feeling a physical tension, and you want to see if you can proceed with the dilator and learn some relaxation of that muscle, go ahead, but stop if there is pain.

Leave the dilator in place for 10 minutes or so. This should be relatively boring. You may want to catch up on a little reading during these minutes. Remove the dilator.

Changing dilator sizes. When you can effortlessly insert the dilator, it may be time to move to a larger size. Follow the steps above. At first use the dilator that you have become accustomed to. Then after a few minutes remove this dilator and use the next size. Again, stop if you have pain.

Care of dilators. Dilators do not need any special treatment. They can be cleaned with soap and water, making sure they are rinsed thoroughly.

Kegal exercises. Kegal exercises can help you gain voluntary control over pelvic muscles. When you are urinating, contract your pelvic muscles to start and stop the stream of urine. The goal of Kegal exercises is not to tense the muscles, but to learn to relax them. When you are contracting the pelvic muscles, you are tensing them. When you stop the contracting, push slightly as if you were attempting to expel urine or a tampon. This is part of the relaxation of the pelvic muscles. Pay particular attention to this relaxation aspect. These exercises should be repeated several times a day, and they can be helpful to strengthen the pelvic floor. Since the pelvic floor muscles are also involved in orgasmic pleasure, you may also be able to enhance orgasm.

The following conditions are frequently seen at the University of Michigan Center Vulvar Diseases. Many of these disease processes will require a biopsy to diagnose your condition. If a biopsy is performed during your visit, after care is important. Keep the area clean, avoid application of creams or ointments to the biopsy site. Sitz baths twice a day for 3 or 4 days following the biopsy will aid in healing. If increased reddness, pain, discharge, or bleeding occur at the biopsy site, call for further instructions. Avoid intercourse until the biopsy site is healed.

Yeast infections are the most common vulvar infection. Diabetes, pregnancy, antibiotic use, a suppressed immune system and zinc deficiencies are factors that predispose women to yeast infections. Candida albicans is the most frequent cause. The vagina may be infected also. Many women in the reproductive age group have yeast present in the vagina or vulva without symptoms. Yeast infections generally are not sexually transmitted, but there are exceptions and you may want to address whether or not your partner should be treated.

Symptoms of yeast infections can include redness, itching and a whitish, clumpy discharge. For women with recurrent yeast infection, the symptoms tend to flare at the same time during each menstrual cycle. Sometimes women have burning with urination. Intercourse may be painful. Some women complain of vaginal dryness.

Many times patients with symptoms thought to be from yeast do not have the fungus. To diagnose this infection, the discharge on the skin of the vulva or in the vagina may be taken and examined under a microscope. A culture may be sent to the laboratory. If an infection is present, antifungal drugs are the usual treatment. A cream or tablet (or both) can be inserted into the vagina and applied to the vulvar skin. Oral medications can also be used to treat yeast infections (see Fluconazole). Many women with recurrent vaginal candidiasis can be effectively treated with intravaginal boric acid. An 0 gel capsule is filled half way (600 mg, boric acid) and placed into the vagina twice weekly (for example, on Monday night and on Thursday night). Many resistant candida strains will respond to boric acid.

Patients with recurrent infections may benefit from limiting large amounts of sugars (sucrose and lactose) from their diets. Such sources would include candies, syrup, milk, cottage cheese and artificial sweeteners containing lactose.

Genital warts (condyloma acuminatum), like warts on other parts of the body, are caused by the human papilloma virus (HPV). This is the same type of virus that causes warts on the hands and feet. They are usually spread to the vulva through sexual contact but can in some instances be spread by other means. Women of childbearing age are the most susceptible to infection with HPV. The growths are occasionally seen before puberty or after menopause. The vulva, particularly at the opening of the vagina (vestibule) and the labial folds, is the most common site of this disease. Lesions can also arise on the skin near the anus, vagina, cervix and urethra. They usually appear first as a small thickened area of skin with definite edges. The wart may become surrounded by seedlings (smaller warts) that may grow to involve other areas. Occasionally, they spread and enlarge, forming a large cluster of warts that look like tiny cauliflower. The warts appear on the vulva as raised and sometimes reddened patches that may hurt or itch.

There are several ways to treat genital warts:

One topical therapy is the application of Trichloroacetic acid (TCA) to the warts. Treatments occur weekly until the warts are gone. Burning may temporarily follow its application. Podophyllin is another drug that is painted on the warts. It needs to be washed off. It is used less often due to side effects and the need to rinse it off. Interferon, a drug that is injected into the warts or into a muscle, may be used for recurrent lesions or for immunosuppressed patients. Laser treatment or Loop electroexcision (regional or general anesthesia for large areas) are used to treat condylomata at times. Excision with a scalpel under local or general anesthesia is sometimes necessary.

These treatments are not always successful; the warts may come back. It is important to watch for recurrences.

Molluscum contagiosum is a viral infection caused by the DNA-poxvirus group. It can occur in both children and adults. The lesions are small, smooth bumps with a central dimple. Generally, there are multiple bumps, although there may be a single lesion. Lesions produced by the virus are distinctive, usually ranging from 1-2 millimeters. When opened or squeezed, the lesions contain a white core of curd-like material. Lesions may also be found on the lower abdominal wall, pubic area, inner thighs, as well as on the vulva. Occasionally the lesions itch or are painful.

Following exposure, the incubation period may extend for many months, making identification of the sexual contact difficult. Treatment of molluscum contagiosum involves opening the lesion with a small blade or needle and removing the core by scraping. It does not usually require anesthesia. Topical numbing medications can be used if multiple lesions require treatment at the same time. The base of the removed papule can then be treated with Monsel’s solution or Silver nitrate to control oozing. After excision, the lesions need to be kept clean and dry to prevent superficial infection. Other forms of therapy include desiccation, freezing or Trichloroacetic acid. Avoiding exposure to untreated partners is necessary to prevent re-infection.

Lichen sclerosus is a skin disorder that affects the vulva. It may occur in any age group of women. The exact cause of lichen sclerosus is unknown. The condition resembles the appearance of lichens (mixture of fungi and algae) found in nature. It is not an infection that you caught from anyone, and you cannot transmit it to others. There have been reports of family members with lichen sclerosus, thus it may have a genetic link, although this is questionable. There is also the possibility that it has an autoimmune component.

It is characterized by small white patches that are thin and have a crinkled appearance, looking like cigarette paper at times. It may involve the entire vulvar area (from the clitoris to the anus). Often, swelling of the clitoral foreskin hides the clitoris. The labia minora almost completely disappears at times. Not uncommonly, splitting of the skin in the midline is seen. Tears may also develop in the natural folds of the vulva. The vaginal opening may become smaller, interfering with intercourse. Occasionally the tissue breaks down, forming an ulcerative lesion. It may be a chronic process which at times is not curable. The disease does not spread into the vagina. Itching is the primary symptom.

A biopsy (a minor surgical procedure to remove a small piece of tissue that is then examined under a microscope), is performed to make the diagnosis.

The goal of treatment is to eliminate itching and protect the skin from damage. Occasionally, complete resolution of the abnormal vulvar appearance may occur. More commonly, the skin changes of lichen sclerosus will not completely resolve. This does not mean the treatments are not helping. Various medications are used to improve the skin condition. Although testosterone has been used most frequently in the past for treatment, the current therapy is potent topical steroids in creams and ointments. Temovateâ (clobetasol propionate 0.05%) is a frequently prescribed topical treatment. Following the initial use of Temovateâ ointment or cream, the steroid content of the ointment or cream is decreased gradually. Long term topical steroid use is often required. During early treatment, avoidance of tight clothing will prevent further tissue damage. Several follow-up appointments will be necessary to evaluate response to treatment.

Many people have wondered if lichen sclerosus can turn into cancer. Lichen sclerosus scars the skin, and in theory, could increase the risk for a local skin cancer (this happens in less than 10% of cases, however). You will need to be followed closely to have the vulva examined at regular intervals. A sore or ulcer that doesn’t heal in a few weeks, a lesion that bleeds easily, or bumps or raised lesions that are becoming larger are signs of a skin cancer. In some cases, a second biopsy may be indicated. You should examine the vulva as you would examine any other part of your skin and have regular visits with your physician to follow the skin appearance. (see Vulvar Self Exam, p. 6)

Squamous cell hyperplasia (hyperplastic dystrophy) is an abnormal growth of the skin of the vulva. Two thirds of patients are premenopausal. It has a variety of appearances. It may present as a pink or red vulva . It frequently appears as elevated white patches. Moisture, scratching, scrubbing and medications may cause variations in the appearance of the lesions. The size of the lesions ranges from small to extensive. The areas most frequently involved are the hood of the clitoris, labia majora, outer aspect of the labia minora and the posterior commissure. Lesions may also extend to the lateral surface of the labia majora and even to the thighs. When the skin becomes too thick, hardened patches on the vulvar area may appear. This is related to chronic irritation. A biopsy (a minor surgical procedure to remove a small piece of tissue that is then examined under a microscope) is often performed to diagnose this problem.

Many things can trigger itching on the vulva. The itching generally stops when the skin heals. Remember that it took a long time for the squamous cell hyperplasia to develop, so don’t expect it to improve overnight. It is often chronic and may require long-term treatment with steroid creams or ointments. These are rubbed into the vulvar tissue. Squamous cell hyperplasia is sometimes observed next to lesions of invasive squamous cell cancer, although the risk of development of invasive cancer for women treated for squamous cell hyperplasia without vulvar intraepithelial neoplasia (VIN) is minimal.

Vulvar intraepithelial neoplasia (VIN) is a type of precancerous vulvar tissue abnormality. Its most severe form is called carcinoma in situ of the vulva. It is caused by changes in the cells of the vulvar tissue that allow them to grow abnormally. Genital warts caused by human papilloma virus (HPV) infection have been linked to VIN. VIN can progress to invasive cancer of the vulva. This happens in only a small portion of cases and usually progresses slowly.

Patients may be without symptoms or complain of pruritus (itching) or burning. Raised brown, red, pink, white, or gray lesions of various colors may be present. Tests to diagnose VIN include colposcopy (viewing of the cervix, vulva or vagina under magnification with a special instrument) and biopsy (a minor surgical procedure to remove a small piece of tissue that is then examined under a microscope).

Treatment depends on the degree of the disease. VIN 3 can usually be treated successfully with minor surgical or laser removal. VIN may reoccur. For this reason, and because VIN may not produce any symptoms, it is important to have regular checkups by your physician. This is especially true if you have a history of genital warts or if you smoke, as both of these factors contribute to the progression of the disease.

The following are instructions for vulvar care after laser therapy:

1. Apply ice for the first 12-24 hours.
2. Take a Sitz bath 3 times per day with warm water and instant ocean, sea salt or Epsom salts.
3. Dry area well thereafter with a hairdryer set on low.
4. Apply silvadene cream, Carrington’s gel, or Bacitracin afterwards.
5. Cleanse area with salt water solution after each void or bowel movement if soiled.
6. For symptomatic relief you may use warm tea bags or lightly apply witch hazel in between Sitz baths.
7. You will be given oral pain medication as well as a stool softener to prevent constipation.
8. If you develop extreme redness around the lasered area or a foul discharge, then contact your physician.

Vulvar Paget's disease appears as a red velvety area with white islands of tissue on the vulva. At times it may be pink. Occasionally there are moist oozing ulcerations that bleed easily. Itching is present in over half of the patients. Soreness may also be present. Almost all patients are postmenopausal, Caucasian women. The cause of Paget's disease is unknown. It is diagnosed by biopsy (a minor surgical procedure to remove a small piece of tissue that is then examined under a microscope) and is usually treated with surgery. It is rarely associated with an underlying cancer. Genital Paget's disease may however be related to a primary carcinoma of the rectum, urethra or bladder.

Lichen planus is a skin condition characterized by itchy bumps in the shins, the inner wrist, and the hands. A type of lichen planus affects the mucous membranes of the mouth and external genitalia. It often involves the vagina as well as the vulva. It can resemble other vulvar skin conditions. It is diagnosed by biopsy. This is a minor procedure often done in the office under local anesthesia. Small areas of skin are removed and sent for analysis.

The exact cause of lichen planus is unknown. It is not an infectious disease. The lesions consist of inflamed skin, but what causes the inflammation is unknown. The thin mucous membranes inside the mouth and vagina lose their top layer when they become involved with lichen planus, so red erosions rather than bumps develop in these areas.

Erosive lichen planus may be painful in the mouth and vagina and secondary infection may occur. If the areas touch one another, scarring may occur resulting in a narrowing of the vagina.

Lichen planus is often improved with various creams and ointments. Several drugs are used to treat this condition. If scarring has occurred, vaginal dilators may be used to help prevent further scar formation. Surgical separation of the vaginal scar tissue is sometimes necessary.

You should pay close attention to any changes in the vaginal discharge. If vaginal discharge occurs, it may indicate an erosion or secondary infection. Medication is most often used on a regular basis to maintain optimal tissue status, rather than only with flares in disease. Regular visits with your physician will be necessary.

Various Medications Used for Vulvar Diseases

 

Multiple medications are used in treating various vulvar conditions. The following information will be helpful to you in understanding the medication prescribed for your particular condition.

The following are several drugs used to treat various vulvar conditions. The first category described, tricyclic antidepressants are often used for vulvodynia treatment.

TRICYCLIC ANTIDEPRESSANTS are classically used to relieve depression and anxiety. Drugs that are in this category include, Elavilâ (amitriptyline), Norpraminâ (desipramine) and Pamelorâ (nortriptyline). Tricyclic antidepressants may also be used for pain conditions including vulvodynia and vulvar vestibulitis. They must be taken regularly to be effective. Do not skip doses, even if you feel that you do not need them. The drug must be taken regularly for three to six weeks before its full effect is felt. Do not stop taking these medications abruptly, especially if you have taken large dose for a long time. You will need to gradually decrease your dose per your doctor’s recommendations.

Before using this medication

Tell your doctor, nurse, and pharmacist if you . . .

• are pregnant or intend to become pregnant while using this medicine
• are allergic to any medicine, either prescription or nonprescription (OTC - over the counter)
• are breast-feeding
• are taking any other prescription or nonprescription (OTC) medicine
• have any other medical problems (for example, seizures, overactive thyroid gland, heart condition)

Proper use of this medicine. Take this medicine only as directed by your doctor.

• This medicine will add to the effects of alcohol and other CNS depressants (medicines that make you drowsy or less alert). Check with your doctor before taking any such depressants while you are taking this medicine.
• This medicine may cause some people to become drowsy or less alert than they are normally. Make sure you know how you react before you drive, use machines, or do other jobs that require you to be alert. Dizziness, lightheadedness, or fainting may occur, especially when getting up from a lying or sitting position. Getting up slowly may help.
• Before having any kind of surgery or dental or emergency treatment, tell the physician or dentist in charge that you are taking this medicine.
• The effects of this medicine may last for 3 to 7 days after you stop taking it. Make sure you continue to follow the precautions during this time.
• If you take tricyclic antidepressants once a day at bedtime and do not remember to take it until the next morning, omit the missed dose. Do not take a double dose.

• Dry mouth, drowsiness, memory loss, and weight gain.
• Less common side effects that should be reported to your doctor: Blurred vision; confusion or delirium; constipation (especially in the elderly); decreased sexual drive; difficulty in swallowing; irregular heart beat
• Tricyclic antidepressants can make your skin more sensitive to sunlight than usual.

Suggestions to counteract specific side effects: suck sugarless hard candies, increase fluids, stool softeners, eat a high fiber diet, and wear protective clothing and a sunscreen preparation.

• Monoamine Oxidase Inhibitors (MAO’s)- do not use in conjunction with cyclic antidepressants. These drugs are Phenelzine (Nardil) and Tranylcypromine (Parnate) and Isocarboxazid (Marplan).
• Amphetamines should not be used with antidepressants
• Antihistamines/anticholinergics (Benadryl, Hydroxazine, Brompheniramine in Dimetapp, Chlorpheniramine in Chlortermacon)- activity may increase with tricyclic antidepressant drugs. The effects are dry mouth, constipation. Urinary retention and glaucoma have been seen.
• Barbiturates (Phenobarbital, Pentabarbital, Amobarbital, Vutalbital in Fioricet) - patients on tricyclic antidepressants respond better without barbiturates; it has been recommended that barbiturates be avoided. Benzodiazepines do not appear to affect tricyclic antidepressant serum concentrations.
• Alcohol- do not drink more than one drink per day
• Bethanidine- avoid cyclic antidepressants.
• Clonidine (Catapres)- Cyclic antidepressants should be avoided if possible.
• Guanabenz (Wytensin)- monitor for reduced antihypertensive response when cyclic antidepressants are added to Guanabenz therapy. If Guanabenz is withdrawn in the presence of cyclic antidepressants, monitor for exaggerated rebound hypertension.
• Guanfacine (Tenex)- monitor for reduced antihypertensive response. If Guanfacine is withdrawn in the presence of cyclic antidepressants, monitor for exaggerated rebound hypertension.
• Debrisoquin- Cyclic antidepressants inhibit the antihypertensive response to Debrisoquin.
• Antabuse (Disulfiram)- acute organic brain syndrome has been reported.
• Prozac- Monitor for increased antidepressant levels; adjustment of the antidepressant dosage is likely to be required.
• Guanethidine (Ismelin)- avoid with antidepressants.
• Cimetidine (Tagamet)- increased serum concentrations of doxepin (Zonalon). Be alert for evidence of Doxepin toxicity (severe dry mouth, blurred vision, urinary retention, tachycardia, constipation, postural hypotension). It also increases Nortriptyline (Pamelor) concentrations.
• Lithium- Lithium and cyclic antidepressants should be used cautiously in elderly patients. Monitor for evidence of neurotoxicity such as tremors, disorders of mentation, ataxia, and seizures.
• Ritalin- enhanced antidepressant effect may occur.
• Neuroleptics- if combined with cyclic antidepressants, be alert for evidence of increased toxicity and altered therapeutic response.
• Neo-Synephrine- Enhanced pressor responses have been reported. Do not use with cyclic antidepressants.
• Other drugs which may interact:

Charcoal

Dicumarol - Coumadin

Haloperidol (Haldol)

Levodopa

Pargyline (Eutonyl)

Phenothiazines

Selegiline (Eldepryl)

 

Remember

• Use adequate birth control with tricyclic antidepressants.
• Keep this and all other medicines out of the reach of children and never share your medicines with others.
• Do not stop taking this medicine without first checking with your doctor. You should not ever stop suddenly on the use of these medicines. A gradual reduction in dosage over time is required, as directed by your doctor.
• Most common side effects (i.e. dry mouth, lethargy) will lessen with time. Be patient.

CORTICOSTEROIDS are used to help relieve redness, swelling, itching, and discomfort of many skin problems. These medicines are like cortisone. They belong to the general family of medicines called steroids.

Before using this medication

Tell your doctor, nurse, and pharmacist if you . . .

• are allergic to any medicine, either prescription or nonprescription (OTC - over the counter)
• are pregnant or intend to become pregnant while using this medicine
• are breast-feeding

• Do not use more often or for a longer time than ordered. To do so may increase absorption through the skin and the chance of side effects. In addition, too much use, especially on areas with thinner skin (for example, face, armpits, groin, vulva), may result in thinning of the skin and stretch marks.
• Do not bandage or otherwise wrap the area of the skin being treated.
• This medicine was prescribed for a specific skin problem. Do not use any leftover medicine on other skin problems without first checking with your doctor since the medicine should not be used on many kinds of bacterial, virus, or fungus skin infections.
• If you miss a dose of this medicine, apply it as soon as possible. Then go back to your regular dosing schedule. However, if it is almost time for your next dose, do not apply the missed dose at all. Instead, go back to your regular dosing schedule.

Possible side effects

• The most common side effect seen on the vulva is increased vascularity and skin thinning.
• When the gel, lotion, cream, ointment or aerosol form of this medicine is applied, a mild, temporary stinging may be expected. This generally resolves gradually.
• Side effects that should be reported to your doctor:
• Less common or rare: blood-containing blisters or pus-containing blisters on skin; increased skin sensitivity; lack of healing of skin condition; loss of top skin; numbness in fingers; raised, dark red, wart-like spots on skin; skin pain, redness, itching, thinning of skin with easy bruising
• With long-term or improper use: acne or oily skin; backache; burning or itching of skin with pinhead-sized red blisters; irritability; mental depression; muscle cramps, pain, or weakness; nausea; rapid weight gain or loss; reddish purple lines (stretch marks) on arms, legs, trunk, or groin; skin color changes; softening of skin; stomach bloating, pain, cramping, or burning; swelling of feet or lower legs; tearing of the skin; unusual increase in hair growth; unusual loss of hair; unusual tiredness or weakness; vomiting; weakness of the arms, legs, or trunk.
• Other side effects not listed above may also occur in some patients. If you notice any other effects, check with your doctor or nurse.

ANTIFUNGALS:

Topic: Azole Topical Antifungals (Vaginal)

About your medicine: Vaginal antifungals are used to treat fungus (yeast) infections of the vulva and the vagina.

Before using this medication

Tell your doctor, nurse, and pharmacist if you . . .

• are allergic to any medicine, either prescription or nonprescription (OTC - over the counter)

Proper use of this medicine:

• antifungals usually come with patient directions. Read them carefully before using this medicine.
• Use this medicine at bedtime, unless otherwise directed by your doctor.

• To help clear up your infection completely, it is very important that you keep using this medicine for the full time of treatment, even if your symptoms begin to clear up after a few days. If you stop using this medicine too soon, your symptoms may return.
• Do not stop using this medicine if your menstrual period starts during the time of treatment.
• Do not miss any doses.
• If you do miss a dose of this medicine, insert it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule.
• To help clear up your infection completely and to help make sure it does not return, good health habits are also required.
• Wear cotton panties (or pantyhose with cotton crotches) instead of synthetic (for example, nylon or rayon) panties.
• Many vaginal infections are spread by having sex. A male sexual partner may carry the fungus on or in his penis. While you are using this medicine, it may be a good idea for your partner to wear a condom during sex to avoid reinfection. Also, it may be necessary for your partner to be treated. Do not have sex during treatment

Precautions while using this medicine:

• If your symptoms do not improve within a few days, or if they become worse, check with your doctor.
• Vaginal medicines usually will come out of the vagina during treatment. To keep the medicine from getting on your clothing, wear a minipad or sanitary napkin.
• The use of nonmedicated tampons (like those used for menstrual periods) is not recommended since they may soak up the medicine.

.

Side effects that should be reported to your doctor:

• Less common--Vaginal burning or other irritation not present before use of this medicine
• Rare--Skin rash or hives

Side effects that usually do not require medical attention:

These possible side effects may go away during treatment; however, if they continue or are bothersome, check with your doctor, nurse, or pharmacist.

• Less common or rare--Abdominal or stomach cramps or pain; burning or irritation of penis of sexual partner; headache.

• Check with your doctor before taking if you are pregnant or breastfeeding or if you have liver disease, kidney disease, or other medical problems.
• Ask your doctor or pharmacist before taking any other medications, including over-the-counter (nonprescription) products.
• Take this medicine exactly as your doctor ordered. If you stop taking it too soon, the infection might return.
• Store at room temperature, and protect from heat, moisture, and direct light.

Missed Dose:

• Take the missed dose as soon as possible.
• Skip the missed dose if it is almost time for your next regular dose.
• Do not take two doses at the same time.

Side effects:

• If you have problems with these or other side effects, tell your doctor: nausea, vomiting, stomach pain, bloating, diarrhea, headache, skin rash. Some patients may have other side effects that are not listed below.
• The following side effects may be associated with more serious complications. Call your doctor immediately if any of the following effects occur: Yellowing of skin and eyes; unusual bleeding or bruising; dark or amber colored urine; severe stomach pain (especially on the right side of the stomach); severe rash or skin blistering
• Rarely reported effects: skin sloughing, hair loss, anaphylaxis

Contraindications:

• Do not use this medicine if you have ever had an allergic reaction to Fluconazole or similar medicines such as Niconazole or Miconazole. Fluconazole should be used cautiously in patients with hypersensitivity to other azoles.
• Dose reductions are recommended in patients with renal insufficiency.
• Immunocompromised patients who develop skin rashes while on Fluconazole should be monitored closely and the drug and discontinued if the lesions progress.

Liver Effects:

• Notify your care provider if you have a history of liver disease.
• Hepatotoxicity has occured with antifungal treatment.
• Abnormal liver function has been observed during Fluconazole therapy. Approximately 1% of Fluconazole-treated patients have serum transaminase elevations of more than 8 times the upper limit of normal. The incidence of elevated transaminases is greater in patients taking concomitant Rifampin, Phenytoin, Isoniazid, Valproic acid, or Oral sulfonylureas.
• When elevations of liver function tests are observed during Fluconazole therapy, close monitoring is recommended to detect the development of more serious liver injury.
• Fluconazole should be discontinued in patients who develop signs and symptoms consistent with liver disease. Hepatotoxicity is usually reversible upon discontinuing Fluconazole.
• Blood studies to check liver function may be required after six months of therapy.

Drug Interactions

• Oral Hypoglycemics: Clinically significant hypoglycemia may be precipitated by the use of Diflucan with oral hypoglycemic agents. Diflucan reduces the metabolism of Tolbutamide, Glyburide, and Glipizide and increases the plasma concentration of these agents. When Diflucan is used concomitantly with these or other sulfonylurea oral hypoglycemic agents, blood glucose concentrations should be carefully monitored and the dose of the sulfonylurea should be adjusted as necessary.
• Coumarin-Type Anticoagulants: Increased anticoagulant levels. Prothrombin time may be increased in patients receiving concomitant Diflucan and coumarin-type anticoagulants. Careful monitoring of prothrombin time in patients receiving Diflucan and coumarin-type anticoagulants is recommended.
• Phenytoin: Diflucan increases the plasma concentrations of Phenytoin. Careful monitoring of Phenytoin concentrations in patients receiving Diflucan and Phenytoin is recommended.
• Cyclosporine: Diflucan may significantly increase Cyclosporine levels in renal transplant patients with or without renal impairment. On occasion, a single dose of Diflucan may be used as treatment for patients on cyclosporine but long-term therapy is not recommended. Careful monitoring of Cyclosporine concentrations and serum creatinine is recommended in patients receiving Diflucan and Cyclosporine.
• Rifampin: Rifampin enhances the metabolism of concurrently administered Diflucan. Depending on clinical circumstances, consideration should be given to increasing the dose of Diflucan when it is administered with Rifampin.
• Theophylline: Diflucan increases the serum concentrations of Theophylline. Careful monitoring of serum Theophylline concentrations in patients receiving Diflucan and Theophylline is recommended.
• Terfenadine (Seldaneâ ): Because of the occurrence of serious cardiac dysrhythmias in patients receiving other azole antifungals in conjunction with Terfenadine, an interaction study has been performed and failed to demonstrate a clinically significant drug interaction. Although these events have not been observed in patients receiving Diflucan, the co-administration of Diflucan and Terfenadine should be carefully monitored.
• Fluconazole tablets coadministered with oral contraceptives: The clinical significance of these effects is presently unknown.