INTRODUCTION

Approximately 10% of the population worldwide each year is diagnosed with chronic pain [1], making it one of the global public health priorities. Chronic pain can be associated with many non-communicable diseases, including but not limited to diabetes, depression, arthritis, and many more. Furthermore, chronic pain is positively correlated with depressive syndrome: 13% of patients in gynecological clinics and 27% of patients in primary care clinics have co-morbid depression and chronic pain [2,3].

A manifestation of primary chronic pain conditions in premenopausal sexually active women under 40 years is vulvar pain or vulvodynia [4,5]. This condition affects 8-10% of the population [6] and commonly co-exists with somatic disorders. The main symptom of vulvodynia is persistent vulvar pain, which usually worsens in sitting or during urination. The pain can be burning, itching, or throbbing and devastatingly impacts sexual intercourse and daily living. Although vulvodynia is the most common cause of chronic pain among premenopausal women, it is still subject to late diagnosis, particularly in the medical communities of eastern cultures. First, young women with unexplainable complaints frequently avoid or postpone visits to a gynecologist. Moreover, doctors in eastern cultures are usually better trained in childbirth concerns, and some diseases that significantly decrease women’s quality of life are often disregarded. Gerhant et al. [2] and many other authors report very low diagnosis and treatment rates in developed and developing countries [2]. Around 50% of patients do not address their problems in time or are referred to as many as three to five medical specialists without being correctly diagnosed. This imposes a severe burden on the psychological well-being of women living with vulvodynia [6,7].

This is a case of a teenager suffering from vulvodynia co-morbid with depression. As discussed previously, vulvodynia is poorly diagnosed and rarely treated in Azerbaijan. Comorbidity with depression significantly decreases well-being and quality of life, leading to severe mental health conditions such as depression and/or suicidal ideation.

CASE PRESENTATION

The patient was a 13-year-old Azerbaijani teenager who presented to for psychiatric opinion with her mother. A gynecologist referred her to a mental health specialist as having “severe mental illness”. In the last three months, she has visited four gynecologists, a family therapist, and an endocrinologist, all of whom could not reveal any dysfunction corresponding to the presented complaints. A patient was born in term, had normal physical and intellectual development and progressed well at school up until the pain manifestation around five months ago. She never exhibited any signs of behavioral problems or personality disorders. Her medical history was unremarkable, except for numerous pain-related visits to gynecologists in the last three months. The gynecological examinations did not reveal any severe disease or condition that could explain the pai; therefore, she was referred to a mental health specialist, preferably a psychiatrist.

During the mental state examination, the eye contact was reduced, the facial expression was sad and anhedonic, and there were no obvious psychomotor abnormalities. The speech of the patient was slow and monotone, congruent to a depressed mood. No positive or negative symptoms corresponding to a psychotic state were discovered. During the conversation, the patient complained of a five-month history of severe itching pain, which developed without clear reason and did not disappear or decrease in intensity after the analgesics. The psychiatrist also discussed psychosocial issues, including any form of sexual or physical abuse, but the patient rejected those as irrelevant. The results of the physical examination were within normal limits. The patient also denied alcohol or cigarette consumption. She told that the pain was unbearable and she also expressed anger with her being referred to psychiatrists and doctors who insisted that the pain has no physical explanation and is due to mental issues only. The patient burst into tears while trying to explain that it is very complicated to live in such pain, and she is even thinking about suicide to escape these sufferings.

The patient was diagnosed with a “severe depressive episode without psychotic symptoms (F32.2)” and was referred to a physiotherapist specializing in pelvic floor dysfunctions before treatment initiation. A thorough gynecological examination established previously undiagnosed vulvodynia. Differential diagnosis was with lichen sclerosis, lichen planus, and vulvar/vaginal dryness and confirmed the diagnosis of chronic pain due to vulvodynia.

The patient was prescribed duloxetine 30 mg/daily, gradually increasing to 60 mg/daily. A month later, on the planned visit, the patient reported significantly reduced pain syndrome and improved psychological well-being. It was suggested to continue with duloxetine 60 mg/daily, and the next visit was scheduled in two months.

DISCUSSION

Thus far, vulvodynia is a poorly understood disease with no explicitly determined causal factors [8,9]. It is frequently misdiagnosed or incorrectly addressed and treated. This significantly limits performance in daily functioning and contributes to mental issues, including severe depressive disorder and suicidal ideation. According to research by Patla et al. [10], vulvodynia causes a 64.5% deterioration in the health- related quality of life. Our literature search revealed a few case studies on vulvodynia and related issues and only one on depression and vulvodynia [2,11,12]. This is an indirect indicator of insufficient interest to the topic. Vulvodynia is still widely misdiagnosed worldwide, causing devastating consequences to the daily routine, sexual life, health-related quality of life, and psychological well-being of premenopausal women. Vulvodynia has a strong correlation with depression and may contribute to the development of suicidal ideation, with chronic pain being a significant risk factor for suicide. The issue becomes exceptionally pertinent for women from low- and middle-income countries experiencing a shortage of necessary economic and healthcare resources, including access to medical help, absence of health coverage, and scarcity of mental health specialists.

This case study highlights the damaging issue of chronic pain, particularly vulvar chronic pain, among sexually active women. The prevalence of vulvodynia in Azerbaijan is unknown, mainly due to low awareness of this condition and omnipresent misdiagnosis. There is an urgent need to bring awareness to this global public health issue, mainly among gynecologists, primary care physicians, and nurses.

More research is needed on this topic. This will build a scientific background for a more targeted approach, evidence-based guidelines, and interventions. Another barrier to timely treatment and prevention of relapses is that the specialization of physiotherapists and physiotherapy is very underestimated as a treatment choice in Azerbaijan. This limits patients’ access to a wide range of possible treatment options.

Ethics

Informed Consent: Informed consent was obtained from the patient.

Peer-review: Externally and internally peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: Z.A., K.G., Concept: Z.A., K.G., Design: Z.A., K.G., Data Collection or Processing: Z.A., K.G., Analysis or Interpretation: Z.A., K.G., Literature Search: Z.A., K.G., Writing: Z.A., K.G.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.