Spironolactone and Vulvar Pain and Irritation: Is this an overlooked side effect?

Spironolactone-Associated Vulvar Pain, irritation, Decreased Lubrication and Dyspareunia

Androgen hormones have an important role in sexual health including libido, arousal, orgasm and lubrication. Antiandrogens have the potential affect many of these function. The best studied are reduced libido and orgasm.

A new study by Mitchell and colleages reports 7 patients with dyspareunia (painful intercourse), vulvar pain and irritation temporary associated with the start of spironolactone. For many of the affected individuals, pain started 5-6 months after starting spironolactone.

The authors describe two patients in detail. The first was a 47 year old female with dyspareunia and vulvar pain starting 5 months after the start of spironolactone. Examination showed vulvar atrophy and the vulvar area was very painful. The patient’s spironolactone was stopped and she started estradiol 0.01 %/testosterone 0.1% gel twice daily. This was applied to the vestibule of the vulva. This reduced atrophy and pain and there was a complete resolution of dyspareunia.

The second patient described by the authors was a 46 year old female. She had vulvar irritation, decrease arousal and dyspareunia. This had been occurring for 3 years and starting 5 months after starting spironolactone. With the use of estradiol 0.01 %/testosterone 0.1% gel twice daily the patient had increased libido and increased lubrication and decreased pain.

Comment and Discussion

Decreased libido is a known side effect of spironolactone. Other issues like decreased lubrication, decreased orgasm, vulvar irritation and painful intercourse are less well studied. It is important that these issues be studied and reported so that we can best counsel our patients on side effects before they start as well as how best to treat these issues when they occur.

The vulvar atrophy, pain, decreased libido and arousal were all treated in this report with cessation of spironolactone. We don’t know if continuing the spironolactone and using the topical agents would provide benefit. Furthermore, we do not know how long these agents were used in this study.

At first read, it would appear that stopping the spironolactone is quite straightforward as an option. In my practice that is not always the case. Many patients are starting to experience reduced hair shedding and improvement in their hair around the exact same time that many of these issues relating to sexual function start to arise. For many patients, stopping the spironolactone is not something they immediately wish to do even if a link to sexual dysfunction is suspected. For some it is. For some it is not.

The key then, is to understand the issues in detail and refer to specialists for assistance. My gynaecology colleagues assist in ruling out other causes of the sexual dysfunction and assist the patient in the decision on stopping spironolactone vs treating with spironolactone continued. They also assist on the use of topical estrogen and testosterone. I don’t think there is one single template for how issues can or should be treated.

The reality is that for some patients the cessation of spironolactone and the start of topical testosterone even if locally applied, can be associated with an acceleration of hair loss once again. This can be quite emotionally difficult for patients. For some, the best plan is to stop the spironolactone or lower the dose an initiate other treatments for the hair loss like oral minoxidil, topical minoxdil, topical finasteride or PRP.

There is no right or wrong answer and each needs to be addressed on a case by case basis

REFERENCE

Mitchell et al. Spironolactone May be a Cause of Hormonally Associated Vestibulodynia and Female Sexual Arousal Disorder. J Sex Med. 2019 Sep;16(9):1481-1483.