There are providers who recommend vaginal diazepam (Valium) for pelvic pain due to pelvic floor spasm. I have never understood why they do this as based on our understanding of how diazepam works it cannot be an effective therapy.
I have written previously about vaginal diazepam (Valium) here, reviewing that diazepam works on GABA receptors which are located in the central nervous system (brain and spinal cord) not the vagina. If women “feel better” after using the product vaginally it is either placebo effect or the fact that the diazepam is being absorbed into the blood stream and they are feeling the effects of diazepam on the brain. As diazepam is not recommended for chronic pain this latter effect on the brain is not a reason to prescribe the drug.
A new study looked at 49 women with a hypertonic pelvic floor and pelvic pain. It is a small study, but sound. The women were randomized to 10 mg of diazepam vaginally or to placebo. Unsurprisingly, there was no difference in pain scores between the two groups.
There are now two randomized studies looking at vaginal diazepam (Valium). The other study is smaller with 21 enrolled women (full data on 14), but statistically and methodologically sound, and also showed no benefit from 10 mg diazepam vaginal suppositories. The only publication to show benefit was retrospective chart review of 26 patients with no placebo arm and the women received vaginal diazepam as well as physical therapy and trigger point injections, meaning a far lower quality study and one that by design could not test the benefit of vaginal diazepam. That 25 of 26 patients had improvement is no surprise as pelvic floor physical therapy is highly effective and retrospective studies have a significant degree of recall bias.
Whether this new study will stop the providers who prescribe vaginal diazepam and the physical therapists who advise their patients to ask for it remains to be seen.
A few years ago a colleague of mine was at a meeting where vaginal diazepam was recommended and when she spoke up that the neurobiology and pharmacology did not support its use she was met with a big “who cares?” and “some patients say it works.”
Some patients also think vaccines cause autism, but that doesn’t make it true. It is our job as medical professionals to do the right thing and prescribing a medical therapy that can’t work based biology, pharmacology and now two prospective clinical trials is not the right thing.
Two randomized, double-blinded placebo controlled trials tell us that vaginal diazepam doesn’t work for pelvic pain due to a hypertonic pelvic floor. This supports what we know about how the drug works. There are sadly few good quality prospective clinical trials in pelvic pain and so we do a great disservice to both our patients and to medicine when we ignore the few that do exist.
Not knowing what to offer is not a license to offer the wrong thing. Our patients deserve better than that.