A common cause (possibly the most common cause) of both pelvic pain and pain with sex is spasm of the pelvic floor (the levator ani and obturator internus muscles). Some physicians have promoted vaginal Valium as a treatment. There is a retrospective study of 26 patients (which has all the inherent problems of small retrospective study – no placebo control, unblinded researchers, and recall bias to name a few) that suggests vaginal Valium might be an option for some patients. The other HUGE problem with that study (Rogalski et al 2010) is the vaginal Valium was part of treatment that also included pelvic floor physical therapy and trigger point injections. And because the Internet seems to be a megaphone for lesser quality studies I am being asked more and more about this option.
I have always had concerns about vaginal Valium for several reasons:
- Benzodiazepines (Valium, or diazepam, is a benzodiazepine) are typically not useful for chronic muscle pain and spasm conditions. They can help acute muscle spasm, but chronic pain and spasm is a different entity. For example, treatment guidelines for chronic low back pain (which is often a muscle spasm condition) do not include benzodiazepines. While benzodiazepines are used for dystonias (involuntary muscle contractions that cause slow repetitive movements or abnormal postures that can lead to pain), pelvic floor spasm is not a dystonia.
- Benzodiazepines do not work topically. I can’t find any studies to support their use as a topical agent. And they wouldn’t be expected to work topically because they work centrally on the neurotransmitter gamma-aminobutyric acid (GABA), which is found in the brain and spinal cord. If vaginal Valium works, given the mechanism of action, it would have to be absorbed systemically to reach the brain and spinal cord, so a vaginal route would offer nothing but mess and expense.
- Valium has a high abuse potential and withdrawal can be fatal, so using this medication requires strict attention to exactly how it is used. It also requires high quality studies that support its use.
A new study confirms the lack of effect of vaginal Valium for pelvic floor muscle spasm and pain. While it is a small study (21 patients, full data only on 14) it is a randomized placebo-controlled trial so very high quality. Patients were required to have EMG evidence of muscle spasm prior to admission into the study. The subjects used a 10 mg vaginal Valium suppository every night for 28 days or a placebo suppository. There was no change in pain scores and no change in baseline EMG measurements (a method of measuring muscle spasm). The only downside of the study is that they didn’t do serum levels of diazepam (Valium). It would have been interesting to know how much, if any, was absorbed.
Understanding the pharmacology of Valium it can’t work topically as it needs to access the central nervous system. This new study offers confirmation. If people do feel better using vaginal Valium then it is either a placebo effect or due to systemic absorption. This study suggests that given there was no difference between the groups any benefit women report from vaginal Valium is most likely placebo. In this new study both groups, the placebo and the vaginal Valium, reported improvement. Any further work with vaginal Valium that doesn’t involve a placebo-controlled trial should be discouraged.
There are many treatments for pelvic floor muscle spasm, but vaginal Valium isn’t one of them.