Vulvodynia

External genital organs of female. The labia minora have been drawn apart. Source: Grey's Anatomy, 1918.

Vulvodynia is pain of the vulva. The vulva is the external genital organ of women. It includes the area from the pubic hair, the external lips (labia majora and minora) of the vagina, the vaginal opening, the glands at the vaginal opening, and the area between the vagina and the anus. Vulvodynia is thought to be due to irritation or hypersensitivity of nerve fibers in the vulvar skin.

Types

Vulvodynia can be generalized (pain throughout the vulva) or localized (pain in one specific area of the vulva).

Signs and Symptoms

Women with vulvodynia generally describe feelings of:

• Burning
• Stinging
• Rawness
• Aching in the vulva.

These symptoms can be a mild discomfort or more severe pain that can prevent daily activities. Other symptoms include:

• Discomfort with sitting
• Some women report an increased vaginal discharge with the pain.
• Pain and burning with urination
• Pain with intercourse or with tampon insertion.
• In more extreme cases there may be pain when tight pants are worn or with riding a bicycle.

Causes

No one knows for sure what causes vulvodynia. Theories include:

Generalized vulvodynia

• Vulvodynia resulting from an injury to or an irritation of the nerves in the vulva or an abnormal response to infection or injury
• Spasms of the vaginal and pelvic muscles
• A continuous pain signal possibly due to injury, back problems or trauma after surgery, childbirth, or accidents
• In some cases, generalized vulvodynia may be part of a larger generalized pain condition like fibromyalgia

Localized vulvodynia

• Inflammation (possibly triggered by yeast)
• A local irritant
• Being rubbed by something in the area
• Chronic pain sensitizing the local nerves. Muscles in the area can also become tense, which causes them to spasm. This produces more pain and sets up a pain loop.

Vulvodynia is not sexually transmitted and is not associated with any cancerous conditions.

Diagnosis

The diagnosis of vulvodynia is made by taking a careful history of symptoms, excluding other infectious or dermatologic causes for the pain and by eliciting discomfort when gentle pressure (usually a cotton tipped applicator) is applied to the area.

Treatment

While there is no cure for vulvodynia, there are several treatments that can help. These include:

Medications

• Topical pain relievers, like lidocaine ointment, can be applied to the vulva.
• Topical estrogen can sometimes help in localized vulvodynia.
• Tricyclic anti-depressants (TCA's) used in low doses can decrease pain. These medications are thought to work by altering the way the nerve fibers send their pain impulses to the spinal cord. Many people have found these drugs to be helpful.
• Gabapentin and other antiseizure drugs are sometimes used to treat generalized vulvodynia. These medications also have pain-blocking properties.

Therapies

• Pelvic physical therapy, including pelvic muscle exercises, may help prevent muscle spasms and pain.
• Biofeedback is sometimes useful.
• Nerve blocks (using local anesthetics) can be performed in specialized pain clinics.
• Surgery can sometimes help localized vulvodynia.

Holistic and alternative treatments

• Avoiding vulvar irritants including any perfumes, deodorant tampons, or pads may help symptoms. Bubble baths, soaps, sprays and douches can irritate delicate genital tissue.
• Not washing the vulva excessively as this can worsen symptoms.
• Using perfume-free laundry detergent designed for sensitive skin.
• Rinsing the vulva with cool to lukewarm water after urination and in the shower.
• Avoiding wearing tight clothes, which can worsen symptoms. Wearing white, 100% cotton underwear and loose-fitting pants or skirts can help.
• It may be helpful to use certain lubricants during intercourse.
• Diet changes may help. For some women, it helps to eliminate highly acidic and sugary foods from the diet. Some believe that eating a diet low in oxalates can help.

Living with Vulvodynia

Many women live daily with significant discomfort and pain due to vulvodynia. They may also experience frustration due to the lack of a known cause or cure. There are a number of internet support groups where women with vulvodynia are able to compare notes.

According to the NIH Record from December 14, 2007, ^[1], The Office of Research on Women’s Health recently announced an NIH Vulvodynia Awareness Campaign to help educate health care practitioners and the public about chronic pain of the vulva, the area around the outside of the vagina. The campaign kicked off with a media conference held at the National Press Club in Washington, D.C.

Clinical Trials

A list of ongoing clinical trials is available at ClinicalTrials.gov: Vulvodynia trials

Research

There is a great deal of recent research on vulvodynia. A selection of recent studies includes:

• Modified vestibulectomy (removal of hypersensitive tissue in localized vulvodynia) was found to be an effective treatment for long-term vulvodynia. ^[2]
• The relationship between vulvodynia and secondary psychosexual problems is discussed. This study theorizes that there is a significant role of psychosocial factors in the development of chronic vulvar pain. ^[3]
• Although no evidence of Helicobacter pylori infection was found in the vulvar area, 73% of women in a study from Israel had complete relief of both gastric symptoms and vulvodynia after they were empirically treated for H.pylori infection. ^[4]
• Vulvar skin biopsy was found to be useful in diagnosing a variety of dermatologic diseases that likely caused chronic vulvodynia. Skin biopsy performed by a dermatopathologist may be a useful diagnostic tool. ^[5]
• A population-based, case-control study of women with and without vulvodynia failed to show an association between dietary oxalate and vulvodynia. ^[6]

Epidemiology

Statistics

Women presenting with vulvodynia typically are white; are in stable, long-term relationships; have had the pain for several years; and have been examined several times by multiple physicians before receiving the diagnosis. The age range is broad, from children (rarely) to women 80 years and older, but most women with this disorder are between 20 and 50 years of age.

Vulvodynia is not associated with sexually transmitted diseases (STDs) or STD risk factors, but affected women often have been treated repeatedly for candidal vulvovaginitis. In the past, it was theorized that the pain of vulvodynia was due to psychological issues. However, recent data indicate that women with vulvodynia are psychologically comparable to women without the disorder and are no more likely to have been abused. Marital satisfaction levels also are similar. ^[7]

Prevalence

Studies that systematically addressed prevalence in different settings found vulvar pain to be much more common than previously thought, with rates of 15 percent in one gynecologist's practice, 1.7 percent in an Internet survey, and 8.6 percent in a population-based study of symptomatic women in the Boston area. These findings would extrapolate to more than 2.4 million women in the United States and approximately 15 affected women in a family practice of 2,000 patients. ^[7]

Interesting Facts

Vulvodynia has been featured in magazines, newspapers and on television shows in the past decade.

TELEVISION

• Private Practice (ABC) October 2007
• The Art of Women’s Health (PBS) April 2005
• Sex and the City (HBO) June 2000
• The Oprah Winfrey Show (NBC) February 2000
• Fox News Health Blog (FOX) March 2008

RADIO

• Voices in the Family with Dr. Dan Gottlieb. WHYY. Philadelphia, PA. November 27, 2006. Women and Healthcare

BOOKS

• The V Book by Elizabeth Stewart, MD and Paula Spencer
• The Vulvodynia Survival Guide by Howard Glazer, PhD and Gae Rodke, MD

References

1. ↑ NIH Record. Vulvodynia Awareness Campaign Begins
2. ↑ Eva LJ, Narain S, Orakwue CO, Luesley DM. Is modified vestibulectomy for localized provoked vulvodynia an effective long-term treatment? A follow-up study. J Reprod Med. 2008 Jun;53(6):435-40. Abstract
3. ↑ Lynch PJ. Vulvodynia as a somatoform disorder. J Reprod Med. 2008 Jun;53(6):390-6. Abstract
4. ↑ Geva A, Sabo E, Levy J, et al. A Search for Helicobacter pyloriin Localized Vulvodynia. Gynecol Obstet Invest. 2008 Jun 6;66(3):152-156. (Epub ahead of print) Abstact
5. ↑ Bowen AR, Vester A, Marsden L, Florell SR, Sharp H, Summers P. The role of vulvar skin biopsy in the evaluation of chronic vulvar pain. Am J Obstet Gynecol. 2008 May 15. (Epub ahead of print) Abstract
6. ↑ Harlow BL, Abenhaim HA, Vitonis AF, Harnack L. Influence of dietary oxalates on the risk of adult-onset vulvodynia. J Reprod Med. 2008 Mar;53(3):171-8. Abstract
7. ↑ ^{7.0 7.1} Reed BD. Vulvodynia: diagnosis and management. Am Fam Physician. 2006 Apr 1;73(7):1231-8. Abstract | Full Text

External Links

The International Society for the Study of Vulvovaginal Disease

Vulval Pain Society (UK)

National Vulovdynia Association