S.H.E. Medical Associates
Vulvodynia : Frequently Asked Questions
What Is Vulvodynia?
Vulvodynia is a broad term used to describe unexplained pain in the genital area that has been present for more than three months. Vulvodynia pain is described by women in many different terms, such as burning, stinging, itching, stabbing, or aching. Some women experience pain only in the opening of their vagina when touched (provoked vulvodynia). Others experience pain without being touched and their pain is throughout the vulva (generalized vulvodynia). This pain may wax and wane and often symptoms feel worse if anything aggravates the vulva (i.e. recent intercourse, prolonged sitting, or tight clothing). Each woman with vulvodynia has a unique story and pain description.
Who Has Vulvodynia?
Vulvodynia affects women of all ages and ethnic backgrounds. Our practice serves women with vulvar symptoms in the pre-adolescent years through the postmenopausal years.
What Causes Vulvodynia?
The exact cause of vulvodynia is uncertain but there are many different theories. It is possible that some women may have a genetic predisposition to chronic pain disorders. This means that this is passed along in your genes. We suspect this because many women with vulvodynia or their family members experience other auto-immune and chronic pain conditions, such as:
- Migraine headaches
- Temporal mandibular joint pain (TMJ) or jaw pain
- Irritable bowel symptoms
- Interstitial cystitis or frequent bladder symptoms
- Chronic fatigue syndrome
- Fibromyalgia or unexplained joint pain
Other theories about the causes of vulvodynia pain suggest that the nerve impulses in the vulvar region are not working properly and stuck in the “on” position. What causes these nerves to flare up may be different for each woman. It is proposed that a chronic irritation or injury could damage the vulvar nerves. For some women it could be a history of recurrent infections like yeast. Other women with vulvodynia report a specific precipitating incident, such as childbirth or surgery. Still others find vulvar pain begins randomly without any warning. Once a woman begins to experience sexual pain, the muscles in the pelvic floor may begin to spasm or tighten in response to this pain. This may further aggravate sexual pain. We don’t completely understand if it was the trigger itself, the treatments, or a woman’s predisposition that causes the resulting pain. Because the exact cause of this pain is unknown or may differ for each woman, finding an effective treatment remains a challenge for providers. Researchers are currently working on trying to understand the cause or causes of vulvodynia in order to provide better treatment options.
What To Expect At Your First Appointment
In order to diagnose and treat vulvar pain, your provider must first rule out all other possible explanations for vulvar pain. This means that your first appointment is often time consuming. First, a very thorough medical history will be obtained. It is helpful for you to complete the following questionnaire prior to arriving: SHE Vulvovaginal Consult Questionnaire. This way you can be assured your provider will know all of the important details about your health and your specific pain symptoms. Women with vulvar pain often have a lot of information to share with their provider and it is a lot to convey in one office visit. By filling in your information prior to arriving, your provider will have something to refer to when they are reviewing your case and developing your plan of care.
After your history is reviewed, a vulvar and vaginal exam will be performed. Great care is taken to be a gentle as possible due to your history of vulvar pain and for some women; a full exam will not per completed if it is not tolerable. The goal is to rule out any vulvar skin disorders, vaginal infections, and determine exactly where your pain is.
Treatments vary based on the findings at the first exam. If there any vaginal infections or skin disturbances, this must be addressed first even if your provider suspects you have vulvodynia along with these issues. If you still experience pain after treating any skin issues and vaginal infections, your pain issues will then be addressed.
Typical treatments include oral and topical vulvar medications and/or physical therapy. Some of the oral medications used fall into the antidepressant family (amitriptyline or Cymbalta). These are not prescribed because we think your problem is “in your head.” Rather, these medications are known to calm down nerves that are fired up in your vulva. Other medications fall into the anticonvulsant family. Again, these medications calm down nerve excitability. Some topical medications are used to provide your vagina with more estrogen and build up the lining of the vaginal wall. Others calm down or numb the nerve pain. It usually takes time and patience to find the best combination to improve and hopefully resolve your vulvar pain.
Physical therapy is also often recommended as part of your treatment plan. Often after experiencing pain with sex, your pelvic muscles automatically tense up even when just thinking about sex. This is a natural tendency when anticipating a painful experience. Physical therapy is helpful to retrain the pelvic muscles how to relax.
Self Help Strategies
Psychotherapy is extremely helpful for anyone who is experiencing chronic pain. This in no way implies that this pain is “in your held.” Talking with a therapist is suggested in order to help you with your personal coping skills and deal with the impact of pain on your relationships.
There is a direct correlation with chronic pain and stress. Finding a way to bring balance into your life is the key to healing. It is essential to explore how the mind impacts your body and the pain response. Some women find the following stress reduction techniques useful: yoga, meditation, massage, hypnosis, and exercise
The process of bringing balance into your life also includes incorporating a healthy diet and exercise program. There is no evidence at this time to support that diet alone improves vulvar pain symptoms but clearly poor nutrition habits or carrying excess weight creates more work for your body. Excess fatty tissue and folds creates a place for heat rashes and fungal infections to develop and possibly aggravate your pain symptoms.
Surveys have revealed that self-esteem is often lower when one suffers with vulvar pain. Caring for your body by keeping it fit and tone will help you maintain a positive self image and feel healthier overall.
Some women find a low-oxalate diet helpful with vulvar pain symptoms. This is especially useful if you suffer with interstitial cystitis or a frequent sensation of bladder spasms or pressure. This includes removing acidic foods from the diet such as, coffee, citrus fruits and tomatoes. For a complete description of this diet the following web site is recommended: http://www.ichelp.org.
Keeping a diary is useful when you suffer with chronic pain. Over time, many women find that their journals help them better understand pain triggers. In addition, it is helpful to be able to track your progress when reporting back to your health care provider. Sometimes the progress is slow. If you are able to review your journal you may find that your ratio of good days to bad days is improving. This is hard to figure out unless you have a report to refer to when you tally up your overall response.
Vulvar Hygiene Suggestions
It is important to provide gentle hygiene in the vulvar area to avoid any further discomfort to your vulvar pain. We recommend you wash with little or no soap and avoid rubbing with any wash cloths, loofahs, or sponges. The best soaps to use are fragrance free Dove or Cetaphil. In addition, you should avoid using any harsh laundry detergents. Try to avoid any tight clothing, thongs, pantyhose or synthetic fabrics. At your office visit we will provide you with a detailed list of products that you should avoid using in the vulvar area.
Resources: National Vulvodynia Association (www.nva.org) International Society for the Study of Vulvovaginal Disease (www.issvd.org) “The V Book, A Doctor’s Guide to Complete Vulvovaginal Health” by Stewart aand Spencer (2002). http://www.thevbook.com “The Vulvodynia Survival Guide: How to Overcome Painful Vaginal Symptoms and Enjoy an Active Lifestyle” by Glazer and Rodke (2002).