• Camelia Brande

Vulvodynia...a modern mistery

Vulvodynia, a condition that has been reported by women for centuries, but only recently has been classified as a real disorder. As it is a health concern affecting women, with multiple implications, the need to find suitable treatment is imperious. What is it and how can it be treated? Let’s find out!


The International Society for Study of Vulvovaginal Disease defines vulvodynia as “vulvar discomfort, most often described as burning pain without relevant visible findings or a specific, clinically identifiable, neurologic disorder.”

Symptoms of this condition can be: sensation of burning, irritating, stinging and soreness usually lasting for more than 3 months, limiting or preventing intercourse. The pain can appear either after the first episode of intercourse or after a period of pain free activities.



Vulvodynia can be classified in two categories:

1. Generalized (pain spread all over the vulva)

  • Provoked: sexual, non-sexual or both

  • Unprovoked

  • Mixed: provoked and unprovoked

2. Localized: vestibulodynia (pain at the entrance of the vagina), clitorodynia (clitoral pain), hemi vulvodynia (vulvar pain on a part of the vulva)

  • Provoked : sexual, nonsexual or both

  • Unprovoked

  • Mixed: provoked and unprovoked


Studies show that vulvodynia is very common. It affects up to 28% of women in reproductive years. Therefore, it represents a significant challenge for society, the healthcare system, the affected woman and her intimate partner (if there is one), and her family. It has been estimated that in the US alone, l $31-72 billions are spent annually due to vulvodynia, as the suffering women may consult different doctors (general practitioners, gynecologists, dermatologists, urologists and alternative practitioners). All these actions result in a delay of diagnosis and management of the condition.


Vulvodynia is a multifactorial disease and the causes of this condition are not entirely elucidated. Researchers suggest multiple factors.


Genetic factors

  • Studies suggest that women with vulvodynia may have a genetic predisposition , due to an inherited increased sensitivity to pain


Muscular factors

  • Changes of the pelvic musculature may induce vulvodynia

  • Pelvic modifications can occur from different factors such as vaginal childbirth, abdominal or pelvic surgery, prolonged sitting, poor posture


Hormonal factors

  • The tissues of the vulva and vagina are dependent on hormones, therefore, a decrease in them may lead to changes in the vagina and vulva

  • The most common decrease of hormones happens during menopause

  • Other factors: anorexia, absence of ovulation during breastfeeding, amenorrhea (absence of menstruation), hysterectomy (surgical removal of the uterus), combined hormonal contraceptive pills (estrogen + progestin)

  • Combined hormonal contraceptive pills are linked to decreased pain threshold, decreased lubrication, decreased sexual frequency and increased dyspareunia (painful sexual intercourse)


Medicine

  • As antibiotics are the most common prescription medication taken by women they can cause vulvar pain in an indirect way. Long-term exposure to antibiotics can cause chronic yeast infections, which have been associated with a higher chance of having vulvodynia


Psychological

  • Studies suggest that anxiety and depression may be a cause and a result of vulvodynia

  • Researches suggest that the chances of having vulvodynia are 4x higher in women with anxiety than in women without anxiety

  • It being a vicious cycle, greater vulvar pain and sexual dysfunction were associated with anticipation of pain, fear of pain, lower self-efficacy


Sexual and physical abuse

  • Studies show that women with vulvodynia were 4x more likely to have reported sexual or physical abuse in the past


Impact on sexuality

  • Women with vulvodynia report low libido, less satisfaction, difficulty in reaching orgasm, less frequent intercourse and a negative approach towards sexuality

  • New studies suggest that partners of women suffering from vulvodynia also experience distress and dissatisfaction

  • This is why the support of a partner is essential. Studies show that women’s response to their pain is influenced by their partners response

  • Encouraging attitude from the partner is associated with better sexual function, sexual and relationship satisfaction, and lower pain.This emphasizes the importance of focusing on intimacy, emotions and communication as a couple coping with vulvodynia

  • 80% of women with vulvodynia still engage in sexual intercourse. The reasons behind this behavior can influence the pain and disposition differently. Women that have sex in order to avoid losing their partner, report lower sexual and relationship satisfaction and higher levels of depression. While women that engage in sexual activities for the purpose of feeling closer to their partner report higher sexual and relationship satisfaction.


Healthcare approach

Vulvodynia combines two specialities: chronic pain and sexuality. Consequently, it becomes a difficult subject to be tackled even by a doctor. As the pain manifests itself in the genital area and during sexual intercourse, discussing this issue can be an uncomfortable topic for health professionals and patients. But it shouldn't be.

Because of this, many women suffering from this condition are silent sufferers and only 60% of them consult a healthcare specialist, from which only 9% are correctly diagnosed with chronic vulvar pain. Another study shows that around 70% of women are comfortable talking about their condition with their partner, but only 27% of them would discuss it with another woman.

The symptoms of vulvodynia have psychological implications as well. Women may feel ashamed and stressed about this condition. They develop depression, altered body image, sexual function, relationships, and difficulty in managing daily activities.


Diagnosis

The relationship between a medical physician and the patient has to be strong. Vulvodynia is a diagnosis of exclusion. The doctor must assess all the symptoms and dismiss all the conditions that would result in pain and ask questions about the sexual history of the patient.


Diagnostic tools


Cotton-swab test

Represents the standard test for the diagnosis of vulvodynia, specifically the localized one. The doctor palpates different regions of the genital area with a cotton-swab while observing the patient’s reactions. The patient has to quantify the pain as mild, moderate or severe. Because the pressure applied can be different from one doctor to another, this method is not that reproductibile and can’t be compared between physicians.


Vulvalgesiometer

A device that can standardize the pressure applied, makes tests and results uniformed and reliable (an improved version of the cotton-swab test)


Tampon test

The intensity of pain during intercourse is considered the “gold standard”. In order to simulate and quantify the pain resulting during sexual activity, a tampon is used and the patient has to quantify the pain.


Treatment

After a correct diagnosis, both the woman and the partner (if there is one) must educate themselves about this condition and prospective treatments or measures that can alleviate the pain.


  • Validate symptoms, be supportive

  • Stop activities and products that can irritate: excessive washing, tight clothing, douching, irritating lubricants, sanitary pads

  • Apply cold compresses on areas of pain

  • Address and manage depression

  • Apply non irritative lubrication during intercourse: vegetable oil (except when using condoms, as the oil can damage the material and break the condom)

  • Apply lidocaine ointment 5% or gel 2%, 20 minutes before intercourse (Attention! Male partners can experience penile numbness and partners in general should avoid oral contact)

  • Pursue sex therapy and counseling as a couple in order to cope with symptoms

  • Antidepressants

  • Anticonvulsivants

  • Injections with anti inflammatories

  • Pelvic floor physical therapy (assessment of pelvic musculature, joints and muscle tension)

  • Biofeedback training: patients learn exercises to strengthen pelvic floor muscles resulting in a reduction in pain

  • Cognitive-behavioral therapy (CBT)

  • Vestibulectomy/perineoplasty: surgical removal of parts of the vestibule (vaginal opening) or perineum (the area between the vulva and anus) that produce pain. It is an effective intervention with success rates between 61% and 94%. Before vestibulectomy, patients should be evaluated for vaginismus. In case of vaginismus, it has to be treated before undergoing surgery, otherwise the surgery is usually less successful.


Before taking any treatment, consult your physician. Do not take medicine (antidepressants, anticonvulsivantes, anti inflammatories) without consent and prescription from your doctor!


As vulvodynia is still poorly defined and understood, future research is imperious. The right treatment for a certain patient is difficult to choose. We hope for a near future where vulvodynia can be easily cured.


Sources:

https://pubmed.ncbi.nlm.nih.gov/26944461/

https://pubmed.ncbi.nlm.nih.gov/27045258/

https://pubmed.ncbi.nlm.nih.gov/20883912/

https://pubmed.ncbi.nlm.nih.gov/24833921/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5568852/

https://pubmed.ncbi.nlm.nih.gov/15870521/


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