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Dealing With Chronic Vulvovaginal Pain

“External and sometimes vaginal itching, burning, rawness, and irritation that can be worsened by wiping, wearing tight clothing, sexual intercourse, cycling, or inserting a tampon.”

These are some of the ways women describe their chronic vulvovaginal pain. For some, it may come and go, but for others it may be constant and relentless. The key to treating chronic vulvovaginal pain is to get an accurate diagnosis and to develop an individualized treatment plan using all of the tools that are available. There are many causes of vulvovaginal pain; therefore, it is important to take a systematic approach to ruling out potential factors causing vulvovaginal pain and to focus on the specific origins of each woman’s symptoms.

Causes of vulvovaginal pain can include:

Infectious conditions, such as recurrent or complicated yeast, trichomonas, and herpes. These conditions are diagnosed by microscopically examining and culturing vaginal discharge. Treatments can include long-term antifungal use, both topical and/or medications, and antivirals and antibiotics.

Inflammatory skin disorders such as atrophic vulvovaginitis, allergic vulvovaginitis, lichens simplex chronicus, lichens sclerosis, lichen planus and desquamative vaginitis. These disorders are diagnosed by distinctive characteristics of the skin and the vaginal tissues, or by biopsy. Treatments can include topical steroids or topical immune modulators, antihistamines, topical numbing preparations and topical estrogens; often a combination of these therapies are used.

Neurological disorders such as pudendal nerve entrapment or injury from childbirth or trauma, including sports injury, referred pain from ruptured disc, herpes neuralgia, pelvic floor dysfunction, or neurologic diseases such as multiple sclerosis. Treatment for these aspects encompasses treating the underlying condition.

Neoplastic (cancerous or precancerous) disorders such as squamous cell carcinoma and vulvar intraepithelial neoplasia (VIN). These conditions are diagnosed by biopsy and have a range of treatment depending on the severity of the lesions. Mild lesions may be treated with topical immune response modifiers; others may need to be excised or removed surgically.

Vulvodynia or vulvovestibulitis syndrome, vestibulodynia, vulvar dysesthesia, clitorodynia, and vaginismus. These conditions are diagnosed by excluding all other causes of the vulvovaginal pain and are based on symptoms. In the case of vestibulodynia, which is the most common vulvar pain condition, the presence of symptoms known as Fredrich criteria confirm the diagnosis.

Fredrich’s Criteria:

  • Severe pain on vestibular touch or attempted vaginal entry.
  • Tenderness to swab pressure localized to within the vestibule.
  • Various degrees of redness in the vestibule with no other sign of problems.
  • Symptoms present for more than six months with tenderness moderate to severe in intensity.

To better understand vulvodynia and vestibulodynia, research in other areas of medicine and chronic pain found that the excessive pain and burning to light touch that women with vulvodynia and vestibulodynia have, with no abnormal findings of exam, were similar to people with phantom limb pain. Patients with amputation of a limb often have hyperalgia or excessive pain when the normal healed skin of the amputation is touched, and allodynia or pain with touch that is normally pleasurable. The similarities between these and other forms of chronic pain led to the theory that vulvodynia and vestibulodynia are pain disorders coming from abnormal pain circuits that develop in the central nervous system through a process called central sensitization. Vulvodynia is most likely from a nerve injury and vestibulodynia is most likely from nerve irritation.

Treatments for these conditions can include avoiding vulvar irritants and possibly some dietary changes. Physical therapy with biofeedback and pelvic floor physical therapy/rehabilitation are an important part of treatment. Medications that are often used for their pain-relieving effects on these abnormal pain circuits include topical or oral forms of tricyclic and various other antidepressants, and seizure medications. Topical estrogens and local numbing medications are also used as are nerve blocks and injected steroids. In women with vestibulaodynia only, if there is no improvement in symptoms after all medical treatments have been tried, then surgical treatment with vestibulectomy or perineoplasty can be effective.

An informative resource on vulvodynia is The V Book: A Doctor’s Guide to Vulvovaginal Health, written by Dr. Elizabeth Stewart, which was written for women having vulvodynia or vestibulodynia. Dr. Stewart makes this very complex subject understandable and also provides information beneficial for spouses and significant others of women experiencing these problems.

The National Vulvodynia Association is a very active support group for women with chronic vulvovaginal pain, and the organization publishes an associated newsletter with helpful information on the topic.

If you have symptoms of chronic vulvovaginal pain and would like to be evaluated, please contact Women First to schedule an appointment.

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