Chronic discomfort in your lady region, the vulva, is potentially the result of vulvodynia. Of course, any one of your sexually transmitted diseases can cause discomfort, as can a number of not-so sexually transmitted conditions such as bacterial vaginosis or candida. Skin conditions, even allergies can also make us less comfortable in our Netherlands, but vulvodynia is more about excessive sensitivity. Even being touched by a cotton swab can cause pain. Certainly these women experience pain with intercourse, with tampon insertion, even after riding a bike or after sitting for a while. This may present spontaneously as well, which makes diagnosis a bit of a challenge (Reed, 2006).
Women may describe this as a chronic discomfort, or maybe burning, stinging, irritation, or rawness but they don't have an apparent skin condition or infection. There is also a more localized type and a more generalized version, even further categories depending upon whether symptoms are provoked, spontaneous, or mixed. Inflammation is not a primary feature though (Reed, 2006).
This condition, vulvodynia, is much more common than previously thought, maybe even as high as 10 to 15 percent of women suffering these symptoms. Certainly makes hearing women share concerns about having their pelvic exams and pap smears even more intriguing.
Let me rule out some bias though, vulvodynia is more often identified in women who are in stable, long-term relationships, typically white women, who have had the pain for several years and have been examined by many practitioners before receiving their diagnosis. Children can even experience vulvodynia, or those as old as 80 years young.
Because vulvodynia is so very ambiguous, women are often treated with many rounds of antifungals for candida before diagnosis, and once diagnosed, psychological issues were to blame. More recent data though has demonstrated that women with vulvodynia are psychologically comparable to those without the disorder and are no more likely to have been abused. Marital satisfaction levels are also similar (Reed, 2006).
Although this does significantly impact intimacy and sexual relations, more than half of women with the diagnosis say they have been sexually active in the last month, and did achieve orgasm.
Little is Known about the Cause
This seems like the common theme of most all issues related to women's health. We simply haven't been the priority and were too long assumed to simply be hysterical, so the literature is nil with regards to pathologic potentials. Interestingly though, affected women are more likely to have altered contractile characteristics of the pelvic floor musculature. Biofeedback does seem to improve muscle function and reduce pain. Interestingly as well, research has demonstrated that not only do these women have more sensitivity, and therefore pain in their vulva region, but also on their upper arms and legs. Is this maybe a muscular issue then, or an increased sensitivity systemically.
There are mild immunologic changes in these women, such as altered levels of interleukin-1 and tumor necrosis factor-a in vestibular tissue, increased production of interleukin-1B and decreased production of interleukin-1 receptor antagonist by lymphocytes following stimulation,, as well as changes in the gene association with interleukin-1 receptor antagonist. This inflammatory process may be associated with the neuropathic changes (Reed, 2006).
This can really present at any time, any age, and at any point in a woman's sexual timeline. When women share that they've had discomfort with intercourse for more than three months though, it is time to investigate the potential for vulvodynia. Sometimes women share this pain as deeper into the vagina or pelvis, but realize on exam it is also a bit more external, at their introitus.
Upon exam, there may be a rash or inflammation, but this is a separate issue from vulvodynia. If infections and other skin issues are ruled out or treated, and symptoms remain then a biopsy may be helpful to identify the cause of the skin condition. A cotton swab is used to identify pain in various regions of the vulva during the physical exam, and if pressure elicits discomfort or even at the posterior introitus or the posterior hymenal remnant, then these women are likely to have vulvodynia. Candida may also be discovered, but treatment will not result in improved symptoms.
Other potential diagnosis for women who present with these symptoms include allergic vulvitis, chronic candida, Lichen planus, Lichen sclerosis, pudendal canal syndrome, vulvar atrophy, vaginismus, and vulvar intraepithelial neoplasia (Reed, 2006).
There are a number of approaches, and I am going to reserve the botanical approaches momentarily and offer the more conventional approaches, but do return into the future if that is more your preference. There are oral medications that can improve symptoms, as well as topical therapies, even surgical therapy. Dietary changes can also help as well as biofeedback and cognitive behavioral therapy (Reed, 2006).
Amitriptyline decreases neuronal hypersensitivity at 25 mg at bedtime for ten days, then 50 mg each night. This one may cause dry mouth and fatigue, constipation and weight gain although the latter is not common. Calcium citrate can decrease oxalate deposition in tissues, starting with 2 tablets daily and potentially increasing to as much as four tablets twice daily. Norpramin and Gabapentin and even Effexor all decrease neuronal hypersensitivity as well. They all have their own dosages, and side effects with anorgasmia and anxiety associated with Effexor and Paxil.
Dietary changes include trying a low-oxalate diet, which may decrease the possible role of oxalate deposition in vulvar tissue. This may be near complete elimination or just eliminating a few more specific foods. Topical therapies utilized may be lidocaine gel or cream (5 percent) or Cromolyn cream (4 percent) which can help decrease possible mast cell degranulation in vulvar tissue which can be applied three times daily, or even being more cognizant of irritants such as perfumes, harsh soaps, colored underwear, and nylon (Reed, 2006).
Tricyclic antidepressants are first-line therapy because the pain of vulvodynia seems to be neuropathic. These are well tolerated after the first week, but initially may cause significant fatigue, constipation, and weight gain. Dry mouth may cause some to discontinue the medication. Amitriptyline is most common, but there are others with fewer side effects, such as Norpramin. Interestingly, some respond well to SSRis although these aren't typically useful for neuropathic pain. Prolonged treatment with Diflucan may be helpful if yeast seems to be chronic. Pain relief medications, even over-the-counter have not shown to be helpful.
The natural history is not clear. Many women have this disorder for years, and it is traditionally considered chronic. Psycho-therapy is helpful. About half though do resolve their symptoms entirely. Treatment also seems to be effective.
Reed, B. D. (2006). Vulvodynia: Diagnosis and management. American Family Physician, 73(7), 1231-1238.