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The term vulvodynia is used to describe pain in the vulva, often severe, of unknown cause. Vestibulodynia (formerly vulvar or vulval vestibulitis) is a related term. more...

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A wide variety of possible causes and treatments for vulvodynia are currently being explored. Some possible causes include: allergy or other sensitivity to chemicals or organisms normally found in the environment, autoimmune disorder similar to lupus erythematosus, chronic tension or spasm of the muscles of the vulvar (or vulval) area.

The guidelines in Vulvovaginal health may be of some help.

Vulvodynia is the term used to describe women who experience the sensation of vulval burning and soreness in the absence of any obvious skin condition or infection. The sensation of burning and soreness of the vulva can be continuous (unprovoked vulvodynia) or on light touch eg. sexual intercourse or tampon use (provoked vulvodynia). Women who have unprovoked vulvodynia were formally know as having dysaesthetic vulvodynia where pain was felt without touch. Vestibulodynia is the term replacing vestibulitis where pain is felt on light touch. A recent change in the terminology of these conditions means that the description of women with vulvodynia can be more uniform amongst health professionals and patients. Many women have symptoms which overlap between both conditions.

Dysaesthetic vulvodynia and vestibulitis are now obsolete terms that you'll hear less and less frequently as they are phased out.

This condition is a cause of vulval burning and soreness usually as a consequence of irritation or hypersensitivity of the nerve fibres in the vulval skin. The abnormal nerve fibre signals from the skin are felt as a sensation of pain by the woman. This type of pain can occur even when the area is not touched. Another example of nerve-type (neuropathic pain) like vulvodynia is the pain some people experience with an attack of shingles. Once the rash of shingles has disappeared the area of skin where the rash was can be intensely painful and sore despite the skin appearing normal. The condition is called post-hepatic neuralgia.

The pain described by women with unprovoked vulvodynia is often of a burning, aching nature. The intensity of pain can vary from mild discomfort to a severe constant pain which can even prevent you from sitting down comfortably. The pain is usually continuous and can interfere with sleep. As with long-term pain of any cause you can have good days and bad days. Itching is not usually a feature of the condition. The pain in unprovoked vulvodynia is not always restricted to the vulval area (area of skin on the outside of the vagina) and some women get pain elsewhere. This can be around the inside of the thighs, upper legs and even around the anus (back passage) and urethra (where you pass urine). Some women also have pain when they empty their bowels. Unprovoked vulvodynia can have an affect on sexual activity and is associated with pain during foreplay and penetration. In some women with unprovoked vulvodynia the burning sensation can be generalised over the whole genital area. Alternatively it can be localised to just the clitoris (clitorodynia) or just one side of the vulva (hemi-vulvodynia).


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First vulvodynia guideline published
From OB/GYN News, 3/1/05 by Jane Salodof MacNeil

HOUSTON -- A new guideline for the diagnosis and treatment of vulvodynia offers multiple treatment options, including experimental and complementary therapies, for the controversial disorder.

"We have oceans of lotions, potions, and notions out there for vulvodynia. There is not going to be one simple cure," Hope K. Haefner, M.D., the lead author of a paper detailing the guideline, said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

What is clear, she said, is, "We have to do a lot more than say, 'Love burns.'"

Dr. Haefner, director of the University of Michigan Center for Vulvar Diseases in Ann Arbor, recruited a panel of vulvar disease experts to draft the guideline at the request of the American Society for Colposcopy and Cervical Pathology (ASCCP). The guideline is published in the society's journal and can be accessed at (J. Lower Gen. Tract Dis. 2005; 9:40-51).

General gynecologists are increasingly aware of vulvodynia but need to start treatment early, according to Dr. Haefner. "The longer a patient has the pain, the less likely we are going to be able to cure" her, she said.

The guideline uses terminology the International Society for the Study of Vulvovaginal Disease (ISSVD) recently adopted for vulvodynia, which has had multiple names, including vulvar vestibulitis syndrome and vulvar dysesthesia. The ISSVD defined vulvodynia as "vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable neurologic disorder."

Symptoms are not necessarily caused by touch or pressure to the vulva, such as with intercourse or bicycle riding, but these activities often exacerbate the symptoms.

The guildeline also classified vulvodynia according to whether pain is generalized or localized. (Dr. Haefner cited vestibulodynia, clitorodynia, and hemivulvodynia as examples of localized pain.)

The ASCCP guideline recommends cotton swab testing along with the taking of a complete medical history for diagnosis. Health care providers should use the swab to test various locations of the vulva, including the labia majora, the labia minora, the interlabial sulci, and the vestibule at the clock positions of 2:00, 4:00, 6:00, 8:00, and 10:00. The degree of pain at each location should be recorded.

They should also do vaginal cultures to rule out conditions such as yeast infection.

Treatment recommendations start with gentle care for the vulva. This includes wearing cotton underwear and nonirritating menstrual pads, avoiding irritants, and using mild soap. Patients are urged to pat the vulva dry.

Other suggestions include lubrication during intercourse, cold packs for irritation, and rinsing and drying the vulva after urination.

The guideline lists the following topical medications as useful for vulvar pain but with caveats and suggests that stopping all treatments may bring relief to some women who are using multiple topical medications:

* Lidocaine ointment 5% (various forms) is the most commonly prescribed topical treatment.

* Plain petrolatum (petroleum jelly) can relieve symptoms.

* Estrogen has had variable results; however, Dr. Haefner questions how it works, given that many vulvodynia patients have low estrogen-receptor expression.

* Capsaicin is cited for neuropathic pain, but again, Dr. Haefner was skeptical that it works because this agent is an irritant.

* Nitroglycerine in one study improved vulvar pain and dyspareunia temporarily but caused headaches.

* Baclofen 2% (Lioresal) and amitriptyline 2% in a water-washable base can soothe point tenderness and vaginismus.

Topical corticosteroids, testosterone, and antifungal medications have not benefited vulvodynia patients, according to the guideline. Dr. Haefner also warned against use of benzocaine in these patients, which she said could cause rebound vasodilation and pain.

Oral medications for vulvodynia generally fall into two classes: antidepressants and anticonvulsants. If these are used, the guideline warns health care providers to check for drug interactions with other medications the patient is taking.

Dr. Haefner said tricyclic antidepressants such as amitriptyline, desipramine, and nortriptyline have had a 65%-70% response rate in multiple studies. When they are prescribed for pain management, smaller doses are recommended than for depression. Selective serotonin reuptake inhibitors such as venlafaxine are another option. Dr. Haefner said she has also used duloxetine (Cymbalta), but a controlled study is needed to assess its efficacy in vulvodynia patients.

The guideline also cites the use of anticonvulsants gabapentin (Neurontin) and carbamazepine.

Other guideline recommendations include biofeedback and physical therapy, intralesional injections in patients with localized pain, and surgery as a last resort in patients with vestibulodynia. Surgery is also an option in rare cases of pudendal nerve entrapment.

"The one time I do surgery without trying the other treatments discussed is when they have a lot of redundant tissue that is painful and tears with intercourse. Then I just resect that tissue," Dr. Haefner said.

The guideline notes without judgment that many women use complementary and alternative therapies "before, during, and after seeking conventional medical diagnosis and treatment for their vulvar pain symptoms." These include acupuncture, calcium citrate, low-oxalate diets, oatmeal water and saltwater baths, and, according to Dr. Haefner, hypnosis and botulinum toxin (Botox) injections.

"There are a lot of different things out there that need to be duplicated in different studies," she said, describing low-oxalate diets, in particular, as being controversial.

Finally, the guideline says that vulvodynia is not a psychopathologic condition, but patients should receive emotional and psychological support during treatment.

For more information about vulvodynia and other vulvovaginal diseases, contact the International Society for the Study of Vulvovaginal Disease by calling 704-814-9493 or go to

RELATED ARTICLE: Experts Dispute Psychosexual Factors in Vulvodynia

The new vulvodynia guideline rejects the assumption that vulvar pain without a clinically identifiable cause is all in a woman's head but notes that "sex therapy, couples counseling, psychotherapy, or a combination thereof" can be very helpful to patients.

"For years, there were people who thought it was a psychosomatic illness, and there are some people who still do believe that," Dr. Haefner said. "I don't think it is. However, psychologically, many of our patients are depressed."

The first description of vulvodynia in an 1880 medical textbook called the condition "hyperaesthesia of the vulva," she said.

Although it has become more prevalent following recent media attention to women's accounts of the disorder, vulvodynia affects far more women and has been around far longer than has been recognized, she said.

Just what causes vulvodynia is still unclear. Dr. Haefner cited current thinking that the condition is neurologic or inflammatory in origin. (She leans toward neurologic but acknowledged it could be both.) While she discounted sexual abuse as no more common in vulvodynia patients than in the general population, she said that it could be a factor in individual cases.

Elizabeth "Libby" Edwards, M.D., chief of dermatology of the Southeast Vulvar Clinic in Charlotte, N.C., said that many vulvodynia patients have psychosexual issues but also described them as a result of the illness.

"Depression, anxiety, psychosexual dysfunction is rarely, if ever, a cause of vulvodynia. I don't discount the possibility that it may occasionally happen," said Dr. Edwards, also of the University of North Carolina at Chapel Hill.

Dr. Edwards, a dermatologist who specializes in vulvar disorders, said she encourages patients to go for counseling, but most won't go. She said her message is "not 'You're crazy, and that makes you hurt,' but 'You hurt, and that will make you crazy.'"

Sexual abuse is a major underlying factor for vulvodynia patients, according to Esperanza McKay, M.D., a biofeedback clinician at the Pain Management Center in Houston. That should not cause anyone to underestimate the women's suffering, she advised.

"Their pain is really very real," Dr. McKay said. "The first thing I do is listen to them. You will be amazed at how many have been sexually abused."

Dr. McKay recommended waiting 3 or 4 months until a treatment begins to succeed before bringing up counseling. Many patients do not trust psychiatry and need to develop trust in the clinician before they will agree to go for counseling, she said.

Peter J. Lynch, M.D., a professor emeritus at the University of California, Davis, also advocated psychiatric help, warning that extreme cases can be the result of severe sexual abuse. "I happen to believe that psychosexual issues are an important cause of vulvodynia," he said.

--Jane Salodof MacNeil


Contributing Writer

COPYRIGHT 2005 International Medical News Group
COPYRIGHT 2005 Gale Group

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