The term “vulvodynia” is a general term that means “chronic vulvar pain”. Vulvodynia affects women of all ages, races, and ethnic backgrounds. It is a highly prevalent condition with life estimation rates ranging from 10%-28%, but the estimates are thought to be underreported because many women remain undiagnosed/not given the correct diagnosis due to a lack of medical knowledge. And, those who are diagnosed do not improve because they are not offered the appropriate evidence-based treatments.
According to a Harvard study, 60% of women with vulvodynia consult three or more practitioners before receiving a diagnosis and 40% of women seeking treatment are not accurately diagnosed after seeing as many as three practitioners. Many have been treated for presumed and non-existent vaginal infections or UTIs, which often exacerbates this painful vulvar condition.
The exact cause of vulvodynia is unknown and this is largely due to a lack of research funding, but experts in this field have incorporated their clinical and research findings to help better understand this distressing condition. In 2015, ISSWSH, ISSVD, and IPPS updated the terminology for vulvodynia to show that several factors may contribute to this condition and it is the result of a multifactorial process. This includes factors such as genetics, drug-induced hormonal factors, inflammation, muskuloskeletal, neurological, psycholosical, structural defects, or comorbid pain conditions (painful bladder syndrome, IBS, TMJ, or fibromyalgia).
There are three main types of vulvodynia: (a) localized (pain occurs at the vestibule/vaginal opening or clitoris), (b) generalized, or (c) mixed (a combination of both localized and generalized pain). The pain can occur (i) provoked (this includes sitting, biking, wearing tight clothes or it can occur with attempted penetration using a tampon or during sexual activity) and/or (ii) unprovoked (spontaneous with no specific trigger).
Localized vulvodynia, also known as vestibulodynia and previously known as vulvar vestibulitis syndrome (VVS), is the most common form of vulvodynia. It is defined as pain confined to the glands that surround the vaginal opening. Most women have experienced the pain for several years and they have been examined by several clinicians before a diagnosis has been made.
Many women with vulvodynia remain undiagnosed due to a lack of training and knowledge among health care professionals. Sadly, women are often told their exam is normal (which is not true) or they are told to just have a glass of wine and relax. This most definitely does not treat the underlying condition and as a result, women may feel hopeless and defeated. If you are experiencing pain in the vaginal area you are not alone. You are not crazy, but not getting the proper treatment can make you feel crazy. We are here to help you.
Women with vestibulodynia may complain of sharp, prickly, or knife-like pain, itching, rawness, burning after intercourse, feelings of a urinary tract infection, or dryness around the vaginal opening. The symptoms range from mild to severe and patients have periods of flare and remission. As mentioned before, the exact cause of vestibulodynia is not known. It most likely arises from multiple factors and may represent several different disease processes. As a result, the tissues surrounding the vaginal opening become inflamed and the glands become hypersensitive. This causes any touch that would normally be perceived as neutral or pleasurable to be felt as painful.
There are different types of vulvodynia and the treatments are not universal. One of the most important aspects in treating vulvodynia is choosing a healthcare provider who specializes in sexual medicine or vulvar pain disorders because they are familiar with current treatments and research.
Topical Vaginal Treatments
- Lidocaine: This is a topical anesthetic that is thought to block the transmission of C-fibers, which carry pain sensation. Lidocaine can be prescribed as a 5% ointment – it is normal to experience mild to moderate burning or stinging for a few minutes when applied to the vaginal opening and that is why the first application is usually done in the office. The long-term, overnight use of Lidocaine ointment has been shown to decrease pain around the opening. You can apply the ointment to a cotton ball and place at the vaginal opening for direct contact overnight or as needed during the day. You can also apply Lidocaine to the vaginal opening 10-15 minutes prior to sexual activity; gently wipe off the ointment prior to penetration to avoid loss of sensation for your partner.
- Local Vaginal Hormones: The use of an estradiol and testosterone cream can be helpful, especially when a woman developed vestibulodynia while taking oral contraceptive pills.
- Topical Medications: This includes compounded preparations that may include one or several medications such as amitriptyline, gabapentin, ketamine, lidocaine, nitroglycerin, baclofen, atropine, estradiol, or testosterone. Also, the use of an estradiol and testosterone cream can be helpful, especially when vestibulodynia developed while taking oral contraceptive pills.
Note: Topical steroids such as clobetasol ointment are not effective in treated pain associated with vulvodynia. In fact, the use of corticosteroids can cause the skin to atrophy or become inflamed (dermatitis). Also, the use of topical antifungals in the absence of a yeast infection may provide temporary relief, but continued use may become an irritant or cause allergic vaginitis.
These medications are commonly used to treat chronic pain because they can desensitize the nerves causing your vulvodynia pain. Antidepressants such as Cymbalta (duloxetine), Elavil (amitriptyline), and Norpramin (desipramine) may be helpful. Anticonvulsants that are often used to treat nerve pain include Lyrica (pregabalin) or Neurontin (gabapentin).
Injections to the Vestibule or Pelvic Floor (Levator Muscles)
The use of Botox (botulinum toxin A) and Dysport (abobotulinumtoxinA) have been used as off-label treatments for vulvodynia. It has been hypothesized that these medications reduce pain by blocking nerve conduction and/or interrupt communication between the nerves and the pelvic muscles thereby relaxing the pelvic floor.