Over the years, yeast infections, HPV infection, herpes
infection, lichen planus, Paget disease, spinal nerve dysfunction and other conditions
have been investigated as possible causes of vulvodynia. Pelvic floor dysfunction can be a cause in
some women. Women with a chronic pain
disorder, like interstitial cystitis or fibromyalgia, are about three times
more likely to have vulvodynia. When
they have more than one disorder, their risk increases over five fold. However, 73% of vulvodynia patients do not
have another known chronic pain disorder.
This condition is diagnosed based on the clinical
presentation and lack of another medical cause for such symptoms. Touching the affected areas with a Q-tip
elicits a pain response. Application of
a vinegar solution and then viewing under a blue light shows affected areas,
which turn white.
Mast cells have been heavily implicated in sexual pain
disorders, including interstitial cystitis, provoked vestibulodynia and
endometriosis. Allergic reactions or
mast cell degranulation may cause vulvodynia, as women with this disorder often
have high numbers of degranulated mast cells in the biopsied tissue. It is thought that the mast cell action
stimulates C-fiber pain receptors, which are sensitized by an overabundance of
histamine. Mast cells also release
neurotrophins that activate the nerve endings of pain fibers, causing
proliferation and growth toward the nerve endings in the inflamed mucosa. Increased amounts of TNF-a, a factor released
by mast cells, is often found in biopsied tissue. The link between mast cells
and vulvodynia is further supported by the fact that women who frequently have
hives are more likely to develop vulvodynia.
Vulvodynia patients have lower levels of interleukin-1
receptor antagonist. This means that
they are less able to stop inflammation caused by interleukin-1B.
People who suffer from vulvodynia should wear cotton underwear
and avoid body washes and scented products if possible. When washing, the area should be washed with
cool water only. Oxalate-rich diets have
been found to irritate vulvodynia but not to cause it.
There are several medication options for treating
vulvodynia. Hormone creams, including
testosterone and estrogen, are sometimes helpful. Tricyclic antidepressants like nortriptyline
or amitriptyline can suppress the neurologic pain. Lidocaine cream can be helpful. Creams containing cromolyn sodium, a mast cell stabilizer, are also effective.
Physical therapy and biofeedback often provide significant
improvement. In this technique, sensors
are applied to various pelvic areas to determine muscle tension. Patients are then taught how to relax these
muscles. Regular Kegel exercises and
relaxation techniques are helpful.
Development of strong ore muscles can take some of the strain off the
pelvic floor and result in less regional pain.
For women who experience pain with penetration, dilation can
be helpful. In this technique, small
rods of increasing size are inserted into the vagina and keep in place for
10-15 minutes at a time. This trains the
muscles and nerve endings to react appropriately to the pressure of
penetration. Lubrication must be used
every time penetration occurs, with the exception of tampon insertion. Vaginal lubricants should be water-based and
sugar-free.
Anesthetics and steroids are sometimes injected directly
into the area to suppress the pain response.
This is reserved for cases of severe pain. As a last resort, a vestibulectomy can be
performed in which the affected tissue is removed. Reports on success from this procedure vary
from 60-93%, with the vast majority of them citing at least 80% effectiveness.
About 116 million people in the US live with chronic
pain. Women living with chronic pain are
at increased risk for sexual pain disorders.
References:
Barbara D. Reed, MD, MSPH, Siobán D. Harlow, PhD, Ananda Sen, PhD, Rayna M. Edwards, MPH, Di Chen, MPHc, and Hope K. Haefner, MD. Relationship Between Vulvodynia and Chronic
Comorbid Pain Conditions. Obstet Gynecol. Jul
2012; 120(1): 145–151.
Graziottin A. Mast cells
and their role in sexual pain disorders in: Goldstein A. Pukall C.
Goldstein I. (Eds), Female Sexual Pain Disorders: Evaluation and Management,
Blackwell Publishing 2009, p. 176-179.
Bernard L. Harlow, Ph.D., Wei He, MS, and Ruby Nguyen, Ph.D.
Allergic Reactions and
Risk of Vulvodynia. Ann Epidemiol. Nov
2009; 19(11): 771–777.
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