The use of euphemisms such as "nether regions" and "privates" keeps women from speaking openly and knowledgeably about their genitals. That's one reason why many patients just say "It hurts down there," with no idea what is causing their problem or what to call it. The word to learn-vulvodynia. Vulvodynia (VVD) means chronic pain, irritation, burning and/or stinging sensations of the vulva (external female genitalia). Typically, pain is most severe around the vaginal opening, but it can extend from the pubic bone to the anus or thigh. Women with VVD may find it uncomfortable if not excruciating to wear slacks, ride a bike or have sex. Some feel pain even when nothing is touching the vulva. Discomfort may be constant but vary in severity...or symptom-free intervals may alternate with periods of intense pain lasting hours, days or weeks.
A Tricky Disorder
The exact cause of VVD is not yet known.
Basic theory: Due to a central nervous system glitch, nerve endings don't work properly and neurological messages get mixed up. There are two types of VVD...
- Provoked VVD. This is the type I see most often. It occurs when inflammation in the genital area makes nerve endings super-sensitive to contact. Clinicians are not sure what type of inflammation this might be. Possible triggers include a vaginal infection...immune system problem, such as a chronic skin disorder or semen allergy...or malfunction of the nerve endings.
- Unprovoked VVD. Characterized by con tinuous pain, this develops when there is a malfunction of the pudendal nerve, which serves the entire genital/anal area and urinary tract. It may arise from childbirth, vaginal or pelvic surgery, injury or herpes infection...then for unknown reasons, the nerve may continue to send pain signals even after the original trigger has healed.
If you have symptoms of VVD, see a gynecologist who specializes in vulvovaginal disorders.
Referrals: National Vulvodynia Association, 301-919-5114, www.nva.org.
With VVD, a physical exam typically reveals little-at most, there may be slight redness and mild swelling. There are no lab tests to confirm VVD Diagnosis is made by testing for and ruling out other possible causes of vulvar discomfort, including a vaginal infection...sexually transmitted disease...shingles (a rash caused by the chickenpox virus)...or a skin disorder, such as eczema, licben sclerosus or licben planus.
Options For Relief
Once VVD is properly diagnosed, symptoms often can be eased or eliminated within a few weeks or months. With provoked VVD, it is critical to eliminate the root cause of the inflammation—for instance, with antifungal or antibiotic medication to clear up infection.
Physical therapy is rapidly becoming a mainstay of VVD treatment. Soaking in a warm tub or applying an ice pack to the area may bring temporary relief. In addition, symptoms may improve with one or more of the following…
- Analgesic cream. A pea-size dab of prescription lidocaine can be used topically up to four times daily. Often, patients apply it 15 minutes before sex. Though it stings at first, it quiets the nerves' response in the painful area (such as at the vaginal opening) and it does so without interfering with sensation in non-affected areas (such as the clitoris).
- Antidepressants. A daily oral tricyclic drug. such as amitriptyline (Elavil), may help by raising levels of brain chemicals that affect nerve messages. The dosage for VVD often is lower than that used for depression. Side effects include dry mouth, sedation and increased heart rate. This drug may not be right for patients with cardiac or liver problems or glaucoma.
- Anti-seizure medication. Some patients are alarmed by the idea of taking these drugs. However, the newer ones-gabapentin (Neurontin) and pregabalin (Lyrica)-have fewer side effects than older anti-convulsants. They block pain by occupying conduction channels on nerve fibers and often are effective for VVD at lower doses than those used to prevent seizures. Some patients use medication until pain is under control, then taper off...others use it indefinitely. Side effects may include sleepiness, dizziness and vision problems.
- Oral pain medication. Because antidepressant and antiseizure drugs take a few weeks to take effect, your doctor may suggest a short course of a prescription painkiller.
- Topical estrogen therapy. This can ease the postmenopausal vaginal dryness that contributes to vulvar discomfort and pain during sex. Topical estrogen therapy-a cream, vaginal ring or suppository-carries fewer risks than oral estrogen.
Trigger Elimination
Certain activities can aggravate VVD symptoms. What to do…
- Avoid biking and horseback riding, which rub against the vulva.
- Don't wear tight pants-they press on the pudendal nerve.
Better: Wear skirts...skip panty hose or cut out the crotch...don't wear thongs (or any underpants at all if they hurt).
- If intercourse is painful, stick to sexual activities that do not involve vaginal penetration until the therapies above take effect. If sex is not painful but itching and/or burning symptoms flare up upon penetration, you may be allergic to your partner's semen. In this case, have him wear a condom.
