Vulvodynia: Real condition, real pain

A written history dating back to the 2nd century 

Vulvodynia is not a “new” condition. Although it was mainly written about in the twenty-first century, there are writings that suggest that vulvar pain has been affecting women since antiquity. There is evidence of vulvar vestibulitis syndrome (VVS) in Soranus's 2nd century text On Midwifery and the Diseases of Women wherein he describes women as having pain and itching in their genitals such that they continually brought their hands to this region. He believed, because of the constant need to bring relief to that area, that they developed an irresistible desire for sexual intercourse. This, in actuality, had nothing to do with sexual desire but is most likely what we refer to as vulvodynia today. Yet it was not until 1980 that Friedrich developed a standard definition of the condition and coined the term vulvar vestibulitis syndrome.1 During the 1980s, sporadic references began to resurface in gynecological texts addressing the diagnosis and treatment of this entity. However, because vulvodynia is a diagnosis of exclusion, and there are no known intervention strategies that guarantee amelioration or elimination of pain, the condition has not been widely worked up or considered universally by physicians who care for women. Regardless of the lapse in medical writings making reference to this condition, the bottom line is that clinicians should consider the diagnosis in women who present with chronic vulvar pain. Women suffering with vulvodynia have not only chronic pain to deal with, but also the sexual and fertility issues that often are superimposed on this pain.

At the end of the twentieth century, the National Institutes of Health recognized the need for research in this area. In 1998, the NIH issued an invitation for grant applications to study the prevalence, pathology, diagnosis, and treatment of vulvodynia. Since that time, seven academic institutions have been awarded funding to examine the epidemiologic, pathologic, and treatment aspects of vulvodynia. Most of these studies either have been completed or are close to completion such that data have been or are currently being analyzed.

Therapeutic approaches under investigation 

The women who have participated in clinical trials for vulvodynia management may have been helped not only physically, but emotionally as well. Their knowledge, their self-esteem, and their hope for permanent relief are supported by these trials. Hopefully, specific interventions will be either shown to be effective or not effective. Among the treatment approaches being studied are dietary and pharmacologic therapies. Interventions that have been looked at include a low oxalate diet and topical preparations including estradiol and anesthetics.2, 3 Oral medication approaches that appear to have some validity include tricyclic antidepressants, anticonvulsants, and selective serotonin and norepinephrine reuptake inhibitor (SSNRI) medications.4, 5, 6 When pharmacologic interventions do not offer relief, surgical interventions should be considered.7 Other interventions that need placebo-controlled, prospective trials include pelvic floor therapy, physical therapy, group therapy, vitamin supplements, and meditative and relaxation exercises. In addition to the dietary modifications, pharmacologic interventions, and other aforementioned traditional therapies, alternative approaches like meditation, yoga, Tai Chi, Reiki, aromatherapy, and massage can ease the body, the mind, and the spirit. Women may find added benefit to any intervention when they embrace the power to help heal themselves. However, the investigation of VVS must not end at single intervention strategies. The need for treatment protocols that use multiple interventions is vital in the quest to identify, define, alleviate, and eliminate the symptoms of vulvodynia.

In caring for women with vulvar pain symptoms, the clinician rules out other causes of the pain according to a diagnostic algorithm based on clinical data (see Figure 1).

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Figure 1. Clinical algorithm useful in diagnosing vulvodynia

Empowerment through a self-management program 

After a woman has been diagnosed with vulvodynia, in addition to the approaches described, there appears to be additional benefit when women commit to an individual program of self-management. Acting on the advice of her physician, clearly defined treatment goals and a plan as to how to manage everyday pain and the exacerbations that often occur is the best form of therapy. Areas that should be addressed include modifying sexual exchange, knowledge and understanding of the pain pathways, and methods to reduce self-generated stress and how to deal more effectively with external stress.

The self-management program that the Robert Wood Johnson Medical School-University of Medicine and Dentistry of New Jersey (UMDNJ) used during a vulvodynia clinical trial was comprised of three components.8

The first is the psycho-educational component. This involves an understanding of the myths/realities of VVS, the different factors that may alleviate or exacerbate the symptoms, and the relationship involvement of pain, thoughts, feelings, behaviors, and stress. Mental preparation (cognitive behavioral therapy) involves understanding that the experience of pain is related to one's thoughts, feelings, attitudes, and behaviors. Becoming aware of these factors, learning that factors are within one's control, and learning to manage these factors is empowering.

The second component is physically training the pelvic floor. Understanding the physiology of vulvar pain, and learning to release the tight muscle groups through stretching and massage exercises can help decrease painful sensations.

The third component of self-management is sexual preparation. The woman's belief that sexual pleasure can be achieved is strengthened by counseling and education. She learns techniques to ease the vaginal opening spasm as well as ways to communicate her needs, likes, and dislikes to her partner in a constructive manner. Because vulvodynia often prevents a woman from participating in sexual intercourse (penetration), other forms of sensual pleasure should be explored. Kissing, caressing, stroking, and massage are sexual expressions that the woman and her partner should be encouraged to participate in. Giving permission for the woman and her partner to share the stimulation of gentle graphic videos or magazines is also helpful. Using some over-the-counter (OTC) preparations can make sexual contact for the woman with VVS more enjoyable as well. Unscented massage oils and warming gels are good sensual aids.

There are some cautions regarding the purchase and use of these emollients that should be emphasized to the woman with vulvodynia. She should be counseled to be diligent in reading labels on creams, gels, and oils. Additives, especially fragrances, can often exacerbate vulvodynia. Also, some preservatives can be irritants. Another area in which the patient should be counseled is to be very vigilant is ordering things from Internet sites. Concerning agents that ameliorate pain, it may be advisable for the patient to go directly to the manufacturer's site than to purchase a product from a third-party. For information on products and information on VVS, healthcare professionals can refer patients to the National Vulvodynia Association (NVA) at www.nva.org. Another source is the International Society for the Study of Vulvovaginal Disease (www.issvd.org). At these sites, the information is based on data.

Not a psychopathological condition 

Vulvodynia is not a psychopathological condition, but one with what appears to have neuroendocrine and genetic etiologies.1 Women with VVS can lead lives that are not governed by their condition, especially if they are involved in a comprehensive vulvodynia management program.