Vulvodynia

Vulvodynia is chronic pain or discomfort of the vulva. Researchers and health care providers currently know little about why and how vulvodynia occurs—the condition and the pain have no known cause or cure. Therapies can help relieve symptoms of vulvodynia, but the condition can have some serious effects on women's reproductive health and day-to-day life. Understanding vulvodynia is an important part of NICHD's mission to improve women's quality of life.

About Vulvodynia

Vulvodynia is a term used to describe chronic pain (lasting at least 3 months) of the vulva that does not have a clear cause, such as an infection or cancer.1 The vulva refers to the external female genitalia, including the labia ("lips" or folds of skin at the opening of the vagina), the clitoris, and the vaginal opening. Vulvodynia is usually described as burning, stinging, irritation, or rawness.

Sometimes, vulvodynia is described with more specific terms.

  • Generalized vulvodynia is pain or discomfort that can be felt in the entire vulvar area.
  • Localized vulvodynia is felt in only one place on the vulva.1
  • Provoked vulvodynia is pain triggered by an activity or contact with the area, such as having sex, using a tampon, having a gynecological exam, or even wearing tight-fitting pants. Alternatively, spontaneous vulvodynia occurs when the pain is not initiated by any known trigger.2
  • Provoked vestibulodynia is vulvodynia with provoked pain that occurs in the vestibular region of the vulva, or the entry point to the vagina. This condition has formerly been called vulvar vestibulitis syndrome, focal vulvitis, vestibulodynia, or vulvar vestibulitis.2

 

Citations

  1. National Vulvodynia Association. (2016). Vulvodynia: A common and under-recognized pain disorder in women and female adolescents - Integrating current knowledge into clinical practice. Retrieved May 27, 2016, from https://cme.dannemiller.com/articles/activity?id=570&f=1 external link
  2. National Vulvodynia Association. (2012). What is vulvodynia? Retrieved May 27, 2016, from http://www.nva.org/what-is-vulvodynia/ external link

What are the symptoms of vulvodynia?

The main symptom of vulvodynia is pain. The type of pain can be different for each woman.

Vulvodynia can cause burning, stinging, irritation, or rawness of the vulva. Some women may also have itching, aching, soreness, throbbing, or swelling. These symptoms may be caused by pressure on the vulvar area, such as during sex or when inserting a tampon. Symptoms may occur during exercise, after urinating, or even while sitting or resting.1

Pain may move around or always be in the same place. It can be constant, or it can come and go.

Citations

  1. American College of Obstetricians and Gynecologists. (2014). Vulvodynia. Frequently Asked Questions (FAQ 127). Retrieved May 27, 2016, from http://www.acog.org/Patients/FAQs/Vulvodynia. external link

What causes vulvodynia?

Health care providers do not know what causes vulvodynia. It tends to be diagnosed when other causes of vulvar pain, such as infection or skin diseases, are ruled out.

Researchers think that one or more of the following may cause or contribute to vulvodynia:1

  • Injury to or irritation of the nerves that transmit pain and other sensations from the vulva
  • Increased density of the nerve fibers in the vulvar vestibule
  • Elevated levels of inflammatory substances in the vulvar tissue
  • Abnormal response of vulvar cells to environmental factors
  • Altered hormone receptor expression in the vulvar tissue
  • Genetic factors such as susceptibility to chronic vestibular inflammation, susceptibility to chronic widespread pain, or inability to combat vulvovaginal infection
  • Localized hypersensitivity to Candida or other vulvovaginal organisms
  • Pelvic floor muscle weakness or spasm

Citations

  1. NICHD. (2012). NIH research plan on vulvodynia. Retrieved June 22, 2016, from https://www.nichd.nih.gov/publications/product/383

How do health care providers diagnose vulvodynia?

Vulvodynia tends to be diagnosed only when other causes of vulvar pain, such as infection or skin diseases, have been ruled out.

To diagnose vulvodynia,1 a health care provider will take a detailed medical history, including pain characteristics and any accompanying bowel, bladder, or sexual problems.2 The provider may recommend that a woman have blood drawn to assess levels of estrogen, progesterone, and testosterone. The provider may also perform a cotton swab test, applying gentle pressure to various vulvar sites and asking the patient to rate the severity of the pain. If any areas of skin appear suspicious, these areas may be further examined with a magnifying instrument or a tissue sample may be taken for biopsy.

Because vulvodynia is often a diagnosis of exclusion, it can be difficult and time-consuming to arrive at an actual diagnosis. The diagnostic process can be especially problematic for women who lack health insurance because they may not have the resources to continue seeking care to exclude the many possible causes of pain. Moreover, some women may be reluctant to discuss their pain or seek treatment.

Researchers sponsored by NICHD are investigating how to better evaluate and understand vulvar pain. Some have proposed ways to better map the pain to identify nerves that may be involved.3 Some researchers believe that vulvodynia and vulvar vestibulitis syndrome involve dysfunction in the pathways that process pain.3,4

Citations

  1. NICHD. (2012). NIH research plan on vulvodynia. Retrieved June 22, 2016, from https://www.nichd.nih.gov/publications/product/383 (PDF 747 KB)
  2. Goldstein, A. T., Pukall, C. F., Brown, C., Bergeron, S., Stein, A., & Kellogg-Spadt, S. (2016). Vulvodynia: Assessment and treatment. Journal of Sexual Medicine,13(4), 572–590. Retrieved July 26, 2016, from http://www.sciencedirect.com/science/article/pii/S1743609516003064 external link
  3. Tu, F. F., Hellman, K. M. , & Backonja, M. M. (2011). Gynecologic management of neuropathic pain. American Journal of Obstetrics & Gynecology, 205, 435-443.
  4. Zhang, Z., Zolnoun, D. A., Francisco, E. M., Holden, J. K., Dennis, R. G., & Tommerdahl, M. (2011). Altered central sensitization in subgroups of women with vulvodynia. Clinical Journal of Pain, 27, 755-763.

What are the treatments for vulvodynia?

There are several options to treat the symptoms of vulvodynia. These may include lifestyle changes and therapy, medical treatment, and surgical treatment.

A variety of treatment options may be presented to patients, including:1

  • Topical medications, such as lidocaine ointment (a local anesthetic) or hormonal creams
  • Drug treatment, such as pain relievers, antidepressants, or anticonvulsants
  • Biofeedback therapy, intended to help decrease pain sensation
  • Physical therapy to strengthen pelvic floor muscles
  • Injections of steroids or anesthetics
  • Surgery to remove the affected skin and tissue in localized vulvodynia
  • Changes in diet (for example, some physicians may suggest a diet low in oxalates, which can form crystals in the body if they aren't filtered out by the kidneys)
  • Complementary or alternative therapies (including relaxation, massage, homeopathy, and acupuncture)

Types of Treatment for Vulvodynia

Citations

  1. Haefner, H. K., Collins, M. E., Davis, G. D., Edwards, L., Foster, D. C., Hartmann, E. H., et al. (2005). The vulvodynia guideline. Journal of Lower Genital Tract Disease, 9, 40–51.

Lifestyle Changes and Therapy

Gentle care of the vulva can help provide some pain relief for some women:1,2

  • Wear 100% cotton underwear (no underwear at night).
  • Avoid tight-fitting undergarments and pantyhose.
  • Avoid douching.
  • Use mild soaps for bathing and clean the vulva with water only.
  • Do not use vaginal wipes, deodorants, or bubble bath.
  • Do not use pads or tampons with deodorants.
  • Use lubrication for intercourse.
  • Apply cool gel packs to the vulvar area to reduce pain and itching.
  • Avoid exercises that put pressure directly on the vulva, such as bicycling.

Vulvar pain can have an emotional or psychological aspect, and some women benefit from psychological counseling, sex therapy, or both. Referral for therapy does not mean that the pain is "all in the head." Sex therapy can provide education and information for individuals or couples. Psychological treatment can provide techniques for relaxation or coping with pain or an opportunity to explore other conditions that may relate to the pain.1 One randomized, controlled clinical trial found that almost one-third of women who had cognitive behavioral therapy reported a decrease in vulvar pain that occurs with intercourse.3,4

Physical therapy and biofeedback also can be helpful for women with vulvodynia.5 Physical therapy for vulvodynia may include exercise, education, or manual therapies, such as massage, joint mobilization, or soft-tissue mobilization. Other forms of physical therapy can involve ultrasound, electrical stimulation, or biofeedback techniques.

Complementary and alternative treatments, such as yoga6 and acupuncture,7 also may be helpful in managing pain from vulvodynia, but there is little evidence about the effectiveness of these approaches.

Some patients find that following a diet that is low in oxalates and taking calcium citrate supplements is helpful, although the evidence to support this approach is limited.8 Foods that are high in oxalates include greens, nuts, tea, chocolate, and soy products.9 Food high in oxalates may produce urine that is irritating, which contributes to the vulvar pain.2

Citations

  1. Haefner, H. K., Collins, M. E., Davis, G. D., Edwards, L., Foster, D. C., Hartmann, E. H., et al. (2005). The vulvodynia guideline. Journal of Lower Genital Tract Disease, 9, 40–51.
  2. American College of Obstetricians and Gynecologists. (2011). Vulvodynia. Frequently Asked Questions (FAQ 127). Washington, DC: American College of Obstetricians and Gynecologists. Retrieved August 17, 2016, from https://www.acog.org/-/media/For-Patients/faq127.pdf?dmc=1&ts=20160817T1318087562   (PDF 84 KB)
  3. Bergeron, S., Binik, Y. M., Khalifé, S., Pagidas, K., Glazer, H. I., Meana, M., & Amsel, R. (2001). A randomized comparison of group cognitive-behavioral therapy, surface electromyographic biofeedback, and vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis. Pain, 91, 297–306.
  4. Bergeron, S., Khalifé, S., Glazer, H. I., Binik, Y.M. (2008). Surgical and behavioral treatments for vestibulodynia: two-and-one-half year follow-up and predictors of outcome. Obstetrics and Gynecology, 111(1), 159–66.
  5. Reed, B. D. (2006). Vulvodynia: Diagnosis and management. American Family Physician, 73, 1231–1238. Retrieved August 17, 2016, from http://www.aafp.org/afp/2006/0401/p1231.html  
  6. Ripoll, E., & Mahowald, D. (2002). Hatha yoga therapy management of urologic disorders. World Journal of Urology, 20, 306–309.
  7. Curran, S., Brotto, L. A., Fisher, H., Knudson, G., & Cohen, T. (2010). The ACTIV study: Acupuncture treatment in provoked vestibulodynia. Journal of Sexual Medicine, 7, 981–995.
  8. Reed, B.D. (2006). Vulvodynia: Diagnosis and management. American Family Physician, 73, 1231–1238.
  9. Mayo Clinic. Kidney stones: Prevention. Retrieved May 27, 2016, from https://www.mayoclinic.org/diseases-conditions/kidney-stones/symptoms-causes/syc-20355755  

Medical Treatment

Although topical pain relievers, corticosteroids, and antidepressants have all been suggested for treatment of vulvodynia, the results of clinical research studies do not support the use of these treatments. For example, NICHD-funded research found that amitriptyline (a tricyclic antidepressant) with or without topical triamcinolone (a corticosteroid used to treat skin conditions) was no more effective than self-management approaches (which included components of education and cognitive-behavioral, physical, and sex therapy) in managing vulvar pain, although the number of people in the study was small.1 Other NICHD-supported investigators conducted a randomized, controlled trial and found that oral desipramine (a tricyclic antidepressant) and topical lidocaine (an anesthetic), alone or in combination, were no better than placebo in helping women with vulvodynia.2 An expert panel, convened in 2016, recommended against the use of antidepressants or corticosteroids for vulvodynia.3

Research sponsored by NICHD is evaluating the use of gabapentin, a drug that helps control epileptic seizures, for women with provoked vestibulodynia (or vulvar vestibulitis syndrome) in a randomized, controlled trial.4 The findings may also shed light on treating other chronic pain syndromes.

Another treatment being tested is botulinum toxin, more commonly known as Botox injection, which is thought to work by causing temporary paralysis of the muscle cells in the pelvic floor.5 Current evidence regarding the efficacy of the treatment is mixed, and further clinical trials are needed.

Citations

  1. Brown, C. S., Wan, J., Bachmann, G., & Rosen, R. (2009). Self-management, amitriptyline, and amitriptyline plus triamcinolone in the management of vulvodynia. Journal of Women's Health, 18, 163–169.
  2. Foster, D. C., Kotok, M. B., Huang, L . S., Watts, A., Oakes, D., Howard, F. M., et al. (2010). Oral desipramine and topical lidocaine for vulvodynia: A randomized controlled trial. Obstetrics & Gynecology, 116, 583-593.
  3. Goldstein, A. T., Pukall, C. F., Brown, C., Bergeron, S., Stein, A., & Kellogg-Spadt, S. (2016). Vulvodynia: Assessment and treatment. Journal of Sexual Medicine, 13(4), 572–590.
  4. Brown, C. A controlled trial of gabapentin in vulvodynia: Biological correlates of response. NIH Project 1R01HD065740-01A1.
  5. Morrissey, D., El-Khawand, D., Ginzburg, N., Wehbe, S., O'Hare, P., & Whitmore, K. (2015). Botulinum toxin A injections into pelvic floor muscles under electromyographic guidance for women with refractory high-tone pelvic floor dysfunction: A 6-month prospective pilot study. Female Pelvic Medicine & Reconstructive Surgery, 21(5), 277–282.

NICHD Vulvodynia Research Goals

Vulvodynia has no known cause or cure. The NICHD supports research that:

  • Addresses basic, clinical, translational, epidemiological, and/or behavioral research on vulvodynia and related symptom-based conditions
  • Seeks to identify new diagnostic, preventive, and therapeutic approaches to vulvodynia, including research that may be useful for developing future prevention or treatment strategies
  • Increases understanding of the pathophysiology, biological and behavioral risk factors, natural history, and genetics of vulvodynia
  • Fosters the introduction of novel scientific ideas, model systems, tools, agents, targets, and technologies that have the potential to substantially advance biomedical research

The Research Plan on Vulvodynia, developed by the NICHD in collaboration with other federal, private, and nonprofit agencies and researchers in the field, lays out an agenda for the rigorous scientific research needed to answer questions and fill in knowledge gaps about vulvodynia. The agenda not only builds on ongoing vulvodynia research but also seeks to advance the field by enhancing the capacity for conducting research related to vulvodynia. In addition, the plan aims to apprise the research community of scientific goals for vulvodynia research and to foster collaborations among agencies and organizations interested in the topic.

Surgical Treatment

Surgery may be an option for women with severe pain from vulvar vestibulitis who have not found relief through other treatment options.1 A vestibulectomy (pronounced ve-STIB-yuh-LEK-tuh-mee) removes the painful tissue of the vestibule and may help relieve pain and improve sexual comfort. However, surgery is usually considered a last resort and is not recommended for women with generalized vulvodynia.2

Citations

  1. American College of Obstetricians and Gynecologists. (2011). Vulvodynia. Frequently Asked Questions (FAQ 127). Washington, DC: American College of Obstetricians and Gynecologists. Retrieved August 17, 2016, from https://www.acog.org/-/media/For-Patients/faq127.pdf?dmc=1&ts=20160817T1318087562 external link (PDF 84 KB)
  2. Reed, B. D. (2006). Vulvodynia: Diagnosis and management. American Family Physician, 73, 1231–1238. Retrieved August 17, 2016, from http://www.aafp.org/afp/2006/0401/p1231.html external link

Vulvodynia Research Activities and Advances

Vulvodynia is a common problem among women, and the pain associated with this disorder can cause not only great physical anguish but also emotional distress. In the absence of effective treatments that can be applied widely, it is important that researchers gain a greater understanding of the disease's causes, develop better treatments, and, if possible, learn how to prevent vulvodynia altogether.

The NICHD conducts and supports research in a variety of areas related to vulvodynia, from basic science to clinical research.

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