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

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

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

• Lifestyle Changes and Therapy
• Medical Treatment
• Surgical Treatment

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

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.

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

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.