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It's not all in your head...

Chronic Vulvar Pain, Part 1.


Though not often discussed, chronic vulvar pain is actually not all that unusual and can profoundly alters women’s lives (1). Estimates are that somewhere between 10-28% of women have chronic pain in the vulva (2). Pain in the vulva can make a fulfilling sex life impossible and threaten even the strongest relationships. For some women, vulvar pain can be unrelenting and prevent them from engaging in even simple activities such as sitting. Of course, this can cause significant disability and affect a woman's capacity to work, play, love and thrive.

Despite how frequently this type of pain occurs, women are often unaware of the problem and suffer in silence and isolation when it strikes them. Unfortunately, when women do speak up and seek support, their problem is often treated dismissively. Insipid advice to “just relax and have a glass of wine,” is the most that many women get.


Even when a woman persists in seeking help, it takes an average of 3-7 years before a diagnosis is made.

The first step to overcoming chronic vulvar pain is to find an experienced health professional who understands the complex nature of chronic vulvar pain. An accurate diagnosis and treatment plan require a detailed history and physical examination. Vulvar pain has many causes and can be linked to chronic infections, inflammation, dermatological conditions, musculoskeletal problems, hormonal imbalances, neurological disorders etc. Treatments can include steroid ointments, hormonal creams, topical muscle relaxants, targeted injections, physical therapy, and even surgery.

For some women, this can be a straightforward process. Take the example of a young woman who has used oral contraceptive pills since she was a teenager due to heavy periods. In her 20’s she began experiencing pain during sex. She finds an experienced provider who performs an exam that uncovers pain with the slight touch of a cotton swab in the vestibule, a thin ring of tissue in the opening to the vagina that can become painful and inflamed due to low testosterone – a common side effect of oral contraceptives. She is diagnosed with hormonally mediated vestibulodynia (3). She stops the oral contraceptive and begins using a topical estradiol/testosterone cream. Her pain resolves quickly and she happily resumes sexual activity with her partner. A medical success story- high fives all around!

Western medicine has made significant strides in understanding the causes of and treatments for chronic vulvar pain.

The case of provoked vestibulodynia, of which hormonally mediated vestibulodynia is a subtype, is an excellent example of how the field of sexual medicine, along with providers from many other disciplines, have revolutionized the approach to treating this type of pain. What used to be considered simply a psychological problem is now understood to have clear physical underpinnings in the hormonal and neurological milieu of the tissue in the vestibule. Perhaps an even more profound contribution has come from the physical therapy community who has established the absolute centrality of assessing and treating musculoskeletal issues, often directly in the pelvic floor muscles themselves, as part of the process of unwinding chronic vulvar pain. Shout out to all the pelvic floor PTs!

The first step to overcoming chronic vulvar pain is to find an experienced health professional who understands the complex nature of chronic vulvar pain. An accurate diagnosis and treatment plan require a detailed history and physical examination. Vulvar pain has many causes and can be linked to chronic infections, inflammation, dermatological conditions, musculoskeletal problems, hormonal imbalances, neurological disorders etc. Treatments can include steroid ointments, hormonal creams, topical muscle relaxants, targeted injections, physical therapy, and even surgery.

Though it is encouraging that we have a better understanding, our knowledge about the causes of and treatments for many types of vulvar pain is limited. Why? Simply put, “It’s the patriarchy, man.”

For most of western medicine, women’s vulvar pain simply wasn’t an area of concern and was treated as “supratentorial” (4) in origin. That’s a sarcastic way of saying, “It’s all in your head, little lady.” Women’s pain, especially pain related to sex, has been pathologized as being an exaggerated expression of repressed trauma, anxiety, and stress – a matter best left for the psychologists and sex therapists to deal with. This messaging belittles women’s suffering and grossly oversimplifies the multifaceted nature of chronic vulvar pain. It is due, in part, to this historical gender discrimination that a satisfying medical diagnosis or medication-based treatment is not yet available for many women. This is also, in part, why the standard medical approach has significant limitations in treating chronic vulvar pain.

Fortunately, overcoming chronic vulvar pain does not end with diagnostic labels, oral medications, or surgery. To continue reading, please see my next post...But It Does Have Everything to Do with Your Brain.

Notes

1 First, a few words about words! The vulva includes all of the external female genitalia—the mons pubis, clitoris, perineum, outer labia, inner labia, vestibule, and the opening to the urethra. The vagina is the orifice that connects the vulva to the cervix and uterus.


2 Pukall, CF et al. (2016). Vulvodynia: Definition, prevalence, impact, and pathophysiological factors. The Journal of Sexual Medicine, 13(3) 291-304.


3 Goldstein AT et al. (2013). The treatment of vestibulodynia with topical estradiol and testosterone. The Journal of Sexual Medicine, 1(1), 30-33.

4 The tentorium is a membrane just under the brain (or cerebrum). So supratentorial just refers to anything about this membrane, i.e. the brain. It is usually used in a derogatory way to indicate that a medical problem does not have a physical basis and is just a psychological problem.


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