This article originally
appeared in the May 1997 Townsend
Letter (Issue 166).
Vulvodynia or vulvar pain syndrome is a multifactoral
clinical syndrome of vulvar
sexual dysfunction, and psychological distress. Recognizing
the four specific
subtypes of vulvodynia is important in the management approach. The most common
four subtypes are vulvar vestibulitis syndrome, cyclic vulvovaginitis, dysesthetic
vulvodynia, and vulvar dermatoses. Simple clinical guidelines can be developed
to improve the evaluation and treatment of these often long-suffering patients.
Vulvodynia is different from itching or vulvar pruritus. Vulvodynia actually
precludes itching because the burning and pain cause an intolerance to scratching.
Over the years, the terminology used to describe vulvodynia has varied. The
term vulvodynia has now been recommended by the International Society for the
of Vulvar Disease (ISSVD) to describe any vulvar pain, regardless of etiology.
Vulvar pain usually has an acute onset. The onset can be associated with vaginitis
(yeast, bacterial), changes in sexual activity (new sexual partner), or medical
procedures on the vulva (cryotherapy, laser). In most cases, the vulvar pain
then becomes a chronic problem varying in length from months to years. The
intensity of the pain can vary from mild to disabling. It can be burning, stinging,
or raw. Most women with vulvodynia have been to many physicians either with
inaccurate diagnoses or unsatisfactory treatment. Many women have been left
frustrated and at times mistreated because they have been told that their problem
is purely psychological and there is nothing physically wrong with them. Because
of the dramatic impact on their lives these women continue to seek help, and
can become increasingly fearful and anxious about cancer or sexually transmitted
The incidence of vulvodynia is not known but it is clearly more common than
is generally thought. In a general gynecological practice the prevalence can
as high as 15% when actively looked for.1 Characteristics of the patients with
vulvodynia are nonspecific. The age distribution ranges from mid-20s to late
60s. Their Ob/Gyn history is unremarkable. They generally do not have other
chronic health problems, and rarely have a history of sexually transmitted
Sexual promiscuity is generally not a factor in these cases. Often, women with
vulvodynia do report depression, but it is just as easily a result of the condition
as it is a cause.
The pain reported can be in the general vulvar area, but is typically located
in the vulvar vestibulum. The vestibule comprises the area between the labia
minora and the hymenal ring, anteriorly from the frenulum of the clitoris,
and posteriorly from the fourchette to the vaginal introitus. The urethra,
glands, Bartholins glands and the minor vestibular glands are all located in
the vulvar vestibule.
Only minimal findings are detected on the physical examination and most of
the time there are not physical findings at all. The cotton tip applicator
to determine the location of the pain. Touching the vestibulum lightly with
a moist cotton-tipped swab reveals a sharp pain most often in the posterior
anterior vestibule or both. Occasionally red spots of inflammation can be detected
at 5 o'clock and 7 o'clock or in a U-shaped area at the posterior fourchette.
Classification of Vulvodynia
Vulvar dermatoses can often cause both itching or pain and can be acute or
chronic. Dermatoses are also dissimilar to other causes of vulvodynia because
be physical signs of erythema, erosion or blisters. A partial list of vulvar
dermatoses includes psoriasis, seborrheic dermatitis, tinea cruris, contact
dermatitis, lichen simplex chronicus, lichen planus, lichen sclerosus, pemphigus,
multiforme. Many dermatoses can be difficult to diagnose and may require a
biopsy for a definitive diagnosis.
Cyclic vulvovaginitis (CVV) is probably the most common cause of vulvodynia.
The pain is typically cyclic and specifically worse during the luteal phase
of the cycle. Symptoms are characteristically aggravated by vaginal sexual
with the pain being usually worse the next day.2,3 CVV is thought to be caused
by a hypersensitivity reaction to Candida antigen. If Candida cannot be detected
during the symptomatic phase by culture, due to the bodys immune response,
then culture specimens during an asymptomatic phase.
Conventional treatments include antimycotics for temporary relief, but symptoms
recur soon after the treatment. Boric acid suppositories twice daily for 4
weeks and then once per day for 5 days during the menses only, for 4 more months
generally more successful for chronic yeast vaginitis than conventional antifungal
agents. Boric acid suppositories were effective in curing 98% of the patients
who had previously failed to respond to the most commonly used antifungal agents.4
However, many women do not tolerate the boric acid that leaks out of the vagina
and further irritates the tissue. Lanolin or vitamin E oil or petroleum jelly
or some other ointment (calendula) can be used to coat the vulvar tissue at
the posterior fourchette where the irritation would be greatest. Other alternative
treatments include local treatments such as lactobacillus suppositories, tea
tree suppositories, garlic suppositories, herbal combination suppositories
douches (berberis hydrastis, usnea); systemic immune support (A, C, E, Zn,
Glycyrrhiza glabra, Allium sativum, Hydrastis canadensis). Swabbing the vagina
violet has been a longstanding specific treatment for candida, as has iodine
douching (one part iodine in 100 parts water, twice daily for 14 days). Reinoculation
from the anus requires attention to hygiene and possibly an approach that also
addresses the gastrointestinal tract. Dietary considerations include a diet
low in simple carbohydrates and refined foods, low in alcohol, and low in fats.
Vulvar Vestibulitis Syndrome
Vulvar vestibulitis syndrome (VVS) is characterized by dyspareunia, severe
point tenderness on touch (positive cotton swab test), and erythema. The etiology
VVS is unknown. Some cases are aggravated by yeast vaginitis. Other suspected
causes include chemical sensitivities, other irritants, a history of laser
or cryotherapy, and allergic drug reactions. Some studies have suggested that
may be associated with human papillomavirus (HPV).5,6
Treatment of VVS is difficult and can require great patience and persistence
on the part of both patient and practitioner. Conventional treatment is often
fraught with overtreatment using antimicrobials and destructive or ablative
therapies for suspected HPV. Conventional treatment can escalate to include
injections and vestibulectomy for severe incapacitating cases. The most promising
alternative treatment that I have experienced in my practice is the use of
calcium citrate. In patients whose urine shows evidence of excess oxalate,
reactions similar to those found in vulvodynia are observed. Women have periodic
hyperoxaluria and pH elevations related to the symptoms of vulvar pain. 1000mg
of calcium citrate daily, in divided doses, is given to modify the oxalate
crystalluria. A low oxalate diet is an additional cornerstone to managing these
In addition, I can cite cases in my private practice where an eclectic
treatment plan of a topical ointment (vitamin A, tincture of thuja and
oral beta carotene (75,000 to 150,000 IU/day), eliminating food intolerances,
and a constitutional homeopathic remedy, have yielded anywhere from 50%
improvement to 100% improvement. Unfortunately, I can also cite cases where
there was only
minimal improvement. I have heard anecdotal reports using elaborate chemical
desensitizing methods and dramatic improvements, but I have not personally
investigated these cases. Psychological intervention must always be considered
in dealing with the illness, and perhaps therapeutic intervention can then
allow the immune system to adequately address the chronic syndrome.
This subtype of vulvodynia is more common among older women who are either
perimenopausal or postmenopausal. Patients have constant noncyclic vulvar or
These women have less dyspareunia and less point tenderness than the women
with VVS. No significant changes are observed on the physical examination except
hyperaesthesia which occurs on a wider area compared to VVS. Sharp pain can
also be elicited with light touch. The hyperaesthesia is thought to be a result
an altered sense of cutaneous perception. A neurological basis is probably
the explanation for the nonspecific burning. The sensation mimics the neuralgia
with herpes. Urethral or rectal discomfort is often associated with their vulvar
Conventional medicine often prescribes tricyclic antidepressants8 for dysesthetic
vulvodynia. Side effects are a common problem with tricyclics, and occur in
up to half of the patients. Theoretical nutritional and botanical alternatives
dysesthetic vulvodynia include Folic acid, B12, Piper methysticum (kava-kava),
Ginkgo biloba, Hypericum perforatum (St. Johns Wort).
Physical Therapy for Vulvar Pain
The use of physical therapy to relieve vulvar pain should not be overlooked.
Spasm of the inner thigh muscles or hip muscles can be a result of guarding
against the pain of weight resting directly on vulvar skin while sitting. There
devices for removing pressure from the vulvar area when sitting. Manual therapy
techniques can also be used to relieve pain by releasing severe muscle spasms.
Trigger points in the pelvic floor muscles from fibromyalgia can refer pain
to the vulvar skin and the vagina. Trigger point therapy and pelvic floor muscle
strengthening and relaxation can also relieve pelvic floor muscle spasms.
Vulvar pain syndromes provoke psychological as well as physical distress. Sexual
relationships become seriously strained in women with vulvodynia. Women tend
to feel defective, less womanly, less sexually attractive ashamed and embarrassed.
Dealing with spouses and partners who are having difficulty coping is an additional
stress. Anxiety and depression set in with unsatisfactory visits to their health
care practitioners and unsatisfactory results. Hopelessness can become the
greater illness but practitioners should be cautioned against being overly
in encouraging them to try another promising treatment. If it fails, it further
escalates the hopelessness.
Knowledge of the specific subsets of vulvodynia is extremely important
in improving the diagnosis and treatment of this complex multifactoral
guidelines and recommendations augment the evaluation and management.9
- Rule out underlying problems
- Biopsy suspicious lesions
- Do not overlook cervix
- Use a multidisciplinary approach
- Differential diagnosis of vulvar
- Differential diagnosis of vulvar erosions
- Provide empathy and support
- Educate the patient in their understanding
of the problem
- Help the patient to cope with the problem
- Inform them that symptoms
- Best questions to be asked
- Are there any days without burning?
- Is the pain related to menses?
- How is the pain associated with
- Set simple goals
- Less bad days, more good days
- Getting better takes some time
- Coach them to stick with the treatment
1. Goetsch MF. Vulvar vestibulitis: Prevalence and historic features
in a general gynecologic practice population. Am J Obstet
Gynecol 1991; 164:1609-16.
2. McKay M. Vulvodynia: a multifactorial clinical problem. Arch
Dermatol 1989; 125.
3. McKay M. Subsets of vulvodynia. J Reprod Med 1988;
4. Jovanovic R, Congema E, Nguyen H. Antifungal Agents vs. Boric
Acid for Treating Chronic Mycotic Vulvovaginitis J Reprod
5. Turner MLC, Marinoff SC. Association of human papillomavirus
with vulvodynia and the vulvar vestibulitis syndrome. J
Reprod Med 1988;
6. Umpierre SA, Kaufman RH, Adam E, Woods KV, Adler-Storz K. Human
papillomavirus DNA in tissue biopsy specimens of vulvar vestibulitis
with interferon. Obstet Gynecol 1991;
7. Sollomons C, Melmed M, Heitler S. Calcium Citrate for Vulvar Vestibulitis.
J Reprod Med 1991; 36:879-882.
8. McKay M. Dysesthetic (essential) vulvodynia. Treatment with amitriptyline.
J Reprod Med 1993; 38:9-13.
9. Paavonen J. Diagnosis and Treatment of Vulvodynia. Ann
1995. Resources The Vulvar Pain Foundation, P.O. Drawer 177, Graham,