• Sex Hurts!!! Part 4- Vulvar Pain Syndromes

    by Dr Angie Stoehr, MD FACOG
    on Nov 7th, 2017

"It hurts to place a tampon, like REALLY hurts"

If this is you, there's a good chance you might have a vulvar pain issue going on. If it hurts to try placing a tampon, or trying to have sex, or worst of all having a speculum exam, listen up!!  There's hope, ladies!

Um, ok, but what's Vulvodynia?

So, this just means pain in the vulva that lasts for a long time without an identifiable cause (like an infection or yeast). The vulva includes the vestibule, the clitoris, the urethra, inner and outer labia (lips), the perineum, and the area above the clitoris called the mons pubis. For diagnosis purposes, vulvodynia can be pain all over the vulva, or just in certain parts of the vulva. It can come and go, or be constant.  If it's all over the vulva, it's called generalized. If it's just in a certain place, it's localized. The localized is then further split in to the particular areas that hurt. Even more, it's classified by whether it hurts all the time, or just with touch, which is called provoked. So, to clarify:

This kind of pain usually feels like burning, or like a knife stabbing. But not everyone is the same, so it can feel like throbbing or uncomfortable pressure too. When it's generalized, the pain is all over the vulva. Usually it gets worse with activities like sitting on a hard surface, riding a bike, or having sex. 

Take me to Church!

I think it's fitting that the entrance to your vagina has the same name as the entrance to a church, don't you? Yep, the vestibule of a church is the outer courtyard or the entrance room. The vestibule of your vagina is the skin just around the vaginal opening. 

So, vestibulodynia is...?

Yes!! It's pain just in the vestibule. Remember, that's the skin just around the outside of the vagina, including the outer hymenal ring and the opening to your urethra (where you pee from). If you take a mirror and look at your bottom...yes I'm serious...it appears just a little more pink that the skin around it. Here's a link to a normal looking vulva; look closely for the slightly pinker area in the middle: https://oncohemakey.com/wp-content/uploads/2016/09/C51-FF1.gif 

If the pain is localized to just this area, it's often provoked, meaning it only hurts when TOUCHED.  This kind of pain tends to be tearing or sharp.  This area gets touched with a handful of activities, like trying to put in a tampon, attempting to have sex, or having a speculum or pelvic exam at the gyno's office. If I know on the front end that you have pain with these activities, I'll do something called the q-tip test. I'll touch a q-tip gently to areas around the vestibule, and if it hurts, that's not normal! Touching a q-tip anywhere on your skin shouldn't hurt. 


What causes these issues?

To make it short and sweet, we don't know. Like science doesn't actually know. There are some theories though. Most of us in the field think that there's at least an inflammatory and immune system upregulaton. This may be triggered by yeast infections, or by muscles that are too tight (see When Ovary Pain Isn't Coming from your Ovary). But to be honest, it's really still a mystery. That doesn't mean we are empty handed for treatments, but it DOES mean that not every treatment works for everyone, because we're not really sure what we're treating. Sounds lovely, right?  So, to treat this, you and I are going to have to be partners, and be willing to try a few things to figure out what works. 

What treatment options are we talking about?

1. Stop putting stuff on your vulva. Please see Sex Hurts!! Part 2 under the contact dermatitis part

2. Creams/ointments for the skin

3. Female pelvic physical therapy- this is a biggie!!

4. Nerve blocks 

5. Nerve Stimulation

6. Surgery

7. Complimentary medicine- chiropractic, acupuncture, herbals

8. Counseling and mindfulness techniques

As Always

If you think you have vulvodynia or vestibulodynia, please make and appointment with me at Boardwalk Ob/Gyn and I'll be happy to figure out what's going on with your "church". 

 

Resources:

https://www.ncbi.nlm.nih.gov/pubmed/22951941 

https://www.ncbi.nlm.nih.gov/pubmed/26132928 

https://www.nva.org/ 

http://www.turner-white.com/pdf/jcom_may10_vulvodynia.pdf 

Author Dr Angie Stoehr, MD FACOG Dr. Angie Stoehr, MD is a Pelvic and Intimate Pain specialist who provides care to women experiencing any type of pain from the belly button to the mid-thigh, front and back. She obtained her medical degree at Creighton University in Omaha, NE, and residency degree at St Francis Hospital and Medical Center in Hartford, CT.

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