Our Bodies, Ourselves (136 page)

Vulvodynia is the term developed in 1976 by the International Society for the Study of Vulvovaginal Disease to describe chronic vulvar pain. Women with vulvodynia experience severe burning, pain, itching, stinging, and/or irritation in the vulva (external genitals).

Vulvar pain can be related to a known disorder such as a bad yeast infection or a herpes outbreak. Recently clinicians have learned that pelvic floor muscle spasm or tightness (caused by a variety of conditions) is a major source of vulvar pain.

Vulvar pain in the absence of relevant visible finding or clinically identifiable disease is called vulvodynia. There are two kinds of vulvodynia. In generalized vulvodynia, symptoms occur in different areas of the vulva, at various times and sometimes even when the vulva is not being touched. In localized vulvodynia (formerly called vestibulodynia, vulvar vestibulitis, or localized vulvar dysesthesia), women feel pain mainly in an area just around the vaginal opening (the vestibule), usually when that area is touched or pressed. (For more information about the anatomy of the vulva, see
Chapter 1
, “Our Female Bodies.”)

As many as 3 to 15 percent of women have chronic vulvar pain.
21
Even so, it can be hard to get a proper diagnosis for it, let alone successful treatment. If your vulva hurts, it is essential to find a health care provider who is familiar with vulvodynia. To rule out vulvovaginal conditions that are known causes of pain, she or he should do a full history, pelvic exam and pH examination of vaginal secretions (wet mount), and vaginal cultures if indicated. During a pelvic exam, the practitioner evaluates the architecture and appearance of your vulva. Then she or he will lightly touch areas on your vulva with a cotton swab (Q-tip) to see where it's sensitive. This may be painful; feel free to bring a close friend or partner with you into the exam room.

It started within the first few times I ever had sexual intercourse. Here I was with this wonderful partner, but the sex hurt so much it made us both cry—me from the physical pain, him because I hurt so much. Once it started, the pain would come back whenever something touched my vulva: a tampon, a finger, a speculum (that was the worst). I saw several nurses and doctors; the first doc told me I was just “tight” and needed to relax. Did she have any idea how insulting, demoralizing, and belittling that was? Finally, I found a physician who respected me, recognized that my pain was real, and was able to give it the label of vulvodynia. Even having a name for it helped. I've since tried many treatments, some more successful than others. Three years later, I'm thrilled to report that my wonderful partner and I are able to have pain-free sexual intercourse (as well as continue to share other kinds of physical intimacy)—my [vulvodynia] isn't totally gone, but it's on its way out!

Because the causes of vulvodynia remain uncertain, there is no standard treatment. You and your clinician will first attempt to identify and treat possible pain triggers, including:

• Irritants applied to the vulva or activities that have an impact on the vulva

• Inflammatory problem such as
Candida
or inflammatory vaginitis (an uncommon vaginitis)

• Viral infections such as herpes

• Vulvar skin problems

• Interstitial cystitis (causing urinary and bladder pain)

• Blocked Bartholin duct (a Bartholin gland cyst occurs when a pea-sized organ under the skin on either side of the labia gets blocked and fluid fills up in the gland)

• Pelvic floor muscle spasms

If pain persists, treatment may include:

• Application of estrogen cream in the vagina, especially if there is atrophy in the vaginal walls.

• Low-dose tricyclic antidepressant, such as amitriptyline, to reduce central nervous pain; some clinicians think there is a connection between pain and the abundance of nerves in the vulva area in some women.

• Physical therapy to evaluate and treat the back and/or pelvic floor; even if there are no apparent muscle spasms, pelvic floor exercises have been found to strengthen pelvic muscles and reduce vulva pain caused by touch.

• Topical anesthetic ointment applied prior to or after intercourse.

• Exploring possible relationship issues or past sexual experiences that could contribute to painful sex; referral to a sex therapist or counselor if needed.

Experts agree that it is a combination of treatments, not any one modality, that is usually successful. If other treatments fail, some experts offer surgery such as vestibulectomy, which is the surgical removal of the vestibule and the hymen. Others feel that the studies showing success of surgery are flawed because of lack of clear definitions of pain and a lack of clear criteria for selecting the women. Other experimental treatments include Botox, which some small studies have found helpful.

Find a supportive practitioner who is knowledgeable about the vulva and has the time and knowledge to explore treatment options with you. If you have a partner, it is important to educate him or her about vulvodynia and, together, explore options for physical intimacy (see
Chapter 8
, “Sexual Challenges”). Also consider connecting with a support group to share stories and successes.

The National Vulvodynia Association (nva.org) offers more information on pain management and treatment, including helpful lists of potential irritants, and can help you find referrals to clinicians and support groups in your area.

Vulvar cancer is relatively rare. Women who have had HPV infections seem to be at greater risk, and some experts believe that vulvar cancer rates will rise sharply in the future because of increased rates of HPV infections. There is no screening test for vulvar cancer, however, and many women are treated for other conditions before realizing a biopsy should be done.

Be aware of changes in your vulvar area such as persistent itching or irritation, and especially growths. Don't be afraid to look. Request a biopsy if you find a suspicious lump or lesion. Because vulvar cancer typically grows slowly, early detection can mean the difference between minor surgery and the more emotionally and physically devastating experience of losing one's genitals. More extensive surgery is also more likely to lead to complications such as problems with sexual functioning. If lymph glands are
removed, fluid buildup in the thighs can cause swelling, making mobility difficult.

All women secrete moisture and mucus from the membranes that line the vagina and cervix. This discharge is clear or slightly milky and may be somewhat slippery or clumpy. When dry, it may be yellowish. When a woman is sexually aroused, under stress, or at midcycle, this secretion increases. It normally causes no irritation or inflammation of the vagina or vulva. If you want to examine your own discharge, collect a sample from inside your vagina—with a washed finger—and smear it on clear glass (such as a glass slide).

Many bacteria normally grow in the vagina of a healthy woman. Some of them, especially lactobacilli, help to keep the vagina healthy, maintaining an acid pH (less than 4.5), and control overgrowth of potentially bad bacteria.

When vaginal infections occur, you may have abnormal discharge, mild or severe itching and burning of the vulva, chafing of the thighs, and (in some cases) frequent urination. Chronic vaginal (and vulvar) symptoms sometimes result from skin conditions of the vulva and vagina, such as eczema or psoriasis.

Vaginal infections may be due to lowered resistance (from stress, lack of sleep, poor diet, other infections in our bodies); douching or use of scented sprays; pregnancy; taking birth control pills, other hormones, or antibiotics; diabetes or a prediabetic condition; cuts, abrasions, and other irritations in the vagina (from childbirth, intercourse without enough lubrication, tampons, or using an instrument in the vagina medically or for masturbation). Infections are also transmitted during sex with an infected partner (see
Chapter 11
, “Sexually Transmitted Infections”). Chronic vaginal infections are infrequently a sign of serious medical problems such as HIV infection and diabetes.

The usual treatment for vaginitis is some form of antibiotic—which can also disturb the delicate balance of bacteria in the vagina and may actually encourage other infections (such as yeast) by altering the vagina's normal acid/alkaline balance (pH). Some antibiotics also have unpleasant or even dangerous side effects.

As an alternative to antibiotics for vaginitis, some women find that natural and herbal remedies can help restore the normal vaginal flora and promote healing, though there are no studies showing how effective most of them are. Some women have tried soothing herb poultices or sitz baths (sitting in the tub with just enough water to immerse your thighs, buttocks, and hips). You should not rely on these remedies if you have an infection that involves your uterus, fallopian tubes, or ovaries.

Below is information about yeast (candida) infections and bacterial vaginosis. Trichomoniasis (“trich”), another common vaginal infection, is almost always transmitted sexually and thus is discussed in
Chapter 11
, “Sexually Transmitted Infections.”

Candida albicans
, a yeast fungus often called simply candida, grows in the rectum and vagina. It grows best in a mildly acidic environment. The pH in the vagina is normally more than mildly acidic. When we menstruate, take birth control pills or some antibiotics, are pregnant, or have diabetes, the pH becomes more alkaline. In a healthy vagina, the presence of some yeast may not be a problem. When our system is out of
balance, yeastlike organisms can grow profusely and cause a thick white discharge that may look like cottage cheese and smell like baking bread. Sometimes this causes intense itching, while at other times it just causes intermittent burning or a sense of irritation.

One study about the risk of recurring yeast infections found that sexual behaviors, rather than the presence of candida fungus on the male partner, were associated with recurrences. Women who had not had candida infections in the vulvovaginal area during the previous year were able to masturbate with saliva without increasing their risk of a candida infection, whereas women with a recent history of such infection in the vulvovaginal area increased the likelihood of a recurrent infection if they masturbated with saliva.
22

The only way to be sure that an infection is caused by candida and not something else is to have vaginal secretions analyzed under a microscope. In some cases, it helps to get a lab culture done. Other conditions causing vaginal irritation may respond temporarily to treatment for candida and then recur a short time later, so accurate diagnosis is important. Self-diagnosis is inaccurate more than half the time, so hold off from self-treatment until diagnosis by a health care provider.

Treatment usually consists of some form of vaginal suppository or cream or an oral antifungal. The former is available over the counter, while pills require a prescription. Antifungal external creams such as clotrimazole may reduce or even eliminate the symptoms, sometimes without actually curing the infection. A small percent of woman have recurrent or chronic yeast infections. Prolonged oral treatment is sometimes required but should be based on a yeast culture. Suppositories and creams have fewer side effects than oral medications, and they can be used during pregnancy. If a woman has a yeast infection when she gives birth, the baby will be likely to get yeast in its throat or digestive tract. This is called thrush and is treated orally with nystatin drops.

Other treatments for candida infection involve boric acid capsules or painting the vagina, cervix, and vulva with gentian violet. The latter is bright purple and stains, so a sanitary pad must be worn. This procedure can help, but in occasional cases, women have a severe reaction to gentian violet. Side effects are rare with boric acid, but it may cause vaginal burning and itching. Do not use boric acid near any cuts or abrasions, as it can enter the bloodstream and may cause nausea, vomiting, diarrhea, dermatitis, and kidney damage. Boric acid is never taken orally and is typically used only after other FDA-approved treatments have failed.

Some of us have had success with the following remedies: acidifying the system by drinking eight ounces of unsweetened cranberry juice every day, or taking cranberry concentrate supplements; inserting plain, unsweetened, live-culture yogurt in the vagina; inserting garlic suppositories (to prevent irritation, peel but don't nick a clove of garlic, then wrap in gauze before inserting). An effective and inexpensive treatment for candida infection is potassium sorbate, commonly used as a preservative in home brewing of beer. Dip a cotton tampon in a 3 percent solution (15 grams of dry potassium sorbate in 1 pint of water), then insert into the vagina at night and remove in the morning.

Also try to boost your immune system by reducing sugar in your diet and getting more rest. Avoid douches and don't use tampons for your period when you have an infection. If you have a male sex partner, have him apply antifungal
cream to his penis twice a day for two weeks, especially if he's not circumcised.

For a long time I felt as though I were on a merry-go-round. I would get a yeast infection, take Mycostatin for three weeks, clear up the infection, and then find two weeks later that the itching and the thick, white discharge were back. Finally, I discovered that reducing my sugar intake and drinking unsweetened cranberry juice would help prevent repeat infections
.

Bacterial vaginosis (BV) is a disturbance of the ecology of the vagina, with an overgrowth of certain microorganisms (possibly including mycoplasmas, gardnerella, and anaerobic bacteria). Many women with BV are unaware that they have it. Some practitioners believe it can be caused by routine douching; it may also be triggered by infections, including STIs. The symptoms can be confused with those of trich, though the discharge tends to be creamy white or grayish and is especially foul-smelling (some call it “fishy”), especially after intercourse. It sometimes comes and goes, getting better after a period and worse again as a woman's cycle progresses.