Vulvodynia is defined as "vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder." Vulvodynia affects an estimated 16% of women in the general population. There are two major types of vulvodynia that are based on pain location. The first is localized vulvodynia, in which pain is restricted to a portion of the vulva, such as the vestibule, as in provoked vestibulodynia (PVD), formally known as vulvar vestibulitis syndrome (VVS). The second is generalized vulvodynia (GVD), in which the pain is more diffuse, involving the whole vulva.

1. What is provoked vestibulodynia (PVD), formerly called vulvar vestibulitis syndrome (VVS)?

PVD is the most common cause of dyspareunia (i.e., painful intercourse) in women of child-bearing age. A recent epidemiological study estimated that VVS affects 12% of pre-menopausal women in the general population. Women with PVD report experiencing a highly localized, burning and/or cutting pain at the entrance of the vagina (called the vulvar vestibule) during sexual intercourse, as well as during other activities that involve applying pressure to the vestibule (e.g., tampon insertion, gynecological exams). Although the pain of PVD typically disappears after pressure to the vestibule is removed, many women report lasting pain or discomfort after sexual intercourse or similar activities.

Approximately 50% of women who suffer from PVD have what is called primary PVD, indicating that the pain has been present since their first intercourse attempt. The other half has secondary or acquired PVD, which develops after a period of pain-free intercourse, and in many cases, after an aggravating factor (e.g., repeated vaginal infections, sexually transmitted diseases). However, little is known about the causes of PVD; most health professionals agree that it is caused by a combination of factors.

How is PVD Treated?

There is scientific evidence that the following treatments are effective for PVD:

• Psychotherapy including a specific focus on pain management and sexuality. This can be done in group, couple, or individual format
• Pelvic floor muscle training/physiotherapy assisted by biofeedback
• Surgical removal of the painful area of the vulvar vestibule (vestibulectomy)

It is generally recommended to begin treatment with either psychotherapy or physiotherapy, or both. Psychotherapy and pelvic floor muscle training via biofeedback are equally successful, with psychotherapy receiving greater rates of satisfaction; both treatments complement each other well. Thirty-five to forty percent of women who followed either of these treatments reported a great decrease in their pain or complete pain relief, as reported in a treatment outcome study published in the journal Pain in 2001. As well, another published study indicated that 70% of women who underwent an average of 7 sessions of pelvic floor physiotherapy reported moderate or great improvement in their pain and sexual functioning.

If there is no significant improvement with psychotherapy or physiotherapy, a vestibulectomy may be indicated. This is a relatively minor day procedure carried out under general or spinal anesthesia. Following the operation, women will typically experience some discomfort in the genital region. Neither intercourse nor any other penetrative activity should be attempted for 6-8 weeks post-surgery. Seventy percent of women who underwent this surgery reported a great decrease in their pain or complete pain relief in the treatment outcome study mentioned above.

You may have come across information about other forms of treatment for PVD, such as vaginal creams, diets, and laser surgery. There is no evidence for their effectiveness, and in fact, some of these treatments may have unintended, negative side effects. Reports have suggested that alternative treatments, such as hypnosis for pain control and acupuncture, have been successful in some women with PVD. However, more research is needed to fully understand the effects of these treatments.

2. What is generalized vulvodynia (GVD)?

GVD is a common form of vulvar pain, affecting 6-7% of women in the general population, with a higher prevalence in women over the age of 30. In GVD, the pain is present on a constant or almost constant basis and affects the entire vulvar region. Like PVD, the pain of GVD is described predominantly as burning; in fact, the original term for GVD was “the burning vulva syndrome.” GVD not only affects sexual functioning in most women, it also affects daily activities (e.g., sitting for long periods of time at work, bicycle riding) due to the constant nature of the pain.

How is GVD treated?

There is little research on the treatment of GVD. A few small studies showed that women who were treated with a low dose antidepressant medication (i.e., amitriptyline; commonly used for the treatment of neuropathic pain conditions which share the “burning” and “constant” qualities of pain with GVD) or gabapentin (also used for the treatment of neuropathic pain) reported pain reduction. While psychotherapy that combines a pain management and sexuality component might be helpful for women with GVD, there is no direct evidence to support this. Surgery, however, should be avoided.

Who can I contact in the Kingston area?

Gynecology
Contact your family doctor for a referral to a local gynecologist.

Pelvic floor physiotherapy
Liz Tata, MClSc(PT)
Progress Physiotherapy Clinic, 817 Blackburn Mews, Kingston, K7P 2N6
Phone: (613) 634-1100
Please note that you need a referral from your family doctor to see Ms. Tata.

Sex Therapy
Sex Therapy Service, Psychology Clinic, Queen’s University
(613) 533-6021
Please note: you would be seen by a student therapist supervised by Caroline Pukall, Ph.D., C.Psych. Arrangements cannot currently be made to see Dr. Pukall directly. Couples welcome. Self-referrals accepted.

Sexual Health Research Laboratory
Phone: (613) 533-3276
Email: SHRL@queensu.ca

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Further information on vulvodynia  

Websites

• www.vulvodynia.com - A website dedicated to vulvodynia
• www.issvd.org - The International Society for the Study of Vulvovaginal Disease (ISSVD)
• www.nva.org - National Vulvodynia Association (NVA):
• www.groups.yahoo.com/group/vulvardisorders - A discussion group for general vulvar problems
• www.groupeelva.org - Groupe Elva, l' Association officielle pour les femmes atteintes de maladies vulvo-vaginales (site en français)

Books

1. When Sex Hurts: A woman's guide to banishing sexual pain.  (see DaCapoPress.com) Authors: A. Goldstein, C. Pukall, I. Goldstein. Other information: Published in 2011 by DaCapo Press  
2. Female sexual pain disorders: Evaluation and management. Editors: A. Goldstein, C. Pukall, I. Goldstein. Other information: Published in 2009 by Wiley-Blackwell.
3. V book: A doctor's guide to complete vulvovaginal health. (see http://www.thevbook.com/) Authors: EG Stewart & P Spencer. Other information: Published in 2002 by Bantam Books.  
4. The vulvodynia survival guide: How to overcome painful vaginal symptoms and enjoy an active lifestyle. Authors: H Glazer & G Rodke. Other information: Published in 2002 by New Harbinger Publications, Inc.