By Michael Goodman, MD
Copyright 2019. All rights reserved.
NB: This will by no means be exhaustive, and is meant for introduction and entry-level information only. It is “…a place to start” for women experiencing pain & distress involving their genitals. For more information, use the search terms “dyspareunia” (painful intercourse), “vulvodynia,” “vulvar pain syndromes,” etc., and visit the NVA (National Vulvodynia Association) website, http//www.nva.org… This is a list of causes only. Each of these issues has an excellent treatment(s), some relatively rapid, but most taking time and a knowledgeable physician and willing patient. Therapeutic options will not be discussed here, as these require a consultation and workup with a therapist knowledgeable in diagnosis and therapy of vulvar pain syndromes.
Causes of Vulvar Pain, aka “Vulvodynia” (pain outside of the vagina)
[The Vulva encompasses the labia majora, labia minora, vulvar vestibule (the area just outside of the vaginal opening) perineum, and clitoral area]
1.“Vulvitis” is pain secondary to infection (bacterial or viral) or inflammation caused by infection, low hormone levels, or an agent (powder, allergy, irritant, trauma, etc.) causing secondary inflammation. Vulvitis is treated by removing the irritant, if any, treating symptoms with anti-inflammatory agents (topical and systemic), treatment with estradiol, estriol, DHEA and/or testosterone, and occasionally with anti-bacterial or anti-viral agents.
2. “Provoked vestibulodynia” (…used to be called “vulvar vestibulitis”). This is pain in and around the vulvar vestibule, that area of the vulva just outside of the vaginal opening, truly the “vestibule” of the vulva. While the pain may be considered “allodynia,” or pain “…just everywhere” around the vestibule, usually most if not all the pain is in the areas of the vulvar vestibular gland openings, from 2/3:00 to 9/10:00 on the clock face just outside of the hymenal ring. This is pain provoked by touch, thus making insertion of anything (tampons, fingers, penises, toys…) distinctly uncomfortable to painful.
3. “Unprovoked vestibulodynia (used to be termed “dysesthetic vestibulodynia”) is burning/itching/pain that is “…just there” and not provoked by touch, although it may become more severe with touch, rubbing/chafing. It can be either localized or generalized throughout the vulvar vestibule, in which case it is termed “allodynia.”
4. Neuropathic pain may be post- viral (herpetic) or post surgical (after childbirth or labial surgery-related scarring.) Herpes genitalis settles into the nerve roots of the vulvar area, where it runs its course and then lurks inactive in the nerve roots where it periodically erupts every month, 3-6 months, annually, or never. So-called “scar tissue” may form in areas of childbirth laceration, or “iatrogenic” (physician-caused) injury secondary to injudicious labiaplasty or perineoplasty surgery with removal of either too much tissue, incisions too close to the clitoral glans, poor choice of suture material or technique resulting in “grooving” and deep scarring of the labum or perineum. The responsible scarring “tugs,” either superficially or deep, on sensitive nerve fibers just under and deep to the skin, producing pain.
5. “Atrophic pain” is pain, usually just at the introitus or vaginal entry (in the “vulvar vestibule & sometimes out onto the perineum) secondary to long-standing low-hormone-caused atrophy, or thinning of the skin. These changes virtually never happen to hormonally complete post-menopausal women (those on HRT or consistent about using vagino-vulvar area estrogen therapy,) but are not uncommon in postmenopausal women not using local or systemic HT consistently. This can be burning; it can be sharp, and is from the thin skin and the chronic little “paper-cut” fissures that develop either spontaneously or from lovemaking.
6. Psychodynamic issues can potentially cause vulvar pain. Vulvodynia is considered by many to be a “functional pain syndrome,” along with interstitial cystitis, fibromyalgia, irritable bowel syndrome, some forms of migraine, etc. These very real pain syndromes are regulated via the “autonomic nervous system,” that part of the nervous system that in not under conscious control, but which is strongly influenced by [sometimes deep-seated] emotions. (**see http://www.drmichaelgoodman.com/what-is-functional-pain-syndrome/ )
Causes of Pain Inside the Vagina:
The vaginal skin itself, termed the “vaginal mucosa” has no nerve endings for pain via pinching or cutting. An examiner can pinch it, cut it, biopsy it and the woman will feel little or no pain. However, the structures under the skin (muscles, fascial planes) do have both skeletal (under conscious control) and autonomic (not under conscious control) nerve supply and respond to stretch (including pain when the fascia & muscles are atrophic and cannot stretch), and to scarring and injury. Structures deep to the vagina inside the abdominal cavity (uterus, tubes and ovaries) also have pain receptors, and stretch, compression/expansion or inflammation of these organs can produce pain that can masquerade as vaginal area discomfort.
Causes of Dysparunia (painful intercourse):
As this is an essay on vulvar and vaginal pain issues, the many intra-abdominal causes of pelvic pain are not covered here. Intra-vaginal causes include “stenosis,” where the diameter of the vaginal canal is too narrow, vaginal dryness/chafing, usually from too-low estrogen levels. Vestibular and perineal causes are also atrophic, and involve thinning or the skin and small liner fissures.
Vulvar Dermatoses (not strictly painful, but these skin conditions are a source of consternation and often secondary pain…)
1. Lichen sclerosis (used to be known as “white dystrophy.) “LS,” as it is commonly termed, is an insidiously progressive atrophic skin condition of uncertain etiology (? Genetic; ? psychogenic; ? viral—really uncertain…) that involves the vulvar skin, especially the vulvar vestibule, labia, and clitoral hood, slowly and progressively causing atrophy, shrinkage, and gradual “disappearance” of these organs. During this process there are “flares” and remissions, but, unless aggressively treated, tissue shrinks and lost, never to be regained. When active, the disease can promote severe itching. There is good treatment for the itching and significant inflammation, but therapies have been less-than-successful for the shrinking and overall atrophy and flattening that eventually occurs, especially if prompt aggressive therapy is not undertaken. Unfortunately, many women wait until too late to go to competent clinicians, or are “on & off” with their therapies, and the condition progresses.
The “tried and true” therapies consist of potent anti-inflammatory topical medications, plus local hormonal therapy, but new hope for LS sufferers is presently being utilized in the form of PRP (platelet-rich plasma) injections, and topical fractional CO2 laser re-surfacing.
2. “Red Dystrophy,” or Lichen Planus is another dermatosis or inflammatory vulvar dystrophy involving severe inflammation of the lower layers of vulvar skin with severe reddish inflammatory changes and pain involving the vulvar vestibule, perineum, and vaginal opening. It must be distinguished from lichen sclerosis, as treatment differs. While frequently the proper diagnosis is obvious to the experienced and trained eye, the “gold standard” for diagnosis involves a careful biopsy of the inflamed area, interpreted by a pathologist specially trained in evaluating vulvar skin conditions.
3. Pre-malignant and malignant changes can involve the vulva and occasionally are painful. Likewise, HPV can involve the vulva in the form of “genital warts” which can prove painful if they are damaged during sexual or athletic activities.
From ISCG, Globexx & Friends