Doctor's Review: Medicine on the Move

December 12, 2017
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When painful sex is something serious

For some women, the slightest pressure to the most intimate part of her body can be unbearable. The brush of her clothes, the insertion of a tampon, or a partner's gentle touch is instantly transformed into an instrument of pain. The mere act of sitting can be problematic and performing exercise or having sexual intercourse is all but out of the question. The stabbing knife-like pain, burning, irritation and rawness can permeate throughout the pelvic area.

While there is no doubt that pain can have psychological ramifications, contrary to what some people believe, this pain is not in a woman's head. Doctors naive to this condition infer the cause to be solely psychological because they can't zero in on a certain source of the pain. But nothing can be further from the truth.

The pain is a real gynecological condition called vulvodynia (aka vulvar vestibulitis) and the medical community is just waking up to high prevalence of this condition and finally starting to do something about it.

What's Going on Down There?

The vulva is the outer area of the vagina, which includes the clitoris, vaginal lips (labia), and the outer entrance of the vagina called the vestibule. Since it is the hub of the sexual experience the number of nerve endings here, particularly around the clitoris, is plentiful. It is also houses the urethra, the end of line for the urinary tract.

Vulvodynia includes any condition that causes pain, burning or itching in the vulva that cannot be attributed to a specific cause such as an infection, skin condition, neurological damage or cancer. The pain can occur unprovoked or it can be triggered by direct contact. It can be constant or intermittent, mild or excruciating, and it can last for 6 months of longer. Childbirth, physical trauma, past surgery, scarring and certain neurological conditions are known to activate vulvodynia.

The actual cause has eluded researchers but a genetic, hormonal, muscular, or neurological component that causes nerves to become overstimulated, overabundant or entangled have been proposed. Some researchers have suggested that whatever is at work with fibromyalgia or chronic fatigue syndrome is at work here, causing intense and frequent firing of nerve signals.

Although it is not caused by infection or sexually transmitted diseases, people with vulvodynia may have a reaction that heightens the response to irritants like infections that produce an overload of immune chemicals to affect nerve function.

Assessing the Area

To get to the bottom of the pain women should receive a full gynecological examination that includes a visual, sensory and internal inspection to see if there is any other reason for the pain – infection, injury or skin dermatitis – and to isolate the affected anatomy. The approach to evaluating the pain takes an expert who is sensitive and knowledgeable in the nuances of vulvar conditions.
Visual inspection Here the doctor exams the area preferably with a colposcope, a magnification device that improves visualization, for changes in the structure and pigment of the vulva and to identify any growths, inflammation, scarring or cracks in the skin.

Sensory Inspection During the sensory test the doctors uses a moistened cotton swab to touch single areas on the labia, clitoris and along both sides of the vestibule.
Internal Inspection During the internal part of the exam a smaller-sized speculum is used to reduce pain during the exam. A digital exam, where the examiner gently inserts a gloved finger to the anus, can also be performed to see if anal muscles trigger vulva pain.

Managing the Pain

Slowly doctors are becoming more familiar with vulvodynia, and can offer natural, pharmaceutical and surgical strategies to help quell the pain. Not all strategies will work for everyone so a period of trial and error can help suffers discover what works best for them.

Self-Care Measures

Many women who have vulvodynia will develop personal strategies that help to control the pain. Here are some tips for everyday living.
- Wear 100% cotton underwear during the day and wear nothing at night and avoid using panty liners or wearing pantyhose
- Don't use harsh soaps or douche but instead cleanse with natural emollients such as olive oil and sweet almond oil or just plain water
- Use non-propylene glycol lubricants during intercourse to improve elasticity of tissue
- Dab the vulva with cool water after urinating
- Apply cool ice or gel packs before engaging in a triggering activity
- Eat a low-oxalate diet (also prevents kidney stones) to reduce the calcium oxalate crystals in urine that might irritate vulvar tissue
- Use a soft "donut" pillow if you need to sit for a long time

Blocking Pain Signals

The goal of pharmaceutical approaches is to desensitize or block pain signals. Medications can be applied topically, directly on the vulva, taken orally or injected. Here are a few options that interrupt pain signals. - Topical anesthetics that contain lidocaine or capsaicin applied 30 minutes prior to activating activity to numb affected area (avoid cortisone topical steroids)
- Estradiol cream if low is estrogen is low
- Antidepressant and anti-seizure medications that are known to have pain-reducing qualities
- Trigger-point injections of steroids or Botox

Practitioner-based Therapies

Patients who see an a physical therapist experienced in treating women with vulvodynia can see marked improvement in symptoms after a series of sessions. The therapist works on stabilizing muscle tone to improve contraction strength and structure of pelvic floor muscles, a potential trigger for pain.

Biofeedback, cognitive and behavioral therapies (CBT) and supportive talk psychotherapy can help patients develop self-regulation strategies to cope with the pain and psychosocial distress that can accompany a diagnosis.

And as a last resort, surgical procedures (perineoplasty or vestibulectomy) removes tissue that is causing the pain.

For more information visit the National Vulvodynia Association.

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