It's Time to Start Talking About Vulvar Pain
For many people with a vagina, penetrative sex can be painful. Vulvodynia, or chronic vulvar pain is more common than asthma, but like so many women's health problems, tends to fly under the radar.
According to Dr. Leslie Sadownik, gynecologist and director of the BC Centre for Vulvar Health at the Vancouver General Hospital, an estimated 8 to 15 percent of people with vulvas have vulvodynia — though the exact figure is unknown.
“Less than half will actually seek help," Sadownik told SheKnows. "There’s only a small portion of women who are confident enough to talk about it.”
But first, what is vulvodynia? The names come from vulva and vestibule (the entrance of the vagina), paired with “dynia,” meaning pain. People who suffer from this condition feel intense pain when attempting to insert something in the vagina, like a tampon, a penis or a speculum.
“Women describe the pain as burning, stabbing or pinching,” Sadownik explained. “We call it primary vulvodynia when the pain happens the first time a woman has intercourse; it’s secondary vulvodynia when the woman has had pain-free intercourse before, but it has now become painful.”
When left untreated, primary and secondary vulvodynia can develop into generalized vulvodynia, or what's known as 'burning vulva syndrome.'
“The sensitivity of the vestibule can increase over time, and as they get older, women can start feeling pain without direct touch," Sadownik added. "They will start feeling it when they wear pants, sit on a bicycle or exercise. This may interfere with their choice of clothing or activities."
Doctors are still trying to determine the causes of this condition. According to research, it is likely a combination of biological, psychological and sociocultural factors. At the biological level, some research indicates that inflammation from yeast infections, contact dermatitis or other infections of the genital area may trigger vulvodynia. Other potential triggers for vulvodynia include trauma to the vulva (with forceps, for example), injury to the pelvic floor or hormonal changes (starting the birth control pill, perimenopause).
A person’s psychological reaction may also increase the feelings of pain and turn it into a chronic condition. Thinking about the pain and fearing it can make the pain feel worse. It also leads those with this condition to avoid sexual contact, which may cause relationship problems.
“There’s a lot of shame and guilt related to having this condition, mostly because people don’t understand it. People can develop a lot of anxiety and distress about the pain, wondering if it will ever go away and how it will affect their relationship,” Dr. Carolin Klein, registered psychologist and director of the multidisciplinary vulvodynia program at the BC Centre for Vulvar Health, explained.
Socially, there is still a lot of stigma attached to sexual pain and dysfunction. “The main problem is dismissive doctors,” Sadownik added.
Not only that, but historically, certain symptoms were not taken seriously by medical providers, Dr. Paul Yong, an OB-GYN and team member at the BC Centre for Vulvar Health, said.
"But now, not only are we talking more about sexual health, but we are realizing that sexual health is just as important as bone or heart health for its impact on a person’s quality of life," he noted. "I consider these symptoms [of vulvodynia] just as important as any other symptom.”
Another major problem lies in the length of time it takes for this condition to be diagnosed properly. Many women will begin by treating it as a yeast infection; however, yeast infection treatments can cause further inflammation, making the pain worse. After that, the next stop is typically a primary care physician, who may not catch the problem.
“The health care provider will do an examination, but will not see anything specific," Sadownik explained. "Because they can’t see anything, they won’t make a diagnosis and will treat the condition with lots of medication, which often make the symptoms worse.”
As the causes are largely unknown, treatment for vulvodynia can be challenging as well and include several possible options, like creams that can be applied to the vulva or vestibule, according to Yong. If the cause is hormonal, doctors can prescribe hormonal creams, while other creams target the local nervous system to reduce pain, he added.
Pelvic floor muscle strengthening can also make a difference, especially for older women and women who have given birth. Specialized physiotherapy increases the person’s ability to control their muscles and relax the pelvic floor. In some rare cases, a surgeon can also remove sensitive tissue in the area, relieving the painful condition.
But the best treatment that works for most women are the therapies that address the way women experience pain, Sadownik noted.
“None of the cream or pharmacological treatments seem to work better than placebo," she said. "However, as soon as you give a woman medication, you are legitimizing her pain and you stop other treatments that may be causing further harm. The expectation of healing can help change the perception of the pain.”
Vulvodynia also affects relationships, and treatment should consider this factor.
“The couples that do very well are the ones with a large sexual repertoire, who still have intimacy and pleasure and who talk openly about sex," Klein explained. "On the other end of the spectrum, you have the couples who go into complete avoidance of all physical contact. They don’t know how to talk about it and they don’t know how to deal with this condition, which impacts the connection within the relationship."
Some recent research out of the University of British Columbia has focused on the effectiveness of mindfulness-based therapies. Evidence suggests that a combination of mindfulness and cognitive therapies can help people in the area of sexuality, sexual health and sexual dysfunction. By recognizing thought patterns and how they are linked to their bodies, people with this condition can learn to unravel the processes that increase their fear and expectation of pain. In the treatment of sexual issues, the mental aspect matters.
For people suffering from this condition, Klein has four messages. The first is that sex should not hurt. “It’s not normal,” she said, “and you should seek help for that pain." The second is that the pain is not in your head. “Health care providers are generally not well trained in this area,” she explained. Thirdly, vulvodynia is very common, and no matter what it feels like, "you are not alone,” Klein said, adding that "there are many women struggling with this condition.”
Lastly, there are treatments available. It’s often a trial-and-error process because there can be multiple causes, but services are available and you should not be afraid to talk about vulvar pain with your doctor. Starting the conversation can mean the difference between chronic pain and relief.