Why sex hurts: Vulvodynia explained

Source: Best Health Magazine, May 2009

When sex hurts

Sex with a loving partner isn’t supposed to be painful. But for women with chronic vulvular pain, it’s excruciating. Instead of enjoying the sexual experience, these women feel a burning or stinging pain that makes intercourse unendurable and may cause a host of problems that go far beyond romantic relationships. Sometimes the pain becomes so chronic and relentless that even walking or sitting becomes difficult, forcing a woman to give up her workouts, her hobbies and even her career.

Vulvodynia symptoms

When there is no identifiable cause of the pain, the condition is called vulvodynia. It can affect females of any age, with or without a sexual history, including girls as young as four.

The vulva refers to the external female genitals, including the outer and inner labia, the clitoris and the entrance to the vagina, called the vestibule. There are two types of vulvodynia. If it is localized, vulvar pain usually flares in one area of the vulva on direct contact such as with intercourse, tampon insertion, a gynecological examination or chafing from a tight pair of jeans; there are usually no symptoms at other times. In generalized vulvodynia, pain affects the entire vulva. It can occur spontaneously and may be chronic and persistent, affecting sitting, driving, walking and most physical activities. In both types, the pain can range from intermittent discomfort to bedridden agony.

A condition that often goes undiagnosed

Awareness of the condition is growing; a number of studies on the topic were published in 2008. And it has shown up on TV, as well: On last season’s Private Practice, a newlywed who couldn’t consummate her marriage was diagnosed with vulvodynia; Charlotte, a character in Sex and the City, also had the condition. Both cases were cured in a single episode. But in real life, not only is vulvodynia rarely treated quickly, it remains appallingly underdiagnosed. Many women don’t seek treatment, but those who do, often see physicians with little training in it. ‘The average woman has seen seven doctors before finding one who knows how to treat vulvodynia,’ says gynecologist Dr. Andrew Goldstein, director of the U.S.-based Centers for Vulvovaginal Disorders and one of the foremost vulvodynia experts in North America.

It’s not known for sure how common the condition is, but according to experts interviewed for this story, it’s estimated that from 330,000 to 2.4 million Can­adian women have vulvodynia. Researcher Caroline Pukall, a clinical psychologist and assistant professor of psychology at Queen’s University, puts the prevalence of localized vulvodynia at 12 percent of women, and generalized vulvodynia at six percent. The website of the North-America-wide non-profit National Vulvodynia Association receives 18,000 visitors every month.

Two big misconceptions about vulvodynia

1. It is exclusively caused by vulvar tissue that has been damaged as a result of sexual abuse, promiscuity or sexually transmitted infections. Pukall says women with vulvar pain are no more likely to have had those experiences than other women.

2. The pain is psychological, stemming from sexual hang-ups. ‘A doctor may say, ‘I can’t find anything physically wrong, so I think you should talk to someone about your sexual issues,”’ Pukall says. ‘It makes women start thinking they’re crazy, or doubting their love for their partner.’ There’s no question that the pain’which many women liken to having acid poured on their skin, sandpaper rubbed against it, or a severe sunburn that never goes away’is piercingly real.

Causes and treatments

A diagnosis of vulvodynia is much like a diagnosis of ‘headache’ or ‘foot pain”it merely describes a symptom that could have dozens of causes and as many treatments. Some of these causes can include:

‘ Hormonal changes
An undersupply of hormones can result in fragile vulvar tissues. While studies have yet to show a strong link, Goldstein thinks the biggest culprit is low-dose birth control pills, which don’t contain enough hormones to replace the natural ones they suppress. Changing hormone levels associated with menopause can also play a role.

Promising treatments: Goldstein is currently running a large study to confirm what he’s seen in his practice: that just taking a woman off the Pill often resolves the pain. If it doesn’t, he has found that tempor­ary supplements of estrogen and testosterone can help. These supplements can also help women who experience the condition as a result of menopause. A possible connection between vulvodynia and the Pill may also explain why so many women develop the problem in their 20s and 30s, which are prime years for oral contraceptive use.

‘ Tight pelvic muscles
Some women develop a tight pelvic floor through unconscious tensing, which makes penetration painful. They may keep their pelvic muscles in a squeeze-and-hold pattern for hours (for example, teachers who aren’t free to use the bathroom whenever they need to because they can’t leave the classroom).

Promising treatments: Pukall says pelvic floor physiotherapy, where muscles are stretched, can work wonders. ‘The results were incredible,’ she says of her study of 13 women, all of whom improved dramatically over eight weeks of physiotherapy. Botox injections, used to paralyze the tight muscles around the vagina, have also been used to treat the condition.

‘ Nerve-related problems
Some women have a higher than normal number of nerve endings in the area of the vulva, which they are either born with or develop after childbirth, injury or infection.

Promising treatments: A 2008 study from the University of Michigan found that treating vulvodynia as a neuropathic pain disorder in girls age four to 11 brought dramatic improvement. Anti-seizure medication, nerve blocks and tricyclic antidepressants can all dull the pain. When vulvodynia affects the vestibule, surgery can remove the overly sensitive tissue. Goldstein, who has performed more than 300 such surgeries, says his patient satisfaction rate is over 93 percent.

Living with vulvodnia

Christin Veasley, 33, associate director for the National Vulvodynia Association, developed the condition after a cervical infection at age 18. Over the next seven years, Veasley tried a variety of treatments: topical creams, physiotherapy, antidepressants, stress reduction and diet modification. As a last resort, she underwent surgery at age 25 to remove a small section of vulvar tissue. For her, it was a cure. The only downside was that she lubricated slightly less than before, but for the first time in seven years she was able to have intercourse. She and her husband then saw a sex therapist, and within three months she was happily pregnant.

‘The biggest hurdle for women with vulvodynia,’ Veasley says, ‘is getting the proper diagnosis and treatment, especially when they are feeling isolated and, in some cases, ashamed.’

This article was originally titled "A Private Pain," in the May 2009 issue of Best Health. Subscribe today to get the full Best Health experience’and never miss an issue!’and make sure to check out what’s new in the latest issue of Best Health.