Vulvodynia

What is Vulvodynia?

Vulvodynia is vulvar pain lasting at least three months without an identifiable cause, although contributing factors may be present.^[1] It is thought to affect 7 to 10 percent of women of all ages, and the pain may occur during sex, in non-sexual situations such as sitting or tampon use, or both.^{[2, 3]}

Vulvodynia is a diagnosis of exclusion, so your gynecologist or another clinician needs to rule out infection, skin disease and other causes first.^[1]

Common symptoms

Symptoms vary in intensity and location. Burning, irritation or sensitivity are typical, and touch, pressure or sexual activity can make the pain worse.^[1]

• Burning or rawness of the vulva
• Pain with sex, with tampon insertion, or with sitting or tight clothing
• Pain that is provoked only by touch or pressure, or that is constant, or both
• Effects on relationships, sexual pleasure and daily life^[1]

Women with vulvodynia are also more likely to report other chronic pain conditions.^[2]

Causes and risk factors

The exact cause is unknown, and research points to several factors acting together, including nerve dysfunction, inflammation and hormonal changes.^[1] The onset and persistence of the pain involve peripheral and central pain mechanisms, pelvic floor muscle and autonomic nervous system dysfunction, anxiety, depression and childhood maltreatment, as well as thought, behavioral and relationship factors.^[2]

How it is diagnosed and treated conventionally

Diagnosis rests on your history and a pelvic exam that includes the cotton-swab test, which maps where touch is painful.^[2] Vulvodynia is often underdiagnosed and misdiagnosed as a yeast infection or other vaginitis.^[3]

There are no firmly established treatment guidelines. A stepwise approach is suggested, starting with pelvic floor physical therapy, cognitive behavioral therapy and medical management, with surgery as the last option.^[2] An international consensus also recommended psychological interventions, pelvic floor physical therapy and, for provoked vestibulodynia, vestibulectomy, and advised waiting for more evidence on many other options.^[4]

A systematic review of provoked vulvodynia rated most trial evidence as very low certainty. Multimodal physiotherapy compared with lidocaine had low-certainty support.^[5] A broader review found that medicines such as topical lidocaine with oral desipramine, intravaginal TENS and botulinum toxin, and also acupuncture, had at least one randomized trial, although few large rigorous trials exist.^[3]

Why Vulvodynia calls for a whole-person approach

Vulvodynia has no single cause, so treatment that addresses only the skin of the vulva often leaves part of the problem untouched.^{[1, 2]}

Researchers describe it as a pain condition shaped by nerves, muscles, hormones, mood and relationships together.

A sensitized pain system

Peripheral and central pain mechanisms are involved in the onset and maintenance of vulvodynia.^[2] The vulva can become very sensitive to touch, which is why ordinary contact such as clothing or tampon use may hurt. This overlaps with the sensitization seen in other chronic pain conditions.^[2]

Pelvic floor muscle tension

Pelvic floor muscle dysfunction is part of the picture for many women, and pelvic floor physical therapy is a first-step treatment.^[2] In a meta-analysis of women with chronic pelvic pain, multimodal physical therapy lowered pain with high-certainty evidence, although that analysis was not limited to vulvodynia.^[6]

Stress, anxiety and mood

Anxiety, depression and childhood maltreatment are linked to the onset and maintenance of vulvodynia, and the pain in turn affects relationships and sexual life.^{[1, 2]} Cognitive behavioral therapy is among the suggested first steps.^[2]

Inflammation and hormones

Inflammation and hormonal factors are thought to contribute in some women, although their role is not settled.^[1] This is why a physician should evaluate each woman for infection, skin disease and hormonal causes.

Acupuncture for Vulvodynia

What the research shows

The research on acupuncture for vulvodynia is limited and the best trial did not show an advantage over placebo needles. In a double-blind trial, 89 women received 10 sessions of real acupuncture or skin-touch placebo needles. The proportion who improved was about the same, 58 percent with acupuncture and 57 percent with placebo, and there were no significant differences in vulvar pain or pain with sex after treatment.^[7]

Among women who did respond, the improvement faded sooner in the placebo group than in the acupuncture group over 12 weeks of follow-up. The authors suggested that a strong placebo response may have masked a real effect, and called for larger trials.^[7] That is a hypothesis, not a result.

Earlier studies were small and had no placebo group. An eight-woman pilot of 10 one-hour sessions for provoked vestibulodynia found significant reductions in pain with manual genital stimulation and in helplessness, but most other measures were not significant.^[8] A study of 12 women who had not responded to other treatments reported that nine felt at least slightly better with acupuncture and three noticed no effect, and the authors noted that part of the benefit may have come from regular specialist contact.^[9] In a meta-analysis of acupuncture for chronic pelvic pain in women generally, the results were too uncertain to draw a conclusion.^[6]

How acupuncture may work

No study has shown how acupuncture might affect vulvar pain. Because the placebo needles in the largest trial also produced improvement, non-specific effects such as touch, attention and expectation may play a part, and the trial authors called for research on who responds and why.^[7] Vulvodynia involves peripheral and central pain mechanisms, but whether acupuncture acts on them in this condition is unknown.^[2]

What treatment involves

Treatment uses fine, sterile, single-use needles at points on the lower abdomen, lower back, legs and arms, usually left in place for about 20 to 40 minutes. No needles are placed on the vulva itself. The trials used about 10 sessions, and we reassess after a short course of visits.^{[7, 8]}

Serious problems from acupuncture are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as brief bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[10] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine for Vulvodynia

The Ayurvedic view

In Ayurveda, burning pain is described as aggravated Pitta, the principle linked to heat, while sharp, shooting or hypersensitive pain is associated with Vata, the principle governing movement and the nervous system. This is a traditional framework, not a biomedical diagnosis.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Diet and daily routine intended to cool Pitta and calm Vata, such as regular meals, fewer very spicy or sour foods, and steady sleep hours
• Warm oil massage of the body, not the vulva
• Breathing practices, gentle yoga and other stress-reduction methods
• Herbs prescribed individually by a qualified practitioner

Panchakarma is not appropriate in pregnancy, acute illness or frailty, and is not a treatment for vulvar pain. Do not apply oils or herbal preparations to the vulva without your gynecologist's advice, because the skin there can be easily irritated.

What the research shows

There is no clinical evidence for Ayurveda in vulvodynia. A PubMed search found no trials and no systematic reviews of Ayurvedic treatment for vulvodynia. We therefore cannot say whether any Ayurvedic therapy relieves it. Any Ayurvedic care here is supportive, aimed at stress, sleep and general well-being, which are part of the picture in vulvodynia, and it is not a treatment for the condition.^[2] The standard first steps remain pelvic floor physical therapy, cognitive behavioral therapy and medical management.^{[2, 4]}

If herbal products are used, they should come from tested sources, since about one fifth of Ayurvedic medicines bought online contained detectable lead, mercury or arsenic.^[11]

Herbal medicine for Vulvodynia

Herbs and formulas that have been studied

We found no herbal or Chinese herbal formula that has been tested in a clinical trial for vulvodynia. Research on traditional Chinese medicine in vulvodynia is at an early stage. One exploratory study of 36 women assessed traditional Chinese patterns and found that all fit either an excess heat or an excess cold pattern, with only a hot-burning pain difference reaching significance.^[12]

What the research shows

There is no clinical trial evidence for herbal medicine in vulvodynia, and expert reviews of treatment do not include herbs among options with trial support.^{[3, 4]} A pattern-based description of a patient does not show that a herbal formula treats her pain.^[12]

Safety and herb-drug interactions

Herbs are active substances. Reported interactions include extra bleeding when warfarin is combined with ginkgo or danshen, lower warfarin levels with ginseng, and reduced levels of several drugs with St. John's wort, which also caused serotonin syndrome with SSRI antidepressants.^[13] Many women with vulvodynia take medicines such as antidepressants, so a full medicine list matters.

About one fifth of Ayurvedic medicines bought online contained detectable lead, mercury or arsenic.^[11] Any herbal product should come from a tested source and be prescribed individually. Tell us if you are pregnant or breastfeeding, or have liver or kidney disease.

Translating traditional medicine into modern biological language

This is interpretation, not equivalence. Chinese medicine describes vulvar pain through patterns such as damp-heat, or stagnation of qi and blood in the lower body. In an exploratory study, researchers asked whether such patterns might correspond to different kinds of pain, such as neuropathic or nociceptive, but the findings were not statistically significant overall.^[12]

Ayurveda's aggravated Pitta and Vata describe burning and nerve-related pain. Researchers instead study nerve sensitization, pelvic floor muscle tension and autonomic function.^[2] No study has shown that a dosha or TCM pattern matches a biological process in vulvodynia.

How this care fits with your medical care

Integrative care for vulvodynia is complementary. For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care. Keep your gynecologist or pelvic pain specialist, pelvic floor physical therapist and any counselor or prescribed medicine, and do not stop or change them without your clinician.

We do not diagnose the cause of vulvar pain, and new or changing symptoms should be evaluated first. Please bring your diagnosis, any exam or test results, and a full list of medicines and supplements.

When to seek urgent medical care

Some symptoms are not vulvodynia and need prompt assessment.

• A new sore, ulcer, lump, or white or colored patch on the vulva
• Fever, pelvic pain, or foul-smelling or bloody discharge
• Sudden severe vulvar swelling, redness or pain
• Burning with urination along with fever or back pain
• Heavy vaginal bleeding, or any bleeding after menopause
• Thoughts of harming yourself because of pain, in which case call or text 988

For emergencies, call 911 or go to the nearest emergency department.