Vulvodynia is chronic vulvar pain, burning, or itching

Generalized vulvodynia is typically classified as generalized pain throughout the vulva that is unprovoked. The pain is often described as burning, itching, sore, or irritated. The standard definition adopted by ISSVD in 1983 was “chronic vulvar discomfort, characterized by the patient’s complaint of burning and sometimes stinging, irritating, or raw sensations.” (1) In the most recent update to terminology in 2015, the categories were expanded to include generalized and mixed (i.e. sometimes local to single structure and sometimes throughout a larger area), and provoked, unprovoked, and mixed. (1) Typically, the term generalized vulvodynia is still used to refer to women with pain in more than one structure of the vulva that is most often unprovoked.

Nearly universally, vulvodynia is under-diagnosed, with many women unable to find a doctor who can help them or even one who believe them. In particular, it seems that generalized vulvodynia is severely under-diagnosed. This is likely due to our lack of understanding of the biological mechanisms behind vulvodynia.

How is vulvodynia treated?

Sadly, our understanding of generalized vulvodynia is very poor. Consequently, the treatment options are as well. Unlike with vestibulodynia where research has been able to differentiate among sub-types with distinct causes, for generalized vulvodynia we do not yet have the ability to determine the root biological mechanism of the pain and treat it optimally. Therefore, the treatments that are being offered are of a wide variety with no single one being especially effective in all women.

Until we understand the biological mechanisms causing the pain, we will not be able to adequately choose a proper treatment. For this reason, research into treatment options has been hindered. Like with vestibulodynia, there are likely many different reasons for vulvodynia that are causing the same kind of pain, but are biologically distinct. Therefore, when patients are chosen for a clinical trial, they actually represent a number of different diseases, and for many of them, the treatment has no chance of working.

Most of the treatments offered have a mechanism related to nerves. It is thought that most vulvodynia is caused by nerve dysfunction, however there are many distinct ways this could happen that would require unique interventions. A few of the most commonly used medications in women with generalized vulvodynia are:

• Local anesthetics, e.g. lidocaine

• Gabapentinoids, e.g. gabapentin & pregabalin

• Tricyclic antidepressants, e.g. amitriptyline & nortriptyline

These medications target different parts of nerve function, whether it be peripheral or central.

Because women with vulvodynia likely have pain for a variety of reasons, women sometime find relief with one treatment or another. Unfortunately, this means that treatment is usually a long process of trial and error that hopefully ends with successful pain relief.

I plan to highlight some of the individual research studies done with these medications in future blog posts.

Reference

Irwin Goldstein, Anita H. Clayton, Andrew T. Goldstein, Noel N. Kim, and Sheryl A. Kingsberg. 2018. Textbook of Female Sexual Function and Dysfunction, Diagnosis and Treatment. John Wiley & Sons Ltd., Hoboken, NJ. https://onlinelibrary.wiley.com/doi/book/10.1002/9781119266136