David S. Klein, M.D.

Vulvadynia

Vulvadynia is a symptom that is defined by pain in the vulva, vagina and perineum.  Generally, the term 'vulvadynia' is used to describe the medical condition whereby the precise nature of the pain is unknown.

Etiology:  Possible cryptogenic etiologies that are often overlooked include:

• Neuralgia due to damage or pathology involving-
  • Genital branch of the Genito-Femoral Nerve.
  • Ilio-inguinal Nerve.
  • Clitoral Nerve.
  • Saphenous Nerve.
  • Pudendal Nerve.

• Enthesopathy (tendinitis):
  • Adductor Magnus.
  • Sartorius.

• Complex Regional Pain Syndrome.

• Myalgia.
  • Iliacus Muscle.
  • Iliopsoas Muscle.

• Cervicitis.

The most common cause of vulvadynia in our practice results from injury to the Genito-femoral Nerve and  Ilio-inguinal Nerves.

Diagnostic Evaluation:  Quite commonly, patients will develop problems, disorders, conditions and diseases as a direct result of an otherwise unsuspected and undiagnosed underlying medical condition.

• Endocrine Disorders (Hormonal Imbalances):
  • Hypothyroidism is perhaps the most common endocrinopathy in our general population.
  • Very commonly mis-diagnosed due to the general lack of understanding of the use of hormone & stimulating hormone levels.
  • Hypothyroidism is very commonly caused by auto-immune disease that present differently from 'garden variety' or 'textbook' cases of hypothyroidism.
  • Often results from or causes sub-clinical hypo-adrenalism.
  • Individuals with hypothyroidism have very low running temperature measurements, often falling into the 96 deg to 97 deg range.  Many of these individuals rarely, if ever, run a true fever, and then only if the infection is very severe.
• Hypoadrenalism (Adrenal fatigue syndrome, Addison's Sydrome)-
  • Evaluation of Cortisol, Testosterone level, Progesterone, Estriol, Estradiol, DHEAs, and Pregnenolone may reveal deficiencies in one or more of these essential hormones.
  • There are important ratios that the body must maintain in order for the immune system, as well as for the rest of the body, to perform normally.
  • The 'normal ranges' for these hormones includes zero, for some reason.  This may be due to the remarkably common occurrence of deficiencies.  Normal values are based on populations, with the top 2.5% and bottom 2.5% being 'abnormal.'
  • If a problem is more prevalent than 2.5% of the population, the rationale would suggest that it is not a problem.
  • NOTE:  if this standard were used to determine obesity, we would define normal weights to be considerably more than what common sense demonstrates as 'normal.'

Treatment:  The most important first step in the treatment of vulvadynia is establishment of the precise structure that is either causing the pain or transmitting the nerve signals.  To this end, the diagnosis is often revealed quickly by employing a peripheral nerve block, using a fine gauge needle and low volume of local anesthetic.

1. The diagnostic nerve block is easy, when performed by skillful hands, and the diagnosis will be revealed through the relief of pain immediatly after the needle is withdrawn.  If a 27 gauge needle is used, there is no need for additional local anesthetic, sedation or anesthesia of any other kind.
2. Hormone replacement should be entertained. Best done using transdermal, 'bio-identical agents,' chemically identical progesterone (not-plant extracts that may be normal for a yam, but somewhat structurally different in a human).  The same is true for testosterone. The hormone should be chemically identical.  Estriol, estrone and estradiol should be used, if these levels need attention.
3. Never administer these hormones without getting adequate blood levels first, and then use periodic blood determinations to adjust the prescription.
4. DHEA and pregnenolone are easily administered by mouth, but blood levels should be performed, in a similar manner to that, above.
5. Thyroid replacement should utilize a combination of T-3 and T-4.  The ratio of T-3 to T-4 is different, from individual to individual.  For this reason, I prefer to use co-administer Armour Thyroid with Cytomel.  By increasing or decreasing the cytomel dosage, the ratio can be adjusted, according to patient need.

Oral Medications

• Nonsteroidal anti-inflammatory medications (NSAIDs) - Must be taken on a regular schedule to fully eliminate inflamation that may be causing neuritis and tendinitis.  NSAID's come from a variety of chemical families and influence several different inflammatory pathways.  It may be necessary to try several chemically dissimilar agents, before finding the right NSAID for any particular person.
• Further, it is necessary to co-administer a diuretic with the NSAID.
• This is due to the phenomenon that results from paradoxical swelling that results from fluid retention caused by the NSAID, itself.
• Particularly true in women, NSAID's may provide temporary relief, that is, for several hours, before the pain relief abates or actually worsens.
• Interestingly, this paradox is most profound during ovulation and menstruation, the time of greatest hormonal shifting. Salt restriction is also beneficial.
• One may notice worsening of the vulvadynia the day after a salty meal.
• Generally, the first medication given to a patient is a NSAID.

Anti-convulsant Medications (ACMs)- remarkably effective when given in low dosage combinations.

• Best started at bed time, due to the sleepiness that accompanies ACM use. When medications used in combinations that result in GABA_A, GABA_B and benzodiazepine receptor stimulation, the pain relief can be rather dramatic at remarkably low dosages.
• Barbiturates are of little value, overall.

• Topical Medications:
• Topical use of anti-inflammatory/anti-convulsant combinations can provide remarkable relief.
• Pain relief can be enhanced by the addition of Sarapin to the mixture.
• Sometimes the addition of a little local anesthetic is helpful, as might be the addition of transdermal TCA.

Birth control pills (oral contraceptives) progestins- commonly prescribed to reduce painful menstruation.

• Oral contraceptives are often prescribed for endometriosis-related pain.
• While there is relief reported in some patients, the long term effects of progestin is not a healthy picture.

• Gonadotropin-releasing hormone agonists (GnRH-As) can relieve endometriosis-related pain. The action is by shutting down the endogenous production of (female) hormones.
• While the symptoms may improve somewhat, the long-term effects may be worrisome.
• An unfortunate result of this short-term treatment is the induction of menopause, with side effects such as hot flashes and loss of bone density.

• Tricyclic antidepressant medications (TCAs) are sometimes used to treat chronic pain.  These medications were some of the first non-opiate medicines used as pain relievers.
• There is very limited data to suggest that TCA's are particularly effective.
• Side-effects can limit use.
• They may help restore sleep, which is a very important factor in the treatment of all pain disorders

• Narcotic pain medication - Many physicians fear the use of narcotics in the treatment of chronic non-malignant pain syndromes.
• This results from fear of addiction as well as fear of legal (police) interference.
• Unfortunately, this un-enlightened opinion has resulted in the unnecessary suffering by innumerable patients.
• Addiction is actually a very unusual occurrence with the use of opiates for patients suffering from organic illness.
• For a number of reasons, addiction is far more likely to occur in the patient that suffers from muscular pain and/or headache, than in the patient that suffers from nerve-related pain.
• Fear of long-term use of pain-relieving medications may make about as much sense as restricting the use of insulin in the diabetic because they may need it 'forever,' or restricting the use of anti-hypertensive patients, anti-depressants, and hormones, for the same poorly conceived notion.

Considerations-

1. No single medication successfully treats any problem in all patients. 
2. Treating chronic pelvic pain with medication is  preferable to performing surgery.
3. Surgery may not relieve pain, in fact it may  cause further problems and worsening of the situation.

David S. Klein, MD, FACA, FACPM, FACMIMS
Director, Pain Center of Orlando
www.suffernomore.com