VULVAR VESTIBULITIS

Treatment options for vulvar vestibulitis

By Elizabeth Gunther Stewart, MD

Considering how successful surgery is, how do you tell a young woman who's unable to have intercourse that she needs to learn to live with her pain? Even so, a surgical approach is only for carefully selected women—usually those with primary vestibulitis who have exhausted other treatment options.

No, it's not all in her head—and she doesn't have a urinary tract infection. A woman with vulvar vestibulitis (VVS) can't have normal sexual relations because it's just too painful. Sex hurts. Yet causes and clear definitions of vulvar pain remain elusive, making our efforts to understand it—and help these patients—a work in progress.

We do know there are three clear-cut categories of vulvar pain. The first—pain of known cause—includes conditions like cyclic candidal vulvovaginitis, lichen planus, Bartholin abnormalities, and genital herpes. A second, unprovoked generalized vulvar dysesthesia—also known as dysesthetic vulvodynia or essential vulvodynia—is characterized by spontaneous burning, stinging, or rawness anywhere on the vulva.¹ The third is the focus of this article: Provoked localized dysesthesia—also known as vulvar vestibulitis (VVS), vestibular adenitis, or vestibulodynia—refers to pain on touch within the vestibule.¹

VVS, the leading cause of dyspareunia in women under 50, can be primary or secondary.² A woman with primary VVS experiences vestibular pain when she first starts using tampons, has a speculum inserted, or becomes sexually active. On the other hand, secondary VVS develops after a period of comfortable sexual relations. The epidemiology is unknown; preliminary data from almost 6,000 women in an ongoing NIH-funded survey of 16,000 women between ages 18 and 64 show that 16% reported a history of chronic burning, knife-like or sharp pain, or pain on contact that lasted for 3 months or longer.³