Women's Bodies, Women's Wisdom (68 page)

What Causes Vulvodynia?

Numerous studies have failed to isolate a cause for vulvar vestibulitis, but some believe that it could be triggered by vaginal yeast infections, gynecological surgery, or childbirth. It has also been associated with sexual abuse. Research has not been able to demonstrate that allergies, human papillomavirus, or bacterial overgrowth are causes of vulvodynia. Under the microscope, the most frequent finding is a nonspecific inflammation in the vestibular gland.
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Inflammation is, of course, associated with virtually all disorders, so this isn’t particularly helpful. Surgical procedures such as laser vulvectomy or vulvar vestibular gland removal often fail to eradicate the pain, though these procedures have helped some.
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What is interesting is that scientists have found that the glands in this area have associated nerve structures containing the neurotransmitters serotonin and chromogranin. This explains why treatments that work for nervous system and mood disorders sometimes also work for vulvodynia.
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Anything that affects neurotransmitter levels in our cells can affect our health. And a wide variety of modalities ranging from biofeedback to antidepressant medication have been shown to alter serotonin levels.

I advise my patients to start with nutritional and mind-body ap proaches to this problem first, and then resort to the other treatments listed here only if necessary.

Nutritional Aspects of Vulvodynia

Some research has indicated that vulvodynia may be associated in some way with calcium oxalate in the urine.
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The calcium oxalate is thought to be highly irritating to the skin of the vulva in affected women. Not all research bears this finding out. But whether vulvar ir ritation is caused by high levels of urinary calcium oxalate or simply abnormally high sensitivity to normal levels of calcium oxalate, the fact remains that many women are helped by following a low-oxalate diet and taking calcium citrate daily. Some doctors claim a 70 percent success rate with this approach. Following a low-oxalate diet can take three to six months to work. Foods rich in oxalate include rhubarb, cel ery, chocolate, strawberries, and spinach. (See Resources for references on low-oxalate foods and low-oxalate recipes.)

Taking calcium citrate also lowers oxalate levels. Citracal is a widely available brand that contains 200 mg calcium and 750 mg cit rate per tablet. Take this or another brand with similar amounts at the rate of two tablets one hour before meals three times per day. Sometimes this alone is all that a woman will need to help relieve her vulvar pain and resume a more normal lifestyle.

I recommend that women with vulvodynia follow the Master Program for Optimal Hormonal Balance and Pelvic Health in chapter 5 on page 123. Add proanthocyanidins (antioxidant substances found in grape pips or pine bark, available at health food stores) at an initial dose of 1 mg per pound of body weight, divided into two to four doses daily, for two weeks. Then decrease to a maintenance dose of 20 to 60 mg per day. A comprehensive regimen of vitamins, minerals, and antioxidants has been shown to improve immune system functioning and help support cellular healing and regeneration throughout the body. This is probably why this regimen sometimes works to help women with vulvodynia.
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A diet that decreases inflammation is also important. (See
chapter 17
, on nutrition.)

Psychological Aspects of Vulvodynia

Like all other conditions, vulvodynia has physical, emotional, and mental aspects. Failure to address all of these aspects of a problem simultaneously may lead to temporary relief only, while your inner guidance tries to find another way to get your attention. Research on the emotional aspects of vestibulitis has compared vulvodynia patients with a control group of women with other vulvar problems. Compared with the control group, women with vulvodynia were shown to be more psychologically distressed, more likely to have sexual dysfunction, and more likely to have increased awareness of completely normal sensa tions throughout their bodies. But instead of knowing that these are normal, they are more likely to believe they are symptoms of serious illness. For example, they may sense that their abdomen bloats a great deal after meals and fear that this indicates some major disease process. Small pink spots and other normal discolorations on the skin are be lieved to be cancerous, or they may think that hearing their heart beating in their ears at night indicates a brain tumor.
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This is known as somatization.

As already mentioned, vestibulitis patients are more likely to have had a history of sexual or physical abuse than women with other vul var problems.
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Since it is well documented that women who’ve expe rienced sexual or physical abuse or assault often have difficulty negotiating healthy sexual relationships, it is not surprising that the vulvar area of the body might be where a woman’s inner wisdom is trying to get her attention for healing. One approach to changing the ner vous system’s messages in this area is through biofeedback. Vaginal biofeedback—that is, learning how to progressively relax and rehabili tate the pelvic floor muscles—has been shown to decrease the subjective experience of pain in 83 percent of the women in one study who practiced this technique for sixteen weeks. The majority of these women were also able to resume intercourse by the end of the treat ment period.
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Kegel exercises can work in the same way, so a woman can try this at home. Many physical therapists are trained in pelvic floor rehabilitation. Those who work with stress urinary incontinence may be able to help with this as well.

Other Treatments

Antidepressant Medication

Tricyclic antidepressants such as amitriptyline and desipramine have been shown to help some women because of the ability of these drugs to block the reuptake of the neurotransmit ters serotonin and norepinephrine, which can affect the function of the vestibular glands themselves or the pudendal nerve. Some clinicians refer to the use of antidepressants in these cases as “giving the nerves a rest.” Antidepressants such as Prozac have not been as well studied for this indication.

Treatment starts with the lowest dose possible, increasing it if nec essary if there are no side effects. With amitriptyline, for example, begin with 10 mg each night for one week, then increase to 20 mg each night for the second week, then 30 mg each night for the third week. You and your physician will need to individualize the dose, but most women will respond at 30 to 75 mg per day.

Benson Horowitz, M.D., an authority on vulvar pain syndrome who sees many more women with this problem than the average doctor, notes that it takes about three weeks for these drugs to work, during which time most patients won’t feel their best. With time, however, and a positive attitude on the part of the health care provider, antidepres sants can be part of an overall regimen that helps women with chronic vulvar pain. If a woman uses these drugs, she should not discontinue them abruptly.
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Generally, a woman with vulvodynia will need to stay on them until she is pain free for six months.

Then she can begin the process of decreasing the dose very slowly by 10 to 25 mg each week.

NAET

Though vulvodynia has not been shown to be associated with allergy, clearly it is related to some immune response. It may respond well to the Nambudripad Allergy Elimination Technique (see page 803 or go to NAET’s website at
www.naet.com
).

Interferon

Interferon is an antiviral substance that stimulates the natural killer cells of the immune system. It is often helpful in certain cases of vulvodynia even though we don’t understand how it works. However, in women with chronic vulvar symptoms, it is ev ident that something is “off” with the immune response in the mu cosal system. So it makes some sense that a substance that affects mucosal immunity, such as interferon, might help. Some researchers believe that interferon works only in those women with evidence of HPV infection; others don’t make that distinction.

Interferon is injected into the vestibular glands three times a week for four to six weeks. Relief has been reported in 40 to 80 percent of the cases, depending upon patient selection. Since studies suggest that HPV is not the cause of the vulvar pain, the success of this treatment is an interesting paradox that can’t be easily explained. Interferon doesn’t work well in women with no evidence of HPV.
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Surgical Treatment

Surgical excision of the vestibular glands is success ful in some women, but not all. I would recommend it only as a last resort, because this procedure doesn’t address the underlying imbalance and often doesn’t work.

Finally, I also highly recommend the book
Ending Female Pain:
A Woman’s Manual
(BookSurge Publishing, 2009) by women’s health physiotherapist Isa Herrera, owner of Renew Physical Therapy in New York City. This comprehensive manual shares just about every technique you can imagine to help the pelvic floor and end chronic pelvic and sexual pain. Herrera details the use of yoga, Pilates, visualization, internal massage, scar therapy, and vulva self-care to lessen the pain not only of vulvodynia but also of vaginismus, interstitial cystitis, vestibulitis, endometriosis, pre-and postnatal pain, and more. (For more information, see her website,
www.endingfemale pain.com
.)

Given all of the scientific evidence and treatment choices, it is clear that the optimal treatment for vulvodynia must address physical, emotional, and psychological aspects simultaneously. A symptom as persistent as chronic vulvar pain requires a great deal of trust in your inner wisdom, and a lot of compassion and patience.

INTERSTITIAL CYSTITIS
(PAINFUL BLADDER SYNDROME)

Interstitial cystitis has more in common with vulvodynia than with urinary tract infection. (See page 306.) Unlike a UTI, the symptoms are not the result of infection. Both vulvodynia and interstitial cystitis are chronic pain syndromes.

Interstitial cystitis is a condition most common in women between the ages of forty and sixty. It is characterized by disabling urinary frequency and urgency, painful urination, needing to get up at night to urinate, and occasional blood in the urine. Pain above the pubic bone is also common, as are pelvic, urethral, vaginal, and perineal pain; this pain is partially relieved by emptying the bladder. Examination of the urine may reveal some blood cells but no bacteria or white cells. It is often present in women who also experience vulvar pain. Though the cause is unknown, many feel that it is, in part, an autoimmune disorder. There is a significant crossover between the population of women who experience vulvodynia and those who experience interstitial cystitis.

Diagnosis is made on the basis of the patient’s history and also by a procedure known as cystoscopy, in which a lighted viewing instrument is placed in the bladder under anesthesia. There are some characteristic findings, such as hemorrhage under the bladder lining and cracking of the mucosal lining; a biopsy reveals evidence of inflammation.
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Treatment

Behavioral Therapy

Biofeedback and behavioral therapy—both of which have definite benefits, with no side effects—have been reported to help many women with this problem.
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Behavioral therapy consists of learning deep relaxation, meditation, or other techniques that boost the immune system and calm the nervous system, thus allowing the body to heal itself. (See section on stress reduction, page 130, for treatment of PMS.)

Nutritional Therapy

Stop bladder irritants such as coffee (even decaf), cigarettes, and alcohol. Castor oil packs help immune system func tioning: Lie down with a castor oil pack over your lower abdomen three times per week or more, while saying— and really feeling—the affirmations suggested in the section on urinary tract infections, below. The same antioxidant therapy that has worked for vulvodynia patients may also help those with chronic interstitial cystitis. (See the section on vulvodynia.)

NAET

My acupuncturist, Fern Tsao, reports good results with NAET (see page 803), which I would personally recommend to anyone who is open to this ap proach.

Bladder Distension

This diagnostic procedure is often also used as an initial therapy and involves filling the bladder with water and allowing it to expand while the patient is under general anesthesia. Although it isn’t certain exactly why this works, it’s possible that it increases capacity and also interferes with pain signals.

Bladder Instillation

This procedure is also called a bladder wash or bladder bath, and it involves filling the bladder with a solution that the patient must then hold for about ten to fifteen minutes before voiding. Generally, women receive treatments once a week or once every other week for six to eight weeks.

Elmiron (Pentosan Polysulfate Sodium)

This pill (the first to be devel oped for interstitial cystitis) is taken three times a day. In clinical trials, it improved symptoms in 30 percent of patients— although it might take as long as four to six months to notice improvement.
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RECURRENT URINARY TRACT INFECTIONS

Most women will experience a few UTIs over their lifetimes. The “honeymoon cystitis” our mothers were told about speaks to one of the primary causes of UTIs—the milking action of sexual activity, which, under certain conditions, causes bacteria from the vaginal or anal area to get into the bladder and urethra. The symptoms include burning on urination, blood in the urine, and fever. If a UTI goes untreated, the infection can ascend into the kidneys, which can be dangerous. This is why a woman who feels she may have a UTI should have a urine culture taken, and an antibiotic prescribed if it is positive for bacteria. This will cure the problem in the vast majority of cases without further treatment.