Understanding VVS / Vulvodynia

A surprising number of women experience pain during sex ("dyspareunia"). As Wikipedia says, "dyspareunia has been estimated to affect between 8-21% of women, at some point in their lives."  The pain is often so intense that it makes sex impossible or extremely unpleasant, and it can cause even devoted couples to break up if no solutions are found.

There are many possible causes, including cysts, strictures, scar tissue, viruses, bacteria, fungal infections, ovarian problems, and endometriosis, so you should get checked by a good gynecologist to rule out anything like that. Ask your doctor to check for micro-ulcers as well. Some infections can leave tiny ulcers on the surface of the vulva and vagina that can burn or sting when something touches them.  These can persist even after any trace of the infection is gone.

This may seem strange, but you should hope that it is some kind of cyst or infection, because those are usually easy to cure.  When doctors find nothing, or prescribe "cures" that don't work, then it's time to worry.  Often women who experience severe pain during intercourse end up being bounced from doctor to doctor to psychiatrist, being told that "it's all in your head."

When these women finally do get an accurate diagnosis and find relief, the pain is usually from one of two common problems that few doctors understand:  vaginismus or VVS (vulvar vestibulitis syndrome), or sometimes both.

The difference between vaginismus and VVS is that vaginismus is caused by muscle spasms or hypertrophy, creating extreme vaginal tightness that prevents comfortable penetration, while VVS is caused by inflammation of the tissue or the nerves.  The pain from vaginismus usually stops immediately when the attempted penetration stops.  The burning sensation from VVS typically continues for at least a minute or two, and often much longer, after the contact has ended. And, just to complicate things, the pain of VVS can trigger vaginismus as well, so it's quite possible to have both at the same time.

I wrote about vaginismus at length in last month's post, so today I want to address VVS (also called vulvodynia).

VVS usually manifests itself as a burning, stinging, or stabbing pain in the vulva (the external genitals) or just inside the vagina, in or near the vestibule or entrance area.  These symptoms are typically triggered by pressure and/or friction, so it can make intercourse extremely painful.

With VVS, the vaginal opening is usually normal in size and there is no physical resistance to penetration.  Women with VVS may even be able to insert tampons without pain. However, if the muscles around the vaginal opening close tightly and obstruct penetration and there is also strong stinging or burning pain on contact, the woman may well have both VVS and vaginismus, where the subconscious mind tries to prevent painful penetration by clamping the entrance muscles shut.

Unfortunately, most doctors know very little about VVS, so misdiagnosis is common, and it is not unusual for women to be referred to psychotherapists, and to waste months or years trying to find a psychological cure for a physical problem.  Even when there is an accurate diagnosis, it often doesn't help, because there are no standard medical therapies for VVS.  

In almost every case, therefore, you are pretty much going to be on your own. Treatment consists mostly of a trial-and-error process of eliminating possible causes until you find out what works for you.  It may be as simple as not wearing tight jeans or avoiding certain kinds of soaps or detergents.  Or it may take years to figure out your triggers and how to avoid them, especially if you have more than one.

These triggers can be anything that is capable of causing persistent inflammation in nerves or sensitive tissues.  Most triggers fall into five categories: 

• Physical irritation from pressure, friction, heat, sweat, or moisture
• A chemical, like chlorine or an ingredient in some product you use, that comes in contact with your vulva/vagina
• Something in your diet that is being secreted in your urine
• Medications
• Repeated urinary tract infections or fungal or bacterial infections

Here's a starter list of things to try, originally from WebMD, but with a lot of edits and additions:

• If you have any chronic conditions, ask your doctor if you can suspend your normal medications or try alternatives.
• Avoid taking unnecessary antibiotics.
• Stop taking all vitamins, herbal remedies, and over-the-counter drugs that you have been taking on a regular basis.
• Avoid foods that make urine more irritating. This can include foods such as herbal teas, hot peppers, artificial sweeteners, greens, beans, berries, chocolate, and nuts.
• Avoid all perfumes, colognes, and scented hair and skin products.

• Wash and rinse your hands BEFORE you go to the toilet as well as after.
• Use ONLY water to wash your vulva - no soap, detergents, or scents.
• Rinse your vulva with cool water after urination and intercourse and pat dry - do not rub!
• Use soft, white, unscented toilet paper.
• Keep the vulva area clean and dry.

• Use only the mildest hypoallergenic/dermatologically-approved soaps, shampoos, lotions, and cosmetics for the rest of your body.
• Avoid getting shampoo on the vulvar area.  (Bend forward when you rinse your hair and make sure the shampoo does not flow down your body.)
• Do not wash or rinse your vagina or put anything in it.  Absolutely no water, soap, douches, or "feminine hygiene" products!
• Avoid hot tubs or pools with lots of chlorine.

• Use hypoallergenic/dermatologically-approved detergent in your washer and don’t use fabric softener (including dryer sheets like Bounce). If necessary, wash all of your panties by hand.
• Wear 100% white cotton underwear, menstrual pads, and tampons
• Avoid ultra- and high-absorbency tampons.  If you have heavy flow, consider switching to a menstrual cup.
• Do not wear pantyhose!
• Wear only skirts, dresses, and loose-fitting pants.  (The zipper in a pair of tight jeans can easily create enough pressure to cause VVS.)
• Think about wearing long skirts and "going commando" (not wearing underwear) to allow maximum air circulation.

• Avoid sitting on hard surfaces; carry and sit on a foam rubber doughnut if necessary.
• Avoid all activities that put direct pressure on your crotch, especially biking and horseback riding.
• If you masturbate in a way that puts a lot of pressure on your vulva or clitoris, stop and find a gentler way.  In particular, if you lie face down or lean agains hard objects when you masturbate, you need to switch.
• If you use a vibrator, try positioning it to one side, pressing against your outer labia instead of right on the centerline of your vulva.

It's better to completely avoid penetrative sex until you can have penetration without any pain.  However, if you feel you have to continue, take these additional steps: 

• Do not use any contraceptive creams and spermicides.
• If you can do so safely, ask your partner to stop using latex condoms; switch to polyisoprene, polyurethane, or nitrile condoms or a different form of birth control.
• Use coconut oil or an unscented, unflavored, water-soluble lubricant during sex.  (But don't use coconut oil with latex or polyisoprene condoms.)

When in doubt, use more lube.  Sometimes the source of VVS is as simple as too much friction during sex.  Changes in diet or medications, anxiety disorders, recreational drug use, smoking, and wide variety of other seemingly unrelated problems can keep you from producing enough natural lubrication, which creates more friction, more irritation, and more pain.  Some women report that they have been able to eliminate pain during sex just by switching to polyurethane condoms and coconut oil.

It's also important for the VVS patient's partner to wash and rinse well before sex and to avoid using potentially irritating soaps or creams on his hands and penis.  I know of one case where the husband was a mechanic and the VVS trigger was the grease-cutting detergent he used to clean his hands after work.  It's the kind of detergent that is advertised as a "waterless hand cleaner," and he was rubbing it in and then wiping his hands with a rag. That left a thin film of grease and detergent on his hands, which irritated her vulva and vagina when he fingered them during foreplay.

The fastest way to get relief from VVS is to follow ALL of these suggestions as strictly as possible for at least six months.  If that eliminates the inflammation that is causing your pain, then you can begin gradually reintroducing possible irritants one at a time, according to how much you miss them.  Perhaps that means trying chocolate first, or bike-riding.  But whatever order you choose, keep a careful diary of what you add back and when, because it can sometimes be months after you reintroduce a trigger before the VVS comes back.

If nothing else works, a doctor may prescribe a topical estrogen cream or even try putting you on tricyclic antidepressants, but these only work for some women, so it's pretty random, and the antidepressants have some potentially nasty side-effects.

Some women have had success using a strong topical corticosteroid anti-inflammatory cream or ointment (e.g., hydrocortisone), which they rub on the painful area several times a day. Also, taking naproxen (Aleve, Naprosyn, etc.) may help. Finally, applying icepacks or very cold water to the vaginal entrance area several times a day helps some women. (All of this is anecdotal information, not backed by any research that I know of.)

Finally, some cases of VVS seem to be caused by one thing, but then they continue after that problem has been eliminated because the woman is so anxious about the pain that she tightens the muscles in her thigh and groin in ways that aggravate the initial irritation.  If you think you might be doing that, try relaxation techniques, like meditation and progressive muscle relaxation (PMR). 

(Actually, both meditation and PMR are very good things to learn on general principles.  Both help you cope with stress and anxiety and contribute to good health.  Getting more exercise and more sleep can also help.)

I hope in your case it turns out to be something simple and easy to avoid. Good luck!

Ref:
National Vulvodynia Association
Vulvodynia and Vulvar Vestibulitis Syndrome FAQ v2.3 | OBGYN.Net
Vulvovaginal Disorders, Vulvodynia, Vulvar Vestibulitis
Vulvodynia: Causes, Symptoms, and Treatments
Vulvodynia: Diagnosis and Treatment

If you need to locate a specialist, here are some referral sources:

The National Vulvodynia Association
The International Society for the Study of Women’s Sexual Health
The American Association of Sexual Educators, Counselors and Therapists
The International Society for Sexual Medicine