Vulvar vestibulitis syndrome (also known as vestibulodynia or vestibular adenitis) is a subset of vulvodynia that is characterized by severe pain during attempted vaginal entry (intercourse or tampon insertion), tenderness to pressure localized to the vulvar vestibule and redness of the vulvar vestibule (Click for photos of vestibulitis). Increased awareness of vestibulitis has led to exciting new research and it has become apparent that vestubilitis is not just one disease but is in fact just a symptom of several different diseases or conditions.
We, at The Florida Center for Vulvovaginal Disorders have identified at least a dozen different causes (diseases or conditions) that cause vestibular pain, redness, and pain during intercourse, i.e. vestibulitis. While many of these diseases look very similar, subtle differences, along with a person’s history can be used to distinguish the causes of the pain and thereby lead to a logical treatment path. This also explains why no one treatment works for every woman with vestibulitis and also explains why the vast majority of research up until this point isn’t very useful. The following is a list of the most common of these causes.
“Atrophic Vestibulitis”. Frequently caused by oral contraceptive pills, surgical removal of the ovaries, chemotherapy for breast cancer, hormonal treatment of endometriosis, and menopause. There is evidence that the vulvar vestibule needs adequate levels of both estrogen and testosterone and these levels are frequently altered with the medications/conditions listed above. Distinctive features of “atrophic vestibulitis” are that the symptoms occur gradually and the entire vestibule is affected. There are low levels of estrogen and free testosterone, and elevated sex-hormone binding globulin levels in the blood. Stopping the Pill does not cause resolution of the symptoms, nor does applying hormonal creams while remaining on the Pill.
“Pelvic floor dysfunction” (aka levator ani syndrome, pelvic floor hypertonicity, vaginismus). In this condition, the muscles that surround the vestibule are tight and tender. This can cause tenderness and redness of the vestibule, without there being an intrinsic problem of the tissue of the vestibule. Often the back part of the vestibule (near the perineum) is affected more than the front part (near the urethra). Pelvic floor dysfunction can be detected by a thorough exam of the levator ani muscles. Treatments include intravaginal physical therapy, warm baths, muscle relaxants such as Valium, biofeedback, and Botox which is used to augment the physical therapy.
“Neuronal proliferation” (NP). A condition in which the density of nerve ending is increased in the vestibular mucosa. This group is split into primary (pain since the first attempt at intercourse) and secondary (acquired after some pain free interval.) There is good evidence that primary NP is a congenital problem (IE a birth defect) while secondary NP can be caused by an allergic or irritant reaction (frequently to vaginal anti-fungal creams.) Treatments for secondary NP include tri-cyclic anti-depressants, lidocaine, capsaicin, and surgical removal of the affected tissue (vulvar vestibulectomy with vaginal advancement.) In our opinion primary NP can only be cured with vestibulectomy. (There are many vulvar specialists who disagree with this opinion.)
“Vaginitis”. Sometimes there is inflammation so severe in the vagina that the inflammatory white blood cells pour out of the vagina and coat the vestibule and cause a secondary vestibulitis. There are two categories of vaginitis: infectious and sterile (non-infectious). Infectious vaginitis is caused by an organism such as yeast and trichomonas- but not bacterial vaginitis (Gardnerella). Sterile vaginitis can be caused by exposure to chemicals such as vaginal creams, spermicides, lubricants, and latex in condoms. In addition, sterile vaginitis can be caused by lack of estrogen (see atrophic vestibulitis above for the causes) and a condition called desquamative inflammatory vaginitis (DIV). The cause of DIV is unknown but it is characterized by copious yellowish discharge. Even though infectious vaginitis is only infrequently the cause of vestibulitis, almost all women with vulvar pain have been unnecessarily subjected to many, many courses of antibiotics and anti-fungals by well-intentioned health care providers.
Vulvar Dermatoses: Several different dermatologic conditions of the vulva can cause pain at the vulvar vestibule. The most common disease affecting approximately 1.3 % of all women is lichen sclerosus. The second most common is erosive lichen planus. More rare diseases include plasma cell vulvitis and mucous membrane pemphigoid.
“Irritant or Allergic Contact Vestibulitis.” Unfortunately, women expose their vulvas to dozens of different chemicals almost every day. Even the most gentle of soaps have many different chemicals in the form of perfumes, dyes, and preservatives. Toilet paper, sanitary pads, tampons all contain chemicals. Laundry detergents and fabric softeners used to wash underwear and towels add to this chemical burden. A woman can be sensitive or allergic to any one of these chemicals and this can cause inflammation and pain in the vestibule.
It is imperative that a woman with vestibulitis have a thorough evaluation by health care provider familiar with all the causes of vestibular pain. In addition, treatments should be directed at the specific cause of the vestibulitis. Just as we don’t treat every case of foot pain with a cast, we shouldn’t treat every case of vestibulitis with one specific treatment.