Vulvodynia- New Concepts
Posted Thu, Mar 10, 2011

On television and in the movies they may note: the following may be considered graphic. Use parental discretion before viewing. I wonder in this graphic internet world whom they are addressing.So- fair warning to all. If discussing skin problems of genitalia or sexual problems is too graphic for you, parental discretion is advised (I am thinking I have not seen these warnings on the Cialis and Viagra commercials; and isn’t there a commercial for feminine hygiene?)
Vulvodynia- painful vulva. This entity has now been anointed legitimate by the medical media but is still in early stages of understanding. The National Vulvodynia Assoc has done much good in educating the public and physicians but it seems to have a schizophrenic philosophy on what constitutes vulvodynia. When I wrote the association an article summarizing the dermatologic causes of vulvodynia they rejected publishing saying that vulvodynia is a state of painful vulvae with no discernable cause. That doesn’t give the millions of women who suffer from this painful disease any solace. According to these experts you can only have a disease if it has no cause, but let’s talk about what we don’t know and maybe we can help you. (In Catch 22 only pilots who were insane could be excused from flying war missions yet any pilot who asked for such an excuse clearly was sane so all pilots had to fly.)
Ignoring my disagreement with this association, vulvodynia is a serious disease with only a handful of gynecologists, dermatologists, pathologists, and physical therapists interested in diagnosing and treating these disorders. (I have excluded pain doctors as their expertise generally does not include diagnosis).
As this is a disease of the vulva it is not a disease of the vagina but severely limits sexual activity because of the pain it produces. In addition, there are signs of skin disorders that impact this disease. I want to emphasize new findings which show the following: an increase in the presence of pain fibers in the vulva of these patients; a history in some of these patients of birth control pill usage with low estrogen and and anti-androgen activity. Since the vulvae contain a plethora of testosterone receptors and many estrogen receptors the use of such pills may predispose the skin to being susceptible to trauma (as in sexual activity). In later years the deprivation of male hormone stimulation to hormone receptors in the vulva may decrease sexual drive. Lastly, chronic pain leads to contraction of pelvic floor muscles which increases pain with sexual activity. The demonstration of pain fibers in the vulvae and the coincidence of testosterone receptors in the same area coupled in some patients with a history of testosterone deprivation courtesy of some birth control pills are relatively new findings.
MetropolitanMD is one of the few dermatologic treatment centers for vulvodynia though many gynecologists grapple with this on a daily basis. After a complete history and physical exam, a biopsy may be needed to rule out certain skin diseases. Then a careful and arduous path of experienced trial and error must begin much as a chef must add and subtract from his recipe to make a dish effective. Given new knowledge the use of topical testosterone and estrogen may be advised in some cases and birth control pills without anti-androgens may be preferred for young women except those suffering from severe acne.


Edward Lack
Edward Lack MD is a board certified dermatologist and a board certified dermatologic cosmetic surgeon. He is President and Medical Director of MetropolitanMD, a multispecialty cosmetic surgery center in Chicago,which is unique in having a double board certified cosmetic dermatologic surgeon, a double board certified facial plastic surgeon, and a double board certified cosmetic plastic surgeon. Dr. Lack is also the Past President of The American Academy of Cosmetic Surgery.

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