Vulvodynia
What does is mean when I have pain and burning after sex?

A few years ago my nephew was looking at a scarf of mine.  It was covered with hearts and romantic designs.  When the scarf opened up there were two voluptuous women in the middle.  They were covered with a demi bra on top.  On the bottom there was no clothing, but the area was minimally depicted with the black outline of the legs forming a V.  My nephew asked me:  "what is that called?"  pointing to the V formed by the tops of the thighs.  I said "what do you think it's called?".  He said:  "well, mine is a penis, so it must be a venus.".  I think that is the best name for the vulva I've ever heard.  So....why do we get pain in the venus?

What is vulvodynia?

Vulvodynia is pain in the area of the vulva.  The vulva is our external genitalia.  It includes the mons, labia majora, labia minor, vestibule.  Vulvodynia is a pain condition like migraine.  It is diagnosed clinically.  It can not be proven by skin biopsy or blood test.  

What is it called?

Vulvodynia can be classified as localized or generalized and provoked or unprovoked.

For example:
Localized Provoked Vulvodynia - This is pain that occurs when a particular spot is touched. A doctor can check for this by touching with a Q tip.  If you have pain that gets activated by placing a tampon then you probably have this. The former name was vulvar vestibulitis.  The more specific name is localized provoked vestibulodynia when the pain is localized to the vestibule. The vestibule is the skin area outside of the hymen and from about 3 o'clock to 9 o'clock.  If you're looking at the vulva the clitoral area is 12 o'clock.

Generalized Unprovoked Vulvodynia - this is when the vulva hurts all over and without being touched

You can have pain in other areas. For example, clitorodynia is pain in the clitorus.

What is it not?

Vulvodynia is a problem of overactive pain fibers and perhaps inflammation.  On examination the skin will look fairly normal.  To the trained eye there may be evidence of chronic inflammation in that the labia minora may be smaller than normal.  But overall the appearance is normal.  Vulvodynia is not a skin disorder.  If the skin is abnormal than a vulvar biopsy should be done to look for skin changes that can cause itch and pain: lichen sclerosis, lichen planus, chronic yeast, herpes, vulvar cancer, changes of menopause, or reaction to topical products or over cleaning. Vulvodynia is not pudendal neuralgia.  This is a problem of nerve entrapment. Pain is usually worse when sitting down.  Vulvodynia is also not vaginismus.  Vaginismus is a contracture of the pelvic floor muscles resulting in difficult penetration of the vagina.  Vaginismus can occur after vulvodynia is present and untreated for some time.  However, it can occur on its own. A doctor can check for this by placing a gloved finger in the vagina and pressing on the pelvic floor.  Treatment is dilators and physical therapy. http://www.vaginismus.com.

What other problems cause painful sex?

Vaginismus - This condition causes difficult penetration due to contracture of pelvic floor muscles which close of vagina. 
Interstitial Cystitis - This is chronic inflammation of the lining of the bladder. Results in frequent urination and urgency, pain with a full bladder, and painful sex.  The pain occurs when penetration touches the front wall of the vagina and therefore the bladder.  Pain is often deep and crampy.
Endometriosis - This is a condition in which tissue from the lining of the uterus is growing in the pelvis.  Women have deep crampy pain with menses.  They may also have pain with intercourse. This pain is usually deep inside the vagina and can occur when penetration touches the cervix which results in movement of the uterus, tubes, and ovaries.
Menopause - Due to less estrogen the vulva and vagina became thin and there is less elasticity.  Women may feel "drier" or that there is rubbing. Estrogen applied in small amounts and in a thin layer to the area will help. Try this for two weeks nighlty then 2x/week.  Also, an emollient like vaseline is helpful and a lubricant like olive oil.
Vulvar skin conditions - if a condition like chronic yeast, herpes, or chronic irritation resulting in squamous cell hyperplasia (thickened patch of skin) exists, then appropriate treatment will improve sexual comfort.

Why does it hurt?

Because the nerve fiber, or nociceptor, becomes activated.  This will feel like burning and swelling.  The activation of the nociceptor results in release of an "inflammatory soup" that results in further increased sensitivity of the nerve endings.

Why is it hard to get help?

Vulvodynia is very under studied.  Physicians consider the best way to study a problem is through a randomized double-blind controlled trial.  Many problems can not be studied in this way.  Ironically vulvodynia can be studied this way, but on my last search I only found 13 randomized double-blind controlled trials on vulvodynia.  However,  there is a fair amount of expert clinical advice.  This information does make it into journals and to conferences for physicians.  You need to see a physician who has been to these courses or made an effort to read the journals.  In general, pain disorders require a multidisciplinary approach, and you will need a team to help you.  A thorough approach to vulvodynia may include a gynecologist and physical therapist.  However,  vulvodynia overlaps with other pain disorders.  You may have irritable bowel syndrome (IBS), painful bladder syndrome/interstitial cystitis, fibromyalgia, and or migraine.  

Where can I get good information?

National Vulvodynia Association
http://www.nva.org
The V Book, Elizabeth Stewart
http://www.amazon.com
The International Society for the Study of Vulvovaginal Disease
http://www.issvd.org
National Institutes of Health
http://www.nichd.nih.gov/health/topics/Vulvodynia.cfm

Montana

St John, USVI

Alaska

Baja

British Columbia

How is it treated?

The nerve needs to be calmed down.  You will need take a combined approach: give things a good try, delete those that fail, and add new things until you find your best treatment.
1.  Topical anaesthetics like lidocaine are usually the first thing to try.  I like to prescribe 5% lidocaine ointment.  A pea-size amount should be placed on the painful area nightly, an hour before sex, or before any activity that aggravates the area (i.e., spinning).  It can be used up to 4 times a day.  If the lidocaine burns then the pharmacist should compound it for you in a petrolatum base. It's burning because of the acidity or pH of the product.
2.  Limit irritants.  It is very important to calm down the inflammation. Do not over cleanse. Use glycerin based soaps like Neutrogena or Pears, or simple soaps like Basis or Dove Unscented.  Do not scrub.  Stop shaving or waxing. No body washes. Use unscented detergent to wash clothes. Use an emollient like Aquaphor to protect the skin. Products with petrolatum, mineral oil, and zinc oxide are soothing to skin.  A&D ointment is a good protective barrier.  Use ice or cold water to calm down burning.  Change bathing suits and gym clothes promptly.  Try loose gym clothes and moisture wicking underwear.  Wear white cotton underwear on most days.  
3.  Try an oral medicine to calm the nerve down.  Elavil (amitryptiline) which is an antidepressant and Gabapentin (neurontin) have been used in several nerve-pain conditions.  For example, migraine.  Some women have a good result from using one of these medicines.  If you add one of these medicines then you should try is for at least 3 weeks.  If you try Elavil, then start low @ 10 mg and then go up every 2 to 3 weeks until you notice you feel better.  If you get to 60 - 80 mg for 3 wks and you are not feeling better it probably is not working for you.  If you have minimal side effects and a small response you could try going up to as much as 100 mg at night.  The usual effective dose is 75 mg nightly, but everyone has different responses to medicines.  Neurontin can be started at 300 mg daily and go up every 3 days by 300 mg.  Take 300 mg at night, then 300 mg morning and night, then 600 mg at night and 300 mg in morning.  Continue increasing until you feel better.  The maximum dose is 3600 mg daily. 
4.  It also very important to treat any anxiety you may have.  Anxiety makes pain worse.  If you are watching a scary movie and someone taps you on the shoulder you jump and maybe scream.  When you are in a heightened state your reactions are more intense.  Anxiety decreases the threshold of the pain response.  The best way to treat generalized anxiety is with a combination of talk therapy and medications.  Not every one will choose medications.  Relaxation techniques, yoga, mindfulness practice, and cognitive behavioral therapy can be used to decrease anxiety.  Medication approaches include an antidepressant that targets anxiety like Zoloft, Celexa, Paxil, or Lexapro.  Some people will need a benzodiazepine like ativan until the levels of the antidepressant are adequate.  Be careful about self-treating anxiety with alcohol or other drugs. In the long-run alcohol will make the anxiety worse.
5.  Your doctor can perform trigger point injections.  These are local injections of lidocaine and a steroid by your doctor.  They may be done weekly for one month.  You may feel worse for a few days, but then better.  You should feel better longer after each injection.  You can then have monthly  injections.  It can be helpful to get Women's Health physical therapy along with the injections.  Acupuncture is also a good treatment to add.
6.  Surgery.  Vestibulectomy is the usual approach for treatment resistant vulvodynia.  The area of skin which provokes pain is removed in the operating room and the remaining skin is sutured to the opening of the vagina.  This is succussful in the correct patient.  

**This advice is not a substitute for partnership with a good doctor.  Please take good care of yourself and look for a good doctor and I strongly encourage a multi-disciplinary approach.