I’m 20 years old. My knees are apart, and my feet are anchored in cold metalstirrups. A doctor is shining a bright, hot light between my legs, prodding megently with a Q-tip, peppering me with questions. I’m here, in a place where nowoman wants to be, because the incessant itching, pain, and burning thatplagued me for two years has gotten so severe I can barely tolerate underwear,let alone the “luxuries” -- tampons, intercourse, and tight jeans -- that mycollege roommates take for granted.
As it would turn out, I was in luck on that tepid spring day back in 1998.For this amazingly compassionate Cleveland doctor -- the 11th gynecologist Iwould see in my quest for answers -- was able to finally give me somethingnobody else could: A diagnosis of vulvar vestibulitis and a treatment plan.
My story isn’t unique. At some point in their lives, millions of women willsuffer from a range of common and less common gynecological or urologicalconditions, including chronic infections, vulvodynia, vaginal dryness,fibroids, and stress incontinence with intercourse.
While each experience (and diagnosis) is different, many women will discovertheir illness goes beyond physical symptoms to affect their sex lives and eventheir general state of mind. Indeed, “these conditions may negatively impactwomen’s physical, emotional, relational, and/or sexual well-being,” says HelenCoons, PhD, ABPP, president and clinical director of Women’s Mental HealthAssociates in Philadelphia.
Following are the most commonly diagnosed health problems “down there.”
Vaginitis
The itching, burning, and pain associated with vaginitis results from adisruption in the natural balance of bacteria that live in every healthyvagina. There’s no single cause. Common culprits include hormonal changes dueto birth control pills, menopause, or pregnancy as well as chronic medicalconditions, such as HIV and diabetes, which weaken the immune system. Frequentsexual intercourse and sex with multiple partners can be to blame as well. Ofthe many types of infectious and noninfectious vaginitis, the following fourare the most common.
Bacterial vaginosis (BV) is “the most common vaginal infection inwomen of reproductive age,” according to the National Institutes of Health.Women with BV may have a copious, thin grayish-white discharge -- or they maybe symptom-free.
Some studies suggest that untreated BV can cause pelvic inflammatorydisease, which can lead to infertility, so it’s important to seek treatmentfrom a health care provider, says Susan Kellogg, CRNP, PhD, director of VulvarPain and Sexual Medicine at the Pelvic & Sexual Health Institute inPhiladelphia. Fortunately, BV is easily treated with oral or vaginalantibiotics.
Yeast infections caused by the overgrowth of one of several strainsof Candida, a fungus that lives normally in the vagina, are also common; threein four women will have at least one at some point in their life. Women maynotice a thick white discharge with a slight odor. However, many women complainof genital itching, soreness, or irritation.
Treatment is painless and easy; most women simply insert at bedtime aprescribed cream or an ovule (a soft suppository) -- generally soothing butmessy -- or they can take a prescription oral antifungal such as Diflucan.You’ll avoid the mess, but relief might take a few days longer.
Atrophic vaginitis can develop if you’re breastfeeding or takingprogestin-only birth control pills; both may cause a dip in estrogen levels.This condition feels like an infection with burning, itching, and pain, butthere’s no active infection. Treatments such as estrogen creams or a vaginalestrogen ring (inserted by your doctor) can help.
Trichomoniasis, a sexually transmitted infection, can cause agreenish-yellow frothy discharge, with some itching and burning. Women mightnotice irritation with intercourse. Like BV, “trich” is easily treated withoral or vaginal antibiotics.
If you think you have any of these, see your doctor. Loading up onover-the-counter creams will only make the problem worse if you have adifferent type of infection. And whatever you do, don’t douche. “When a womandouches, she rinses out the bacteria in question but also [healthy] bacteriathat are responsible for normal secretions,” says Kellogg.
Vulvodynia
Imagine vaginal burning and pain so severe you can’t sit comfortably, wearfitted clothing, or have intercourse. That’s the reality women with vulvodyniaface -- and there’s no quick fix. Some suffer for years before finding theright treatment (or even any relief).
That’s why Phyllis Mate, executive director of the National VulvodyniaAssociation, was incensed by a recent episode of ABC’s Private Practice, inwhich Dr. Addison Montgomery (played by Kate Walsh) diagnosed and cured apatient’s vulvodynia in a single episode. “While the producers deserve creditfor trying to depict the symptoms of vulvodynia, 13 million women in the realworld would painfully disagree with the show’s fairy-tale ending,” Matesays.
Doctors don’t know exactly what causes vulvodynia, but possible contributorsinclude injury to nerves in the vulva, hypersensitivity to Candida, and pelvicfloor muscle spasms. The most common form of vulvodynia is vulvar vestibulitissyndrome (VVS), which affects the tiny glands that lie at the top and bottom ofthe vaginal opening.
For years, patients have been treated with tricyclic antidepressants (toblock pain receptors in the vulva), topical estrogen creams and anesthetics(such as lidocaine), anticonvulsants, and surgery. But newer, less invasivetreatments are working wonders. To curb pain and restore sexual function,Kellogg treats some patients with Capsaicin cream, a specially compoundedointment that contains the active ingredient in chili peppers. It might causediscomfort on contact but can dramatically reduce symptoms.
If a woman’s condition is flared by a Candida hypersensitivity -- to whicheven a slight imbalance can cause itching and burning -- weekly doses of anoral antifungal medication over several weeks or months can help alleviatesymptoms.
For patients who have a secondary condition called lichen dermatoses -- agroup of skin conditions in the vulva that can cause severe itching and/or scartissue -- a mix of topical steroids with a tiny dab of estrogen cream can helpheal the damage to the vulvar tissue and decrease symptoms.
Physical therapy (with a highly trained specialist) is another valuable formof treatment for some patients. By correcting misalignments, strengtheningpelvic floor muscles (the layers of muscles stretching between your legs andsupporting your organs, bladder, uterus, and ovaries), and working to loosenmuscles that have become painfully tight, these therapists can helpdramatically reduce pain.
Vaginismus
If you have vaginismus -- a rare condition that fewer than 2% of women inthe United States develop -- the muscles surrounding the vagina involuntarilyspasm so tightly that you can’t have sexual intercourse or even insert atampon.
The specific cause of vaginismus is unknown, but, as with vulvarvestibulitis and stress incontinence, physical therapy can be an invaluable“first line of treatment,” according to Erica Fletcher, PT, MTC, founder ofFletcher Physical Therapy in Narberth, Pa.
Fletcher and other physical therapists who specialize in pelvic floordisorders can correct structural abnormalities and design a manual therapy andexercise program that will retrain pelvic muscles that are too tight or tooweak, depending on the condition. Their efforts can dramatically reducesymptoms-without the side effects of medication.
They also teach women the proper way to perform techniques at home, withdilators and their own fingers, to gently stretch and massage the muscles.
If a woman’s symptoms persist despite physical therapy, a doctor can injectBotox to paralyze muscles and prevent the spasms for up to six months.
Other treatments for vaginisimus include sex therapy, medications such asvalium, and hypnotherapy.
Vaginal Dryness
Vaginal dryness can cause pain, irritation, and light bleeding during sexual intercourse -- and it’s a problem that can happen to women of all ages.
“The biggest misconception is that vaginal dryness affects only postmenopausal women,” says Kellogg.
For premenopausal women, common causes of vaginal dryness include breastfeeding, certain medications such as antidepressants and progestin-only birth control pills, and some chronic medical conditions such as diabetes and multiple sclerosis. For many women, OTC water-based lubricants such as Astroglide and K-Y can alleviate discomfort during intercourse.
For more severe cases, vaginal estrogen cream or a vaginal estrogen ring (inserted by your doctor) can help restore vaginal moisture and make sexual intercourse much more comfortable.
Stress Incontinence
A recent study by The Cleveland Clinic shows that more than a third of adultwomen have incontinence (involuntary leakage of urine) at some point in theirlives.
For some women, incontinence occurs when there’s increased pressure orstress on the bladder or lower abdomen, such as when sneezing, when coughing,or during thrusting while having intercourse.
“To me, leaking during intercourse is equally as problematic and bothersometo women as leaking when you’re jogging, or playing tennis, or swinging a golfclub,” says Jennifer Berman, MD, a urological surgeon and director of theBerman Women’s Wellness Center in Beverly Hills, Calif.
The most widely recognized cause of stress incontinence is pregnancy(especially if you have a prolonged or traumatic vaginal delivery), but chronicstraining from constipation, obesity, and previous pelvic surgeries are factorsas well.
While Berman says that, in her opinion, “Kegel exercises [which build uppelvic floor muscles by repeatedly contracting and relaxing them] generallyaren’t enough to strengthen weakened muscles from childbirth,” a physicaltherapist specializing in pelvic floor dysfunction can help correct structuralabnormalities and weakened muscles that are causing the leakage.
Berman says some women can manage this problem with “simple conservativemethods such as emptying their bladder just before sex.” Other women findsuccess by inserting a small, custom-designed silicone plug into their urethrasjust before intercourse.
Fibroids
“About 77% of women are estimated to have fibroids, but most don’t realize they have them,” says Cynthia Morton, PhD, research director of the Center for Uterine Fibroids at Brigham and Women’s Hospital in Boston. “In many cases there are no symptoms.” The growth and development of these uterine tumors, which are cancerous only 0.1% of the time, according to Morton, is fueled by the surge of hormones women have during their childbearing years.
Fibroids may regress naturally after menopause. But if you develop cramping, excessive bleeding during menstruation, and painful intercourse, treatment is in order -- and a hysterectomy isn’t your only option. If a surgeon can’t remove a fibroid (and leave the uterus intact), they may recommend a procedure called uterine artery embolization, which cuts off the blood supply and forces the fibroid to shrink.
Even less invasive is a newer nonsurgical ultrasound treatment, which dissolves the fibroid with heat. “From my perspective it’s one of the most promising treatments,” says Morton. “Women are generally able to return to work the next day and report minimal or no side effects.”
For me, 11 years have passed since my diagnosis, and my journey with vulvar vestibulitis hasn’t been easy. But thanks to a dedicated group of health care providers, my symptoms are manageable today. If you can relate to my experience -- or if you’re suffering from another condition mentioned here -- take hope that you can find relief. It will make all that I’ve been through worth it.
