Another genetic aberration results in unstable production of a substance that normally responds to an invasion by yeast or bacteria, placing them at increased risk of chronic infections.
Using a dermatological instrument that reveals two cell layers beneath the skin, Ledger said, "we're seeing much more widespread inflammation in these patients than appears to the naked eye." He added that he had treated patients who had vulvar inflammation with local estrogen or steroids; while they looked 80 percent better on the surface, their symptoms were only about 20 percent better, because the inflammation remained beneath the surface.
In addition, Ledger said, "there's good evidence that with vulvodynia as a whole, the women have more nerve fibers in the vulva and they are firing more pain signals to the brain." He continued: "It's a kind of vulvar fibromyalgia. Most patients with vulvodynia have very tender glands at the entrance to the vagina."
In fact, several recent studies have shown up to a tenfold increase in the density of nerve endings in what is called the vulvar vestibule. In some cases the women appear to have been born with this overabundance of nerve endings. But as Andrew Goldstein, a gynecologist at Johns Hopkins School of Medicine, and colleagues reported in 2006 in The Journal of Sexual Medicine, excessive nerve endings may also be caused by nerve growth factors after an inflammatory response or from hormonal changes like those induced by oral contraceptives.
HELPFUL TREATMENTS
Veasley, now a 32-year-old wife and mother of two, spent seven years trying "a laundry list of treatments," which, she said, "only provided minimal relief" for her condition, called vulvar vestibulitis. Shortly after marrying, she decided to try surgery to remove the layer of tissue containing an overabundance of nerve endings. She and her husband were finally able to have intercourse, and a year later their first daughter was born. Veasley said she had been "virtually pain-free" ever since.
But as successful as her final treatment was, Veasley, who serves as associate executive director of the vulvodynia association, also knows that surgery is not an option for everyone. As Goldstein reported, it is most successful in women whose pain is limited to the vulvar vestibule and those without extreme muscle dysfunction of the lower pelvis. Surgery is also more effective if done sooner, rather than later, after the development of life-inhibiting symptoms.
Mate's symptoms responded to another approach - two treatments to inhibit firing of the pudendal nerve, which enervates the lowest muscles of the pelvis, plus regular use of an anticonvulsant drug. The combination, she said, "enables me to lead a reasonably normal life," though both pressure and heat, as occur with prolonged sitting or wearing fitted pants, make her symptoms worse.
Ledger said patients with low production of inflammatory blockers are often helped by Cox-2 inhibitor drugs like Celebrex (though Vioxx, which is no longer marketed, worked better). Others find relief with drugs used off-label, like low-dose hydroxyzone or gabapentin to reduce nerve impulses from the vulva to the brain, mood elevators in low doses and the muscle relaxant Flexoril.
The National Institutes of Health recently began a vulvodynia awareness campaign at orwh.od.nih.gov/health/vulvodynia.html, which offers resources and information. Also free is a professional paper, The Vulvodynia Guideline, by Hope Haefner of the University of Michigan and 13 other experts. It is available in The Journal of Lower Genital Tract Disease, www.jlgtd.com, under the archives tab, on Page 40 of the January 2005 issue.
RSS