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non-surgical treatments for provoked vulvodynia
Image Courtesy of Mike Baumeister via Unsplash

Did You Know That There Are Non-Surgical Treatments for Provoked Vulvodynia (PVD)?

Provoked Vulvodynia affects approximately 10% of women

PVD is known as a chronic overlapping pain condition with endometriosis... While there are pharmacologic and surgical options, there are also other more conservative non-surgical treatments for provoked vulvodynia.

Provoked vulvodynia (PVD) is a chronic pain condition characterized by pain in the vulva when provoked by touch such as a tampon, speculum, clothing and/or sexual penetration. This condition affects approximately 10% in young women and can be truly debilitating. The etiology of PVD is complex and includes a combination of biologic and psychological factors. Other factors that may contribute to PVD are neural proliferation (an increase in nerve endings in the area), pelvic floor dysfunction, hormonal imbalances, recurrent infections, inflammation, high urinary oxalate levels and other psychological factors.

It is also a known chronic overlapping pain condition with endometriosis, however those with PVD do not necessarily have endometriosis. We see that those with preexisting disorders of depression or anxiety are four times more likely to develop PVD than those without. In addition, those who have been diagnosed with PVD are 10x more likely to develop anxiety disorders and 4x more likely to develop depression. While there are pharmacologic and surgical options, there are also other more conservative treatments to try if you suffer from PVD, including pelvic floor physical therapy, cognitive behavioral therapy, mindfulness and acupuncture. 

Pelvic Floor Physical Therapy & PVDPVD Treatment by a Pelvic Floor Physical Therapist | Image Courtesy of Annie Spratt via Unsplash

Pelvic floor dysfunction is thought to be an influential factor in developing PVD.

Those who have trouble coordinating their pelvic floor muscle function may be consciously or unconsciously engaging their pelvic floor too often. This can lead to short and tight pelvic floor muscles. These muscles are working in overdrive and start to develop trigger points that can then lead to localized or generalized pain in the pelvic floor and vulva. Pelvic floor physical therapists would address the tight pelvic floor muscles and perform some gentle manual therapy techniques and teach you how to do pelvic floor releases at home with a tool. We provide education on vulvar hygiene and optimize bladder and bowel health. We would also give you an individualized program including stretches and strengthening exercises that would benefit you. 

Cognitive behavioral therapy (CBT)

CBT addresses both psychological and social aspects of PVD. This approach focuses on increasing awareness and activity modification in response to pain. CBT has been shown to decrease pain intensity, improve physical functioning, coping, psychological distress, and mood. Studies also show that CBT significantly improved sexual functioning more than topical steroid treatments. As a bonus, depression and anxiety were reduced even after 1 year from completion of CBT treatment. 

Mindfulness

Mindfulness for PVD Treatment | Image Courtesy of Keegan Houser via UnsplashMindfulness as a treatment course in dealing with symptoms of PVD, provoked vulvodynia. 

There are 4 elements of mindfulness: attention regulation, body awareness, emotional regulation, and change in perspective of self.  Whereas CBT is a change-oriented strategy, mindfulness focuses on acceptance. Studies have shown that mindfulness significantly improves self-efficacy, pain hypervigilance, rumination, helplessness and magnification. In addition, resarch showed a consistent pattern of a decrease of fear of pain, which benefits the quality of life in patients dealing with PVD. 

It is important to recognize that both CBT and mindfulness are not “quick fixes,” and do require time, dedication and patience. However, they are noninvasive and proven to be efficacious long term while providing a comprehensive biopsychosocial approach. It is not usually offered as first line treatment for PVD, but maybe it should be offered more routinely in conjunction with other treatments. Researchers have found that psychological factors play an instrumental role in treatment outcomes.

Chinese Herbs/Acupuncture

Acupuncture and Chinese Herbal Medicine as Treatment for PVD | Image Courtesy of Antonika Chanel via Unsplash From a Chinese medicine perspective, PVD is often seen as coming from imbalances of the liver, spleen, or kidney. More often than not, this one practitioner believes PVD stems from a liver qi stagnation. There are many herbal medicines that would help release liver qi stagnation: Chai Hu, Zhi Shi, Bai Shao, and Zhi Gan Cao to name a few. There are two case studies using a combination of herbal medicine and acupuncture to help with PVD and other common symptoms that go with PVD (such as digestive issues, menstrual dysregulation, etc.). These two women were able to achieve pain-free sexual intercourse, decrease vulvar irritation/itchiness, restore menstrual regularity, improve digestive symptoms and decrease stress/anxiety. It is recommended to have both herbal treatments with acupuncture sessions to maximize its potential for improvement in symptoms. 

Uterosacral ligament support

New research studied the hypothesis of improving PVD through uterosacral ligament support.

The uterosacral ligaments connect the uterus to the front of the sacrum (one on each side). It is known that these ligaments are part of the parasympathetic (“rest and digest”) and sympathetic (“fight or flight”) nervous systems, and authors wondered how these ligaments would affect someone’s PVD. In general, chronic pelvic pain is associated with a loss of the sympathetic plexus. The nerve fibers from the sympathetic plexus discontinue in a region that is very close to the vestibule, clitoris, Bartholin’s glands, and superficial vagina. The theory is that due to its connections to the plexuses, support of the ligaments could indirectly influence pain and hypersensitivity associated with PVD.

One study injected 10 women with PVD with an anesthetic in the uterosacral ligaments at their insertion point on the cervix. The majority of the women had at least 30 minutes of PVD relief. Another study used a swab stick to stretch the posterior fornix, providing temporary support to the ligaments. During this support, provoked vulvar pain was temporarily alleviated. Essentially, laxity of the uterosacral ligaments could be yet another contributor to PVD and should be ruled in/out as a factor, and thus a consideration factor towards your treatment plan. 

Discuss Non-Surgical Treatments for Provoked Vulvodynia

As you can see, PVD can be a debilitating condition and not only affects us physically but also mentally and socially. While it may be very overwhelming to hear about the different treatments for PVD, it is important to know all the factors that may be contributing to your PVD to help best treat your individualized symptoms! On top of the standard first line treatments, it may be worth exploring different or combining types of treatments like physical therapy, CBT and acupuncture to embody a more biopsychosocial approach. Have any questions about non-surgical treatments for provoked vulvodynia? Having a pelvic floor physical therapist on your team can be truly beneficial in guiding you to the right practitioners and treatments. Give us a call or contact us for questions or an appointment

 

References:

Craven MK, Thelen RL, Elliot L & Lazear J. Provoked Vulvodynia: A holistic Treatment Approach. J for Nurse Practitioners 2016;12(8): 530-535.

Schonfeld, M. Petros P & Bornstein J. Mechanically Supporting Uterosacral Ligaments for the Relief of Provoked Vulvodynia: A Randomized Pilot Trial. J of Pain Research 2021;14: 1281-1288. 

Zilberman O. The Treatment of Vulvodynia with Acupuncture and Chinese Herbal Medicine. J of Chinese Med 2015;109:28-36.

What Our Patients Have to Say

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Testimonial by Julie T.

Femina PT (née Fusion Wellness & Physical Therapy) has honestly changed my life. Before receiving treatment at Femina, I was going doctor to doctor to try and find the answer to my pelvic pain. It has taken me YEARS to find someone that can help fix this. It wasn't until my gynecologist recommended your clinic that I finally felt relief. My pelvic pain is almost gone, and granted I still have a lot more to work on with Laureen (my PT), my original problem is nearly cured. I am so grateful to her.

What is even better is she gave me practical exercises to do at home that were not tedious and provided instant (and lasting) relief. Although I mainly work with Laureen, my interaction with the owner (Heather) has been great. She is very generous, kind, and committed to her business.

It hurts to know there are women out there suffering who will never know or have the opportunity to work with women like Laureen and Heather because this issue is hardly talked about and this field is so rare. I hope more doctors and physical therapists see the value in this work and can relieve more woman of their pain.

-- Julie T., 12/4/16 via Yelp!

Testimonial by R.H.

No one could tell me why I was having pain during sex--sharp pain, not just uncomfortable, pain. I was referred to Heather Jeffcoat after researching several different options. I had seen a specialist who told me physical therapy would not help and my only option was surgery. I really didn't want to go that route, so when we got a referral, I decided to try it--it can't hurt, I thought. I am so glad I did. She diagnosed the problem right away, which was a relief in itself.

To know why I was having pain eased my mind immensely. And to hear that she could fix it without surgery was another relief. She said she could fix the problem in 6 weeks. I think it was actually 4 for me. She was very methodical, and treated me as an intelligent human being capable of participating in my own recovery. I would absolutely recommend her to anyone. She did not try to prolong my session numbers, she worked hard to accommodate my schedule (and the fact that I had to bring a baby to sessions), and she was completely honest the entire time. It is so hard to find someone with these characteristics, much less a professional who is so good at what she does. She has my highest respect.

-- R.H.

Testimonial by A.W., age 32

I wanted to let you know that my pelvic floor held strong and gave me no trouble whatsoever in my trail race this morning (12 miles)! In a way, I felt like I ran better than ever because my core feels so rock solid from all the exercises you have me doing. That was especially valuable on the technical downhill - I just flew down the trail because I had confidence in my balance and form. Thank you for helping me get back to doing what I love.

-- A.W., age 32
(completed Post-partum Renewal Program using the InTone biofeedback/stim unit)

Testimonial by S.P., Age 26

I would like to start off by thanking Heather Jeffcoat for educating me and curing me of Vaginismus. I had been married for almost three years before I was referred to Heather. I never knew about Vaginismus until almost three years into my marriage. I knew something was wrong when I went on my honeymoon and came back a Virgin. I had always imagined how magical my first night would be but boy was I wrong.

Read more: Testimonial by S.P., Age 26

Testimonial by Amanda W.

Heather's unique physical therapy program literally changed my life! After years of struggling with vaginismus, a condition that made it impossible for me to have intercourse and very difficult to use tampons without pain, a gynecologist referred me to Heather. I was nervous for my first appointment, but Heather's professional and friendly demeanor put me at ease. She did a great job explaining each technique she was using to help my muscles relax. Heather uses a combination of internal and external stretches and exercises to relax the pelvic floor and build muscle strength. Her specially developed home program helped me quickly recover from an issue that seemed insurmountable before meeting Heather. She was optimistic about my progress and incredibly encouraging. Less than 6 months after my first session, I was able to have pain-free sex for the first time in my life! If you are suffering from vaginismus or any other pelvic floor issues, I highly recommend making an appointment with Heather and reading her book!

-- Amanda W., 2/15/16 via Yelp!

Testimonial by S.B.

As someone who suffered the debilitating physical and emotional effects of vaginismus (as well as a complicated history of back injuries) for more than 15 years, I thought a "normal" life was just a fantasy. Then I found Heather.

Read more: Testimonial by S.B.

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