I’m 20 years old. My knees are apart, and my feet are anchored in cold metal stirrups. A doctor is shining a bright, hot light between my legs, prodding me gently with a Q-tip, peppering me with questions. I’m here, in a place where no woman wants to be, because the incessant itching, pain, and burning that plagued me for two years has gotten so severe I can barely tolerate underwear, let alone the “luxuries” -- tampons, intercourse, and tight jeans -- that my college 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 I would see in my quest for answers -- was able to finally give me something nobody 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 will suffer from a range of common and less common gynecological or urological conditions, including chronic infections, vulvodynia, vaginal dryness, fibroids, and stress incontinence with intercourse.
While each experience (and diagnosis) is different, many women will discover their illness goes beyond physical symptoms to affect their sex lives and even their general state of mind. Indeed, “these conditions may negatively impact women’s physical, emotional, relational, and/or sexual well-being,” says Helen Coons, PhD, ABPP, president and clinical director of Women’s Mental Health Associates in Philadelphia.
Following are the most commonly diagnosed health problems “down there.”
The itching, burning, and pain associated with vaginitis results from a disruption in the natural balance of bacteria that live in every healthy vagina. There’s no single cause. Common culprits include hormonal changes due to birth control pills, menopause, or pregnancy as well as chronic medical conditions, such as HIV and diabetes, which weaken the immune system. Frequent sexual intercourse and sex with multiple partners can be to blame as well. Of the many types of infectious and noninfectious vaginitis, the following four are the most common.
Bacterial vaginosis (BV) is “the most common vaginal infection in women of reproductive age,” according to the National Institutes of Health. Women with BV may have a copious, thin grayish-white discharge -- or they may be symptom-free.
Some studies suggest that untreated BV can cause pelvic inflammatory disease, which can lead to infertility, so it’s important to seek treatment from a health care provider, says Susan Kellogg, CRNP, PhD, director of Vulvar Pain and Sexual Medicine at the Pelvic & Sexual Health Institute in Philadelphia. Fortunately, BV is easily treated with oral or vaginal antibiotics.
Yeast infections caused by the overgrowth of one of several strains of Candida, a fungus that lives normally in the vagina, are also common; three in four women will have at least one at some point in their life. Women may notice a thick white discharge with a slight odor. However, many women complain of genital itching, soreness, or irritation.
Treatment is painless and easy; most women simply insert at bedtime a prescribed cream or an ovule (a soft suppository) -- generally soothing but messy -- 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 taking progestin-only birth control pills; both may cause a dip in estrogen levels. This condition feels like an infection with burning, itching, and pain, but there’s no active infection. Treatments such as estrogen creams or a vaginal estrogen ring (inserted by your doctor) can help.
Trichomoniasis, a sexually transmitted infection, can cause a greenish-yellow frothy discharge, with some itching and burning. Women might notice irritation with intercourse. Like BV, “trich” is easily treated with oral or vaginal antibiotics.
If you think you have any of these, see your doctor. Loading up on over-the-counter creams will only make the problem worse if you have a different type of infection. And whatever you do, don’t douche. “When a woman douches, she rinses out the bacteria in question but also [healthy] bacteria that are responsible for normal secretions,” says Kellogg.
Imagine vaginal burning and pain so severe you can’t sit comfortably, wear fitted clothing, or have intercourse. That’s the reality women with vulvodynia face -- and there’s no quick fix. Some suffer for years before finding the right treatment (or even any relief).
That’s why Phyllis Mate, executive director of the National Vulvodynia Association, was incensed by a recent episode of ABC’s Private Practice, in which Dr. Addison Montgomery (played by Kate Walsh) diagnosed and cured a patient’s vulvodynia in a single episode. “While the producers deserve credit for trying to depict the symptoms of vulvodynia, 13 million women in the real world would painfully disagree with the show’s fairy-tale ending,” Mate says.
Doctors don’t know exactly what causes vulvodynia, but possible contributors include injury to nerves in the vulva, hypersensitivity to Candida, and pelvic floor muscle spasms. The most common form of vulvodynia is vulvar vestibulitis syndrome (VVS), which affects the tiny glands that lie at the top and bottom of the vaginal opening.
For years, patients have been treated with tricyclic antidepressants (to block pain receptors in the vulva), topical estrogen creams and anesthetics (such as lidocaine), anticonvulsants, and surgery. But newer, less invasive treatments are working wonders. To curb pain and restore sexual function, Kellogg treats some patients with Capsaicin cream, a specially compounded ointment that contains the active ingredient in chili peppers. It might cause discomfort on contact but can dramatically reduce symptoms.
If a woman’s condition is flared by a Candida hypersensitivity -- to which even a slight imbalance can cause itching and burning -- weekly doses of an oral antifungal medication over several weeks or months can help alleviate symptoms.
For patients who have a secondary condition called lichen dermatoses -- a group of skin conditions in the vulva that can cause severe itching and/or scar tissue -- a mix of topical steroids with a tiny dab of estrogen cream can help heal the damage to the vulvar tissue and decrease symptoms.
Physical therapy (with a highly trained specialist) is another valuable form of treatment for some patients. By correcting misalignments, strengthening pelvic floor muscles (the layers of muscles stretching between your legs and supporting your organs, bladder, uterus, and ovaries), and working to loosen muscles that have become painfully tight, these therapists can help dramatically reduce pain.
If you have vaginismus -- a rare condition that fewer than 2% of women in the United States develop -- the muscles surrounding the vagina involuntarily spasm so tightly that you can’t have sexual intercourse or even insert a tampon.
The specific cause of vaginismus is unknown, but, as with vulvar vestibulitis and stress incontinence, physical therapy can be an invaluable “first line of treatment,” according to Erica Fletcher, PT, MTC, founder of Fletcher Physical Therapy in Narberth, Pa.
Fletcher and other physical therapists who specialize in pelvic floor disorders can correct structural abnormalities and design a manual therapy and exercise program that will retrain pelvic muscles that are too tight or too weak, depending on the condition. Their efforts can dramatically reduce symptoms-without the side effects of medication.
They also teach women the proper way to perform techniques at home, with dilators and their own fingers, to gently stretch and massage the muscles.
If a woman’s symptoms persist despite physical therapy, a doctor can inject Botox to paralyze muscles and prevent the spasms for up to six months.
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.
A recent study by The Cleveland Clinic shows that more than a third of adult women have incontinence (involuntary leakage of urine) at some point in their lives.
For some women, incontinence occurs when there’s increased pressure or stress 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 bothersome to women as leaking when you’re jogging, or playing tennis, or swinging a golf club,” says Jennifer Berman, MD, a urological surgeon and director of the Berman 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 chronic straining from constipation, obesity, and previous pelvic surgeries are factors as well.
While Berman says that, in her opinion, “Kegel exercises [which build up pelvic floor muscles by repeatedly contracting and relaxing them] generally aren’t enough to strengthen weakened muscles from childbirth,” a physical therapist specializing in pelvic floor dysfunction can help correct structural abnormalities and weakened muscles that are causing the leakage.
Berman says some women can manage this problem with “simple conservative methods such as emptying their bladder just before sex.” Other women find success by inserting a small, custom-designed silicone plug into their urethras just before intercourse.
“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), he or she 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.