Q I have been diagnosed with vestibulitis, which I have been suffering from for the past two years. During that time, I have been receiving treatment from a dermatologist. I've tried steroid creams, local anaesthetic gels and antidepressants. None of these has worked. The next suggested treatment is antispasmodic drugs which, I believe, are more of the same thing.
This week at the hospital, I saw a gynaecologist, who suggested surgery for removing the affected area of skin and remodelling. I understand this is a painful operation and the gynaecologist had no figures to hand regarding success rates. I have since looked on the Internet and at information sent me by Women's Health in South Tyneside, but have found no details on success rates. In fact, I read that some women are in worse pain afterwards.- D.D., via e-mail
A Vestibulitis refers to an inflammation of the entrance - called the 'vestibule' - to the vagina, the moist pink part immediately inside. These little hot spots of inflammation can occur near the urethra, the canal through which urine passes, or at the back or sides of the vagina. Often, those areas most inflamed are the four glands which provide lubrication to the vaginal entrance.
Doctors can't always pinpoint any problem and any medical tests often turn out negative. The pain can be so acute that even just touching the affected area with a cottonbud can cause the patient to cry out in sometimes severe pain.
Nevertheless, vestibulitis can often be missed on a general medical examination because the pain only occurs when the areas are touched or pressure is applied. There are no obvious signs of infection such as a discharge, bleeding or a visible lesion.
At best, even with a biopsy, a doctor may only see a slight increase in blood supply - not much on which to determine that anything significant is wrong. In one study, two-thirds of patients required more than six visits to various doctors before a diagnosis was finally made (J Reprod Med, 2001; 46: 227-31).
One theory is that this condition could be the result of a rare gene, and that symptoms are caused by an immune imbalance in the regulation of inflammation. In one recent study, the researchers found the presence of increased numbers of nerve fibres in vestibulitis sufferers (Obstet Gynecol, 1998; 91: 572-6), a situation that is similar to that seen in other diseases of chronic inflammation, such as Crohn's disease and interstitial cystitis.
The fact that, initially, doctors usually can't find anything wrong with a patient who complains of pain during sexual intercourse presents them with a golden opportunity for labelling the condition as all in the patient's pretty little head. Nevertheless, more and more doctors are acknowledging this condition to be a very real problem, even if their only solutions are crude, solely suppressive or, in your case, the drastic offer to remodel your vagina.
As you mentioned, the typical treatment involves an assortment of pills and creams, including oral antibiotics, which are thought to reduce inflammation in general; the antidepressant amitriptyline, which supposedly can reduce pain when taken in small doses at night; steroid creams, to be applied to the affected areas; or even steroid injections.
In one study, researchers were experimenting with a steroid/anaesthetic combination administered in such a way as to provide a slow drip-feed of the drug (J Reprod Med, 2001; 46; 713-6). Nevertheless, even with this double-whammy, nearly a third of the study patients failed to respond. One of the latest attempts at finding the magic bullet employed cromolyn, usually administered for asthma, in a cream, but this drug did no better than a placebo in reducing symptoms (Sex Transm Infect, 2001; 77: 53-7).
None of these measures is curative and, at best, they represent a solution only so long as you are taking them. Doctors note that vestibulitis can go away by itself, but it may take months or even years to do so.
With nothing that works in their medicine chest, doctors are now turning to surgery that seeks to cut out the offending tissue and reassemble what's left. In a study in which 69 women who'd had such surgery were sent a questionnaire, 78 per cent responded. Altogether, 45 patients - 85 per cent of the responders - reported moderate-to-excellent improvement after surgery.
Nevertheless, seven women had to have repeat surgery and, out of those, three noted no improvement. After surgery, 34 per cent of these patients still required 'conservative treatment' - that is, the pills or creams - so they were effectively no better off than they had been before the operations.
Although nothing short of surgery in conventional medicine offers a cure, a number of alternative remedies have proved successful.
An often overlooked cause of the condition is a generalised or specific Candida infection. In one study (J Reprod Med, 1998; 43: 952-8), researchers discovered that, of the women complaining of pain during sexual penetration, nearly one-third had candidiasis.
The researchers also discovered that, in women where a cause for coital pain couldn't be found, there were no increases in stress, anxiety or depression, indicating that these women were not psychologically disturbed.
In some cases, when doctors suspect a yeast infection, they will prescribe an oral antifungal, such as fluconazole (Diflucan).
Nevertheless, doctors often don't appreciate that the problem is not limited to the vagina, but instead is present as a systemic infection affecting the whole of the body. In this case, a single or short course of antifungals will not be sufficient to get the yeast overgrowth under control.
Before you submit to surgery, with all its attendant risks, you may wish to consult an alternative practitioner or nutritional doctor who has experience in successfully treating Candida and can therefore determine if you have a yeast overgrowth. If this is found to be your problem, you will need to embark on a course of treatment using conventional or alternative antifungals and an anti-Candida regime. Although this used to be more or less a life sentence, these days, experienced practitioners can cure chronic cases of candidiasis in as little as one month (see WDDTY's new The Candida and ME Handbook for a selection of specific regimes that may work for you).
If an anti-Candida regime doesn't resolve the problem, you could try one of several other tried-and-tested approaches. Some have had success with pelvic-floor muscle rehabilitation. In one study, the patients themselves were able to monitor whether their exercises were working with the use of electronic biofeedback.
In this study, the researchers provided patients with portable electromyographic biofeedback instruments as well as instructions on how to do daily biofeedback-assisted pelvic-floor muscle rehabilitation exercises. After four months, they found that the patients' pelvic-floor muscle contractions had increased by 95 per cent. Subjective reports of pain decreased by an average of 83 per cent, and 22 of the 28 patients were able to resume sexual intercourse by the end of the treatment period (J Reprod Med, 1995; 40: 283-90).
In a follow-up study of 29 patients using the same technique, a little over half reported markedly decreased tenderness, and 69 per cent of the women became sexually active again. By the end of the treatment, 89 per cent reported negligible or mild pain.
Another possible alternative treatment is acupuncture. One study of 14 women showed significant improvements in all areas after 10 sessions of acupuncture (Acta Obstet Gynecol Scand, 2001; 80: 437-41).