Vulvodynia

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Vulvodynia
Specialty Gynecology

Vulvodynia is a chronic pain condition that affects the vulvar area and occurs without an identifiable cause. [1] Symptoms typically include a feeling of burning or irritation. [2] It has been established by the ISSVD that for the diagnosis to be made symptoms must last at least three months. [3]

The causes of vulvodynia are not fully understood, but there are many sub-types of vulvodynia with different causes, [4] including an excess of nerve fibers, hormonal imbalances, inflammation, and muscular dysfunction. Some factors influencing the diease may include genetics, immunology, and possibly diet. [2] Diagnosis is by ruling out other possible causes. [2] This may or may not include a biopsy of the area. [2]

Treatment may involve a number of different measures; however, as vulvodynia has many sub-types, none is universally effective, and the evidence to support their effectiveness is often poor. [2] Some of these measures include medications, pelvic floor physical therapy, surgery, and counselling. [2] Vulvodynia is estimated to affect up to 10-28% of women. [5]

Signs and symptoms

Pain is the most notable symptom of vulvodynia, and can be characterized as a burning, stinging, irritation or sharp pain that occurs in the vulva and entrance to the vagina. It may be constant, intermittent or happen only when the vulva is touched, but vulvodynia usually has a long duration. [6]

Symptoms may occur in one place ("localized") or the entire vulvar area ("generalized"). It can occur during or after sexual activity, when tampons are inserted, or when prolonged pressure is applied to the vulva, such as during sitting, bike riding, or horseback riding. [7] The pain can be provoked by touch ("provoked") or constant ("unprovoked"). Some cases of vulvodynia are idiopathic where no specific cause can be determined. [6]

Vestibulodynia

Vestibulodynia, formerly known as vulvar vestibulitis syndrome (VVS), or simply vulvar vestibulitis, [8] refers to pain localized to the vestibular region. It tends to be associated with a highly localized "burning" or "cutting" type of pain.

Vestibulodynia is the most common subtype of vulvodynia that affects premenopausal women – the syndrome has been cited as affecting about 10%–15% of women seeking gynecological care. [9] [10]

Clitorodynia

The pain of vulvodynia may extend into the clitoris; this is referred to as clitorodynia. [11] Clitorodynia may be sometimes caused by clitoris adhesions, a condition where the hood of the clitoris becomes stuck to the clitoris itself. Symptoms may include pain, hypersenstivity, hyposensitivity, difficulty with arousal, muted or absent orgasm. Clitoral adhesions are common among female patients with lichen sclerosus, but also occur among the general population. [12] The prevalence of clitoral adhesions is unknown. Clitorodynia has been neglected in medical research and under-recognized in clincical practice. [13]

Causes

Vulvodynia has many different sub-types and causes. The disease is highly idiopathic. Identifying the cause is important to determine the appropriate treatment. [4]

Pain confined to the vulval vestibule, known as vestibulodynia, has at least three known sub-types: [4] neuroproliferation, hormonally-mediation, and inflammation. Neuroproliferation can be present from birth or acquired later in life. This type of vestibulodynia is known as neuroproliferative vestibulodynia. Hormonally-mediated vestibulodynia can be caused by hormonal medications like oral birth control. Inflammatory vestibulodynia can develop as part of an immune response.

Other possible causes include Sjögren syndrome, the symptoms of which include chronic vaginal dryness. Others include genetic predisposition to inflammation, [14] allergy or other sensitivity (for example: oxalates in the urine), an autoimmune disorder similar to lupus erythematosus or to eczema or to lichen sclerosus, infection (e.g., yeast infections, bacterial vaginosis, HPV, HSV), injury, and neuropathy—including an increased number of nerve endings in the vaginal area. Some cases seem to be negative outcomes of genital surgery, such as a labioplasty. Initiation of hormonal contraceptives that contain low- dose estrogen before the age of 16 could predispose women to vulvar vestibulitis syndrome. A significantly lower pain threshold, especially in the posterior vestibulum, has also been associated with the use of hormonal contraceptives in women without vulvar vestibulitis syndrome. [15] Pelvic floor dysfunction may be the underlying cause of some women's pain. [16]

Many co-morbidities are commonly associated with vulvodynia, including fibromyalgia, irritable bowel syndrome, interstitial cystitis, pelvic floor dysfunction, endometriosis, depression and anxiety disorders. [17]

Diagnosis

The condition is one of exclusion and other vulvovaginal problems should be ruled out. The diagnosis is based on the typical complaints of the patient, essentially normal physical findings, and the absence of identifiable causes per the differential diagnosis. Cotton swab testing is used to differentiate between generalized and localized pain and delineate the areas of pain and categorize their severity. Patients often will describe the touch of a cotton ball as extremely painful, like the scraping of a knife. A diagram of pain locations may be helpful in assessing the pain over time. The vagina should be examined, and tests, including wet mount, vaginal pH, fungal culture, and Gram stain, should be performed as indicated. Fungal culture may identify resistant strains. [18]

Surveys have estimated that only about half of the women who meet the criteria for vulvodynia will seek medical help. [5] Many will see several doctors before a correct diagnosis is made. [5] Less than 2% of the people who seek help obtain a diagnosis. [19] Many gynecologists are not familiar with this family of conditions. Affected women are also often hesitant to seek treatment for chronic vulvar pain, especially since many women begin experiencing symptoms around the same time they become sexually active. Moreover, the absence of any visible symptoms means that before being successfully diagnosed many patients have been told that the pain is "in their head". [20] The misattribution of women's vulvo-vaginal pain to a psychological origin rather than a medical one is traceable back to the influence of Freudian psychoanalysis. [21]

Differential diagnosis

  1. Infections: urinary tract infection, [22] candidiasis, herpes, HPV, vaginitis
  2. Dermetological diseases: lichen sclerosus, lichen planus
  3. Neoplasm: Paget's disease, vulvar carcinoma
  4. Neurologic disorder: neuralgia secondary to herpes virus, spinal nerve injury[ citation needed ], pudendal nerve entrapment

In recent years, diagnostic algorithms for the diagnosis of the various sub-types of and causes of vulvar pain have been developed and refined. The International Society for the Study of Women's Sexual Health (ISSWSH) supports this diagnostic algorithm.

Treatment

There are a number of possible treatments with none being uniformly effective. [2] Treatments include:

Medications

A number of medications have been used to treat vulvodynia. [2] Evidence to support their use, however, is often poor. [2] These include creams and ointments containing lidocaine, estrogen or tricyclic antidepressants. [2] Antidepressants and anticonvulsants in pill form are sometimes tried but have been poorly studied. [2] Injectable medications included steroids and botulinum toxin have been tried with limited success. [2]

Physical therapy

Many patients who have vulvodynia also have high-tone pelvic floor, meaning that their pelvic floor muscles are too tight. This may may contribute to their pain in the area. Pelvic floor physical therapy may help treat the pelvic floor dysfunction and help the patient gain greater control over their pelvic floor muscles.

Surgery

Vestibulectomy is a surgery to remove the vulval vestibule, and it may be recommended for certain patients. It has been suggested as a first-line treatment for neuroproliferative vestibulodynia. [23] It has successful long-term outcomes, [24] but is often only offered after conservative measures have failed.

Lifestyle

A number of lifestyle changes are often recommended such as using cotton underwear, not using substances that may irritate the area, and using lubricant during sex. [2] The use of alternative medicine has not been sufficiently studied to make recommendations. [2]

Counseling

Gynaecologist-led educational seminars delivered in a group format have a significant positive impact on psychological symptoms and sexual functioning in women who have provoked (caused by a stimulus such as touch or sexual activity) vestibulodynia (pain localized in the vulvar vestibule). [25]

Epidemiology

The percentage of women affected is not entirely clear, but estimates range between 10-28%. [17] [5] Many other conditions that are not truly vulvodynia (diagnosis is made by ruling out other causes of vulvar pain) could be confused with it. Vulvar pain is a quite frequent complaint in women's health clinics.

Patient communities

Given the difficulty of getting diagnosed and treated for vulvodynia, [5] patients have formed communities to help each other access healthcare and to advocate for better recognition of the disease.

Founded in 1994, the National Vulvodynia Association (NVA) is a non-profit that helps connect patients to each other and to medical providers who can help them. They maintain a healthcare provider referral list and have geographically-organized patient support groups. The NVA secured the first funding for vulvodynia research in the 1990s, and it continues to provide seed grants for research on vulvodynia. [26]

Tight Lipped is a second, younger community of vulvodynia patients. Founded in 2019, Tight Lipped started as a story-telling podcast focused on ending the stigma and mystery surrounding vulvovaginal pain. It has evolved into a grassroots, patient-led organization devoted to changing how chronic vulvovaginal pain conditions like vulvodynia are understood by the medical community and by society. [27] [28]

There are several online communities of patients on sites like Facebook and Reddit. Because medical knowledge is so hard to access, patients resort to other patients' knowledge to get help.

Related Research Articles

<span class="mw-page-title-main">Vaginismus</span> Involuntary muscle spasm that interferes with vaginal penetration

Vaginismus is a condition in which involuntary muscle spasm interferes with vaginal intercourse or other penetration of the vagina. This often results in pain with attempts at sex. Often it begins when vaginal intercourse is first attempted. Vaginismus may be considered an older term for pelvic floor dysfunction.

Anorgasmia is a type of sexual dysfunction in which a person cannot achieve orgasm despite adequate stimulation. Anorgasmia is far more common in females than in males and is especially rare in younger men. The problem is greater in women who are post-menopausal. In males, it is most closely associated with delayed ejaculation. Anorgasmia can often cause sexual frustration.

Dyspareunia is painful sexual intercourse due to medical or psychological causes. The term dyspareunia covers both female dyspareunia and male dyspareunia, but many discussions that use the term without further specification concern the female type, which is more common than the male type. In females, the pain can primarily be on the external surface of the genitalia, or deeper in the pelvis upon deep pressure against the cervix. Medically, dyspareunia is a pelvic floor dysfunction and is frequently underdiagnosed. It can affect a small portion of the vulva or vagina or be felt all over the surface. Understanding the duration, location, and nature of the pain is important in identifying the causes of the pain.

Persistent genital arousal disorder (PGAD), originally called persistent sexual arousal syndrome (PSAS), is spontaneous, persistent, unwanted and uncontrollable genital arousal in the absence of sexual stimulation or sexual desire, and is typically not relieved by orgasm. Instead, multiple orgasms over hours or days may be required for relief.

Sexual dysfunction is difficulty experienced by an individual or partners during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal, or orgasm. The World Health Organization defines sexual dysfunction as a "person's inability to participate in a sexual relationship as they would wish". This definition is broad and is subject to many interpretations. A diagnosis of sexual dysfunction under the DSM-5 requires a person to feel extreme distress and interpersonal strain for a minimum of six months. Sexual dysfunction can have a profound impact on an individual's perceived quality of sexual life. The term sexual disorder may not only refer to physical sexual dysfunction, but to paraphilias as well; this is sometimes termed disorder of sexual preference.

Pudendal nerve entrapment (PNE), also known as Alcock canal syndrome, is an uncommon source of chronic pain in which the pudendal nerve is entrapped or compressed in Alcock's canal. There are several different types of PNE based on the site of entrapment anatomically. Pain is positional and is worsened by sitting. Other symptoms include genital numbness, fecal incontinence and urinary incontinence.

<span class="mw-page-title-main">Lichen sclerosus</span> Itchy skin rash usually affecting the genitals

Lichen sclerosus (LS) is a chronic, inflammatory skin disease of unknown cause which can affect any body part of any person but has a strong preference for the genitals and is also known as balanitis xerotica obliterans (BXO) when it affects the penis. Lichen sclerosus is not contagious. There is a well-documented increase of skin cancer risk in LS, potentially improvable with treatment. LS in adult age women is normally incurable, but improvable with treatment, and often gets progressively worse if not treated properly. Most males with mild or intermediate disease restricted to foreskin or glans can be cured by either medical or surgical treatment.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

Vulvitis is inflammation of the vulva, the external female mammalian genitalia that include the labia majora, labia minora, clitoris, and introitus. It may co-occur as vulvovaginitis with vaginitis, inflammation of the vagina, and may have infectious or non-infectious causes. The warm and moist conditions of the vulva make it easily affected. Vulvitis is prone to occur in any female especially those who have certain sensitivities, infections, allergies, or diseases that make them likely to have vulvitis. Postmenopausal women and prepubescent girls are more prone to be affected by it, as compared to women in their menstruation period. It is so because they have low estrogen levels which makes their vulvar tissue thin and dry. Women having diabetes are also prone to be affected by vulvitis due to the high sugar content in their cells, increasing their vulnerability. Vulvitis is not a disease, it is just an inflammation caused by an infection, allergy or injury. Vulvitis may also be symptom of any sexually transmitted infection or a fungal infection.

<span class="mw-page-title-main">Vaginal discharge</span> Medical condition

Vaginal discharge is a mixture of liquid, cells, and bacteria that lubricate and protect the vagina. This mixture is constantly produced by the cells of the vagina and cervix, and it exits the body through the vaginal opening. The composition, amount, and quality of discharge varies between individuals and can vary throughout the menstrual cycle and throughout the stages of sexual and reproductive development. Normal vaginal discharge may have a thin, watery consistency or a thick, sticky consistency, and it may be clear or white in color. Normal vaginal discharge may be large in volume but typically does not have a strong odor, nor is it typically associated with itching or pain. While most discharge is considered physiologic or represents normal functioning of the body, some changes in discharge can reflect infection or other pathological processes. Infections that may cause changes in vaginal discharge include vaginal yeast infections, bacterial vaginosis, and sexually transmitted infections. The characteristics of abnormal vaginal discharge vary depending on the cause, but common features include a change in color, a foul odor, and associated symptoms such as itching, burning, pelvic pain, or pain during sexual intercourse.

Vulvar vestibulitis syndrome (VVS), vestibulodynia, or simply vulvar vestibulitis, is vulvodynia localized to the vulvar vestibule. It tends to be associated with a highly localized "burning" or "cutting" type of pain. Until recently, "vulvar vestibulitis" was the term used for localized vulvar pain: the suffix "-itis" would normally imply inflammation, but in fact there is little evidence to support an inflammatory process in the condition. "Vestibulodynia" is the term now recognized by the International Society for the Study of Vulvovaginal Disease.

A vaginal disease is a pathological condition that affects part or all of the vagina.

Genital leiomyomas are leiomyomas that originate in the dartos muscles, or smooth muscles, of the genitalia, areola, and nipple. They are a subtype of cutaneous leiomyomas that affect smooth muscle found in the scrotum, labia, or nipple. They are benign tumors, but may cause pain and discomfort to patients. Genital leiomyoma can be symptomatic or asymptomatic and is dependent on the type of leiomyoma. In most cases, pain in the affected area or region is most common. For vaginal leiomyoma, vaginal bleeding and pain may occur. Uterine leiomyoma may exhibit pain in the area as well as painful bowel movement and/or sexual intercourse. Nipple pain, enlargement, and tenderness can be a symptom of nipple-areolar leiomyomas. Genital leiomyomas can be caused by multiple factors, one can be genetic mutations that affect hormones such as estrogen and progesterone. Moreover, risk factors to the development of genital leiomyomas include age, race, and gender. Ultrasound and imaging procedures are used to diagnose genital leiomyomas, while surgically removing the tumor is the most common treatment of these diseases. Case studies for nipple areolar, scrotal, and uterine leiomyoma were used, since there were not enough secondary resources to provide more evidence.

Female genital disease is a disorder of the structure or function of the female reproductive system that has a known cause and a distinctive group of symptoms, signs, or anatomical changes. The female reproductive system consists of the ovaries, fallopian tubes, uterus, vagina, and vulva. Female genital diseases can be classified by affected location or by type of disease, such as malformation, inflammation, or infection.

<span class="mw-page-title-main">Vulva</span> External genitalia of the female mammal

In mammals, the vulva consists of the external female genitalia. The human vulva includes the mons pubis, labia majora, labia minora, clitoris, vulval vestibule, urinary meatus, the vaginal opening, hymen, and Bartholin's and Skene's vestibular glands. The urinary meatus is also included as it opens into the vulval vestibule. The vulva includes the entrance to the vagina, which leads to the uterus, and provides a double layer of protection for this by the folds of the outer and inner labia. Pelvic floor muscles support the structures of the vulva. Other muscles of the urogenital triangle also give support.

<span class="mw-page-title-main">Atrophic vaginitis</span> Medical condition

Atrophic vaginitis is inflammation of the vagina as a result of tissue thinning due to not enough estrogen. Symptoms may include pain with sex, vaginal itchiness or dryness, and an urge to urinate or burning with urination. It generally does not resolve without ongoing treatment. Complications may include urinary tract infections.

A vulvar disease is a particular abnormal, pathological condition that affects part or all of the vulva. Several pathologies are defined. Some can be prevented by vulvovaginal health maintenance.

A vestibulectomy is a gynecological surgical procedure that can be used to treat vulvar pain, specifically in cases of provoked vestibulodynia. Vestibulodynia is a chronic pain syndrome that is a subtype of localized vulvodynia where chronic pain and irritation is present in the vulval vestibule, which is near the entrance of the vagina. Vestibulectomy may be partial or complete.

Pelvic floor physical therapy (PFPT) is a specialty area within physical therapy focusing on the rehabilitation of muscles in the pelvic floor after injury or dysfunction. It can be used to address issues such as muscle weakness or tightness post childbirth, dyspareunia, vaginismus, vulvodynia, constipation, fecal or urinary incontinence, pelvic organ prolapse, and sexual dysfunction. Licensed physical therapists with specialized pelvic floor physical therapy training address dysfunction in individuals across the gender and sex spectra, though PFPT is often associated with women's health for its heavy focus on addressing issues of pelvic trauma after childbirth.

References

  1. ↑ Feldhaus-Dahir, M (2011). "The causes and prevalence of vestibulodynia: A vulvar pain disorder". Urologic Nursing. 31 (1): 51–4. doi:10.7257/1053-816X.2012.31.1.51. PMID   21542444.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Stockdale, C. K.; Lawson, H. W. (2014). "2013 Vulvodynia Guideline update". Journal of Lower Genital Tract Disease. 18 (2): 93–100. doi:10.1097/LGT.0000000000000021. PMID   24633161. S2CID   410660.
  3. ↑ Bornstein, J.; Goldstein, A. T.; Stockdale, C. K.; Bergeron, S.; Pukall, C.; Zolnoun, D.; Coady, D. (April 2016). "ISSVD, ISSWSH, and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia". J Sex Med. 13 (4): 607–12. doi:10.1016/j.jsxm.2016.02.167. PMID   27045260.
  4. 1 2 3 Goldstein, Andrew (2020). Goldstein, Andrew T.; Pukall, Caroline F.; Goldstein, Irwin; Krapf, Jill M.; Goldstein, Sue W.; Goldstein, Gail (eds.). Female Sexual Pain Disorders: Evaluation and Management (2 ed.). pp. 157–162. doi:10.1002/9781119482598. ISBN   978-1-119-48266-6.
  5. 1 2 3 4 5 Harlow, Bernard; Kunita, Christine; Nguyen, Ruby; Rydell, Sarah; Turner, Rachel; MacLehose, Richard (January 2014). "Prevalence of symptoms consistent with a diagnosis of vulvodynia: population-based estimates from 2 geographic regions". American Journal of Obstetrics and Gynecology. 210 (1): 40.e1–8. doi:10.1016/j.ajog.2013.09.033. PMC   3885163 . PMID   24080300.
  6. 1 2 "Persistent Vulvar Pain". American College of Obstetricians and Gynecologists. Retrieved 30 October 2020.
  7. ↑ National Research Center for Women and Families (October 2007). "Vulvodynia and Genital Pain". Archived from the original on 25 July 2011. Retrieved 27 August 2009.
  8. ↑ Moyal-Barracco, M; Lynch, P. J. (2004). "2003 ISSVD terminology and classification of vulvodynia: A historical perspective". The Journal of Reproductive Medicine. 49 (10): 772–7. PMID   15568398.
  9. ↑ Bergeron, Sophie; Binik, Yitzchak M.; Khalifé, Samir; Meana, Marta; Berkley, Karen J.; Pagidas, Kelly (1997). "The treatment of vulvar vestibulitis syndrome: Towards a multimodal approach". Sexual and Marital Therapy. 12 (4): 305–311. doi:10.1080/02674659708408174.
  10. ↑ Bergeron, Sophie; Binik, Yitzchak M.; Khalifé, Samir; Pagidas, Kelly (1997). "Vulvar Vestibulitis Syndrome: A Critical Review". The Clinical Journal of Pain. 13 (1): 27–42. doi:10.1097/00002508-199703000-00006. PMID   9084950.
  11. ↑ "What is Vulvodynia?". The National Vulvodynia Association. Retrieved 29 January 2019.
  12. ↑ Romanello, Jennifer; Myers, Monica; Nico, Elsa; Rubin, Rachel (March 2023). "Clitoral adhesions: a review of the literature". Sexual Medicine Reviews. 11 (3): 196–201. doi:10.1093/sxmrev/qead004. PMID   36973166 . Retrieved 29 March 2024.
  13. ↑ Gross, Rachel (October 2022). "News: Half the World Has a Clitoris. Why... (The New York Times) - Behind the headlines - NLM". NCBI. The New York Times. Retrieved 29 March 2024.
  14. ↑ Gerber, Stefan; Bongiovanni, Ann Marie; Ledger, William J.; Witkin, Steven S. (2003). "Interleukin-1β gene polymorphism in women with vulvar vestibulitis syndrome". European Journal of Obstetrics & Gynecology and Reproductive Biology. 107 (1): 74–77. doi:10.1016/S0301-2115(02)00276-2. PMID   12593899.
  15. ↑ Basson, Rosemary; Weijmar Schultz, Willibrord (2007). "Sexual sequelae of general medical disorders". The Lancet. 369 (9559): 409–424. doi:10.1016/S0140-6736(07)60197-4. PMID   17276781. S2CID   44628975.
  16. ↑ Kellogg-Spadt, S (October 2003). "Differential Diagnosis of Pelvic Floor Dysfunction and Vulvar Pain" . Retrieved 11 September 2012.
  17. 1 2 Hill, DA; Taylor, CA (15 May 2021). "Dyspareunia in Women". American Family Physician. 103 (10): 597–604. PMID   33983001.
  18. ↑ Haefner, H. K.; Collins, M. E.; Davis, G. D.; Edwards, L; Foster, D. C.; Hartmann, E. D.; Kaufman, R. H.; Lynch, P. J.; Margesson, L. J.; Moyal-Barracco, M; Piper, C. K.; Reed, B. D.; Stewart, E. G.; Wilkinson, E. J. (2005). "The vulvodynia guideline". Journal of Lower Genital Tract Disease. 9 (1): 40–51. doi: 10.1097/00128360-200501000-00009 . PMID   15870521. S2CID   18081230.
  19. ↑ Reed, Barbara Diane; Harlow, Siobán Denise; Sen, Ananda; Legocki, Laurie Jo; Edwards, Rayna Monique; Arato, Nora; Haefner, Hope Katharine (February 2012). "Prevalence and demographic characteristics of vulvodynia in a population-based sample". American Journal of Obstetrics and Gynecology. 206 (2): 170.e1–170.e9. doi:10.1016/j.ajog.2011.08.012. PMC   3779055 . PMID   21963307.
  20. ↑ Shallcross, Rebekah; Dickson, Joanne M.; Nunns, David; Taylor, Kate; Kiemle, Gundi (1 April 2019). "Women's Experiences of Vulvodynia: An Interpretative Phenomenological Analysis of the Journey Toward Diagnosis". Archives of Sexual Behavior. 48 (3): 961–974. doi:10.1007/s10508-018-1246-z. ISSN   1573-2800. PMC   6418055 . PMID   30047005.
  21. ↑ Srajer, Hannah (March 2023). "Imperfect Intercourse: Sexual Disability, Sexual Deviance, and the History of Vaginal Pain in the Twentieth-Century United States". Journal of American History. 109 (4): 782–803. doi:10.1093/jahist/jaad001 . Retrieved 29 March 2024.
  22. ↑ Khasriya, Rajvinder; Barcella, William; De Iorio, Maria; Swamy, Sheela; Gill, Kiren; Kupelian, Anthony; Malone-Lee, James (2018). "Lower urinary tract symptoms that predict microscopic pyuria". International Urogynecology Journal. 29 (7): 1019–1028. doi:10.1007/s00192-017-3472-7. PMC   6004270 . PMID   28971220.
  23. ↑ King, Michelle A.; Mitchell, Leia S.; Belkin, Zoe; Goldstein, Andrew T. (April 2018). "Vulvar Vestibulectomy for Neuroproliferative-Associated Provoked Vestibulodynia: A Retrospective Analysis". Journal of Gynecologic Surgery. 34 (2): 58–62. doi:10.1089/gyn.2017.0030. ISSN   1042-4067 . Retrieved 29 March 2024.
  24. ↑ Arik, David; Bornstein, Jacob (October 2020). "Evaluation of Long-Term Surgical Success and Satisfaction of Patients After Vestibulectomy". Journal of Lower Genital Tract Disease. 24 (4): 399–404. doi:10.1097/LGT.0000000000000552. PMID   32569021.
  25. ↑ Brotto, L. A.; Sadownik, L; Thomson, S (2010). "Impact of educational seminars on women with provoked vestibulodynia". Journal of Obstetrics and Gynaecology Canada. 32 (2): 132–8. doi:10.1016/s1701-2163(16)34427-9. PMID   20181314.
  26. ↑ "NVA". National Vulvodynia Association. Retrieved 29 March 2024.
  27. ↑ Brown, Kailyn. "Painful sex? Broken vaginas? This underground zine normalizes the taboo". Los Angeles times. Retrieved 29 March 2024.
  28. ↑ "Tight Lipped". Tight Lipped. Retrieved 29 March 2024.
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