Vulvodynia—It Is Time to Accept a New Understanding from a Neurobiological Perspective

Abstract

Vulvodynia is one the most common causes of pain during sexual intercourse in premenopausal women. The burden of vulvodynia in a woman’s life can be devastating due to its consequences in the couple’s sexuality and intimacy, in activities of daily living, and psychological well-being. In recent decades, there has been considerable progress in the understanding of vulvar pain. The most significant change has been the differentiation of vulvar pain secondary to pathology or disease from vulvodynia. However, although it is currently proposed that vulvodynia should be considered as a primary chronic pain condition and, therefore, without an obvious identifiable cause, it is still believed that different inflammatory, genetic, hormonal, muscular factors, etc. may be involved in its development. Advances in pain neuroscience and the central sensitization paradigm have led to a new approach to vulvodynia from a neurobiological perspective. It is proposed that vulvodynia should be understood as complex pain without relevant nociception. Different clinical identifiers of vulvodynia are presented from a neurobiological and psychosocial perspective. In this case, strategies to modulate altered central pain processing is necessary, changing the patient’s erroneous cognitions about their pain, and also reducing fear avoidance-behaviors and the disability of the patient.

Dyspareunia

“…Vulvodynia is considered to be a central sensitization syndrome, a type of chronic pain syndrome. Examples of other central sensitization syndromes include fibromyalgia, irritable bowel syndrome, and myalgic encephalomyelitis (chronic fatigue syndrome) 16. Psychosocial issues that commonly present in patients with vulvodynia include childhood or adulthood sexual and/or physical abuse, anxiety, depression, and other sexual dysfunction 7.…”

“…The provider should also identify a pattern of the patient's pain, such as persistent, constant, intermittent, immediate (occurring during the provocation), and delayed (occurring after the provocation). Vulvodynia symptoms can include scorching, tearing, aching, or stabbing of the vulva or structures such as the clitoral hood and vestibule 7,16. Many patients with vulvodynia have weakened pelvic floor muscles on physical exam.…”

Characterization of Early Inflammatory Events Leading to Provoked Vulvodynia Development in Rats

“…And, it should be noted that the development of chronic vulvar pain is not solely induced by inflammation. 6,62 PV is a complex pain disorder, and the etiology is multifactorial. 6 Thus, it is possible that in women's the combined effects and the interaction of several factors (eg, psychological stress, genetic predisposition, hormonal imbalance, and recurrent inflammation) are essential in promoting PV development.…”

Central Sensitization in Vulvodynia and Endometriosis: What Have We Been Overlooking So Far?

“…A third new category of pain transmission, which overcomes the dichotomy between nociceptive and neuropathic pain, namely, nociplastic pain, has been introduced and a common etiology for overlapping chronic pain conditions has been hypothesized. 6 The presence of chronic pain in one location has been found to more than double the risk of developing chronic pain in another location, suggesting an alteration in the functioning of pain processing pathways in the central nervous system. 7 A new point of view that embraces other chronic pain conditions and focuses on the painful symptoms per se more than on the anatomical region in which the pain is perceived, namely, central sensitization, may be the key we have been looking for.…”

“…However, clinical research has lead to a rethinking of neurophysiopathology and has included mood and pain disorders in a larger perspective. A third new category of pain transmission, which overcomes the dichotomy between nociceptive and neuropathic pain, namely, nociplastic pain, has been introduced and a common etiology for overlapping chronic pain conditions has been hypothesized 6 . The presence of chronic pain in one location has been found to more than double the risk of developing chronic pain in another location, suggesting an alteration in the functioning of pain processing pathways in the central nervous system 7 .…”