How Do You Treat Vulvodynia in Your Practice?

While strides are being made to bring acupuncture and herbal medicine into the mainstream—and they may be the first intervention for some patients—all too often, patients are dismissed by conventional providers and told that their pain is not real. This happens disproportionately with women. It is paramount that we, as acupuncturists, embrace our own oaths of Kan Bing and the practice of Tong Shen Ming. It is vital to unravel any psychologic exacerbations our patients are experiencing and to acknowledge the bodily felt sense of the conformation. This is particularly indicated when the chief complaint involves sensitive areas as the genitalia, in men, in women, and perhaps more acutely in our nonbinary population.

Given that the genitals are a nexus point—and that the Chong, Ren, and Du meridians all run through the area—bodywork and acupuncture with the Harmonizing method is a good beginning. Systemic tui'na is indicated for any condition involving the pelvis, and tui'na's methods of Sacral Knocking/Pounding, and Abdominal Vibration are especially effective penetrating and regulatory techniques.

Acupuncture's dynamism is helpful for treating vulvodynia, as it is one of those maddening conditions, similar to fibromyalgia, wherein the condition itself does not lend to an etiology. Determining if the patient on the whole is Deficient or Excess, or Yin or Yang, is most helpful. The Extraordinary Meridians' function as reservoirs to shunt Excess and Deficiency is typically beneficial in this case; thus, Confluent pairings of Chong/Yin Wei, Ren/Yin Qiao, and Du/Yang Qiao are the root. I augment these with the same regulatory shunting action of Source/Luo-connecting where this is appropriate. Xi-Cleft points on Yang meridians work for Wei level pain, and Yin meridians treat Ying- and Blood-level pain, thus, Spleen and Liver points are considered. When working primarily in Yang Ming, CV-6 (Qi Hai), the Influential Point of Fu CV-12 (Zhong Wan), and Front-Mu of the Large Intestine ST-25 (Tian Shu), is an effective palette for regulatory treatment. Locally, CV-2 (Qu Gu) stimulated until sensation is felt in and around the affected area is helpful if the patient consents to the pubis being accessed. Dorsally, BL-35 (Hui Yang) and BL-29 (Zhong Lu Shu) benefit the genitals and Kidney, which, of course, stores Jing, governs reproduction, and is key in affecting the genitalia.

Acupuncture is highly effective with Qi conditions and is more efficacious when paired with herbs for conditions where Blood Disharmony is involved. If the patient's condition is generally Deficient and Cold, I consider Gui Zhi Jia Long Gu Mu Li Tang, whereas, for the warmer, constricted, Liver-static condition, I consider Chai Hu Jia Long Gu Mu Li Tang. If Blood Deficiency predominates, I consider Ba Zhen Tang. For generalized Kidney Deficiency, I consider Liu Wei Di Huang Wan. For Deficient-Fire, I consider Ba Wei Di Huang Wan/Jing Gui Shen Qi Wan. If the patient is older and has night sweats and/or hot flashes, I consider Zhi Bai Di Huang Wan.

Address correspondence to:

David Simpson, MSOM, LAc

E. 10th Street

Bloomington, IN 47408

USA

E-mail: david@simpsonacupuncture.com

In their 2007 article entitled, “Vulvodynia as a Possible Somatization Disorder: More than Just An Opinion,” Mascherpa et al., open in the title their argument that the issue of vulvodynia is one of emotionally based pain presenting as a physical pain (i.e., a somatoform disorder).¹ I concur with that insight. They state that this is a condition defined as vulvar pain, burning, or soreness that is distinct from other dermatologic conditions, such as pruritus. Despite vulvodynia's prevalence—and the problems that occur with it—the etiology, diagnosis and management of this disorder remain largely unclear to professionals facing it. According to theories developed in the field of psychosomatic medicine, vulvodynia shares criteria that define other functional pain disturbances, meaning that vulvodynia should primarily be considered as a somatoform disorder, one specifically affecting the vulva. Thus, Mascherpa et al. suggest that all patients with vulvodynia should undergo psychologic and sexual evaluation, because they believe that psychotherapy may offer the best approach for reducing vulvar pain.

These researchers also posit that it is now understood, according to the neurophysiology of somatization processes, that a body signal is perceived and processed both in terms of interpretation and attribution, and on the basis of inborn and partially learned psychophysiologic patterns. In this sense, the meaning of the signal is elaborated upon by the central brain, while manifesting individual variability, for instance, in where the pain is presenting. Toward the end of their article Mascherpa et al. claim that, in the case of pain lasting months or years, the mechanism of somatization has reached “a high degree of structuration and appears deeply integrated into the patient's life.” The researchers add that, given the chronicity often associated with this condition, “recovery from the symptoms is rarely reached, and the therapeutic approach may be considered successful if the pain can be tolerated by the patient.”

Their final conclusion is: “It is mandatory to seek the origin of the pain in the mental processes.” Hence, vulvodynia is both a pain condition, but, based upon the previous information, rather than being a locally generated condition, vulvodynia is a central nervous system or centrally based pain disorder, manifesting locally; it is also a disorder based in psychoemotional dysregulation.

As practitioners of what I term Our Medicine, we can use our methods to either tactically reduce pain and/or to “harmonize Mind–Heart–Shen,” however we would diagnostically choose to do that. In my clinical interactions, in metropolitan Los Angeles, CA, with patients experiencing vulvodynia, I found that there was a very high association with either sexual trauma and/or emotional abuse in the patient's history, increasing the level and intensity of difficulties in the therapeutic encounter for both the patient and the practitioner.

For this kind of case I would now approach that range of comorbidities using an electroacupuncture (EA) protocol, possibly connecting to points LR-8 (He-Sea) and LR-6 (Xi-Cleft) as these points could be indicated for psychoemotional conditions. That core EA protocol would be combined with other Constitutional points based on the Traditional Chinese Medicine differential diagnosis for a more-balanced treatment, likely for a Zang-fu diagnosis of Liver Qi Stagnation and a Shen diagnosis of Shen Irritability. Any herbal therapy would follow the diagnoses. For this particular condition, I buttress my choice of using distal points on the Liver channel, because it courses to the localized genitalia, and treats the psychoemotional level issue quite well. I normally begin with 10 minutes of stimulation using 2 Hz and then increase the duration by 5-minute intervals during subsequent treatments, up to roughly a total of 30 minutes of electrostimulation during a session. For cases of major depression, I have found that 5 Hz seems to be the magic number; thus, potentially, after a few applications of 2 Hz to the selected points, moving up to 5 Hz would then be explored for best outcomes in what is a similar type of complicated chronic condition.

What would be assessed after a number of EA sessions would be subjective pain-scale reductions, as well as observing changes in the patient's Shen energy—to then determine how to proceed further in her care. Can she now make normal eye contact although she could not do so before? Is the quantity or quality of positive or negative energy emanating from the patient's biofield changing, getting better, or getting worse based upon the treatment provided?

Using acupuncture/EA would be a superior modality for addressing this difficult psychoemotional/psychosexual-intermeshed-with-pain condition, compared to surgery, that would likely involve local neurotomy with subsequent effects to increasing anhedonia, etc.; and very possibly outperforming drugs of various iterations in any long-term efficacy comparison.

Address correspondence to:

Fritz Hudnut, MTOM, DAOM, LAc

Emperors College & Yo San University

706 Milwood Avenue

Venice, CA 90291

USA

E-mail: dr.fritz.hud@gmail.com

Since 1990, 85% of my practice has been treating women and other patients with vulvas. Vulvodynia can be straightforward or quite complex. Many, but not all, of those patients who are treated for vulvodynia in my practice come in with histories of sexual violation and/or abuse. In these cases, a treatment approach including trauma informed care based on where the patient is in the healing process is necessary. Herewith a description of the modalities typically used, followed by a recent case I saw in my office.

Modalities Typically Used

Acupuncture is used, and based on patient presentation, I use distal points.

I also use moxa. The reason why moxa is used when vulvodynia involves Heat and pain stems from something Sharon Weizenbaum, LicAc, DiplAc (NCCAOM) taught me. She always reminded her students that “a pathological entity cannot perform a physiological function.” This means when there is pathologic Heat as part of the pain syndrome, moxa supports the true Qi and physiologic function of the organ systems involved. Warming the fascia and muscles with moxa, helps the pelvic floor heal (R. Lang,, LAc, personal conversations during my apprenticeship, 1988).

In addition to moxa, other kinds of Heat treatment are used. Patients may be asked to soak their feet in hot water with 1 cup of Epsom salts to Root the Heat in the Kidneys. Soaking a patient's feet can support the moxa treatment given in the office, or the feet soaking can be used instead of moxa for patients who cannot tolerate it. Another alternative Heat treatment to moxa can be turning on a hair dryer at Du 4. The dryer produces a similar effect to soaking the feet. Additionally, patients report feeling less stressed and report that their symptoms lessen when using the hair dryer as part of the care routine.

Dietary recommendations are also offered, based on the pattern diagnosis of the patient to support healing.

Both internal and external herbal medicines are prescribed specific to the patient's presentation. External herbal medicine is prescribed for a patient to use a sitz bath to treat the symptoms.

Other beneficial modalities include visualization and breathing techniques and the Emotional Freedom Technique (EFT). If suitable for a patient, I use visualization and breathing techniques to facilitate healing. For some patients, that is box breathing. That involves breathing in through the nose for 4 seconds, holding the breath for 4 seconds, and breathing out through the mouth for 4 seconds. For other patients, the counts are 4–7–8 breathing to stimulate the vagus nerve and calm the nervous system. The EFT helps many patients who are experiencing anxiety and/or who are overwhelmed concurrently with vulvodynia or because of their symptoms. It is a way for patients to use acupuncture point stimulation to shift brain patterning. Patients can be taught this, learn it themselves, or work with a therapist. For those with vulvodynia and severe trauma, it is necessary to refer the patient to a therapist who is familiar with EFT.

Working with vulvodynia, in my practice, always involves use of hypnotic language and breath and bringing breath and fluids down into the vulva. I remind patients that we learned from Candace Pert, PhD, that every thought we have, every emotion we experience, has a direct, measurable, biochemical reaction in our bodies, and we want to bring our attention and intention down into the vulva to generate healing and nourish it. Below is a recent case from my private practice.

When Vulvodynia Walked into My Office

A 47-year-old patient who identifies as female reported having severe pain and itching in her vulva post intercourse at a level of 7/10 along with dryness and pain throughout the day at a 5/10 level. This also reported experiencing spontaneous pain. A Certified Nurse Midwife diagnosed this patient with vulvodynia. She patient provided the following information to the Mayo Clinic staff:

• (1)Having a history of sexual trauma
• (2)Giving birth to her third child 10 months prior to presentation at the clinic.
• (3)Having pain that had begun 4 months prior to her presentation at the clinic
• (4)Having yeast infections throughout each of her 3 pregnancies.

Upon palpation, the patient's pulse was noted to be slippery and soft. Her tongue was pale red, with no “fur” on the sides and shiny. She denied having any issues with her bowels or lungs, headache, and any digestive symptoms, other than gluten sensitivity.

The Chinese medicine pattern diagnosis for this patient was Yin Deficiency with Heat. The treatment principle in this case was to tonify her Yin and clear her Heat so her fluids could nourish her tissues.

Acupuncture points used in this case included:

• ST-36, Ren 6 and 4 with moxa on needle for 15 minutes 1:1

• Added SP-3, 6, 9, and 10; LR-2 and 3 for 15 minutes 1:1

• Added Ear Shen Men, Yin Tang, and Bai Hui for 15 minutes 1:1.

While the needles were in, the patient was encouraged to meditate using Simply Being and she was instructed to breathe, using box breathing (breathing into the nose for 4 seconds, holding the breathe for 4 seconds, and breathing out through the mouth for four seconds).

This patient reported, after treatment, that her pain was reduced by half and that she had no vulvar itching. Additionally, she reported that she felt significantly more relaxed and was grateful for that.

She was sent home with a granular formula and was instructed to take 3 tablespoons dissolved in warm water in a sitz bath for 20 minutes once in the morning and once at night. This formula consisted of:

• 20 g of Huang Bai

• 12 g of She Chuang Zi

• 12 g of Huang Lian

• 6 g of Ku Shen.

This patient was given Wen Jing Tang, with the Huai Niu Xi and Huang Bai. The additions of Huai Niu Xi and Huang Bai directed the herbal formula down to the Lower Jiao.

She was also advised to soak her feet in hot water up to Spleen 6 (as taught to me by Miriam Lee, OMD, LAc) to Root her Heat Under the Cooking Pot so her Heat would perform appropriate physiologic functions to nourish the Liver, Kidney, and Spleen organ systems.

This patient reported that she planned to discuss adding EFT to her treatment with her therapist, as the therapist was trained to teach EFT.

One week after the above treatment, this patient reported a 50% decrease in pain that remained reduced throughout the week. Additionally, she reported that adding the EFT to her treatment at home was making a difference.

Conclusions

The most important thing to remember in cases of vulvodynia is to respect where patients are in their personal healing processes, and to provide patients with options that respect and reflect their values, beliefs, and life experiences. Whether a patient has suffered from trauma or not as part of their vulvodynia presentations, Chinese Medicine—either alone or in combination with other treatment methods—can be an effective treatment approach for these patients.

Address correspondence to:

Amy Mager, DACM, DiplOM (NCCAOM)

27 Brewster Court

Northampton, MA 01060

USA

E-mail: Amy@WellnessHouseNorthampton.com