Contraception and vulval pain
Contraception for women with vulval pain due to vestibulodynia (vulval vestibulitis) or vulvodynia often plays a secondary role in the overall management of the condition. Many women with vulval pain need to consider contraception when symptoms resolve with treatment and sexual activity returns. Vulval pain often does not stop women from having sex and many women can have intercourse with the help of local anaesthetic gels, lubrication, relaxation etc. There are plenty of choices of contraception for women to use; however, certain methods might aggravate symptoms and therefore restrict your options. In this article we will outline some choices that you might not be aware of.
The ideal contraception is one which is 100% effective, free from side-effects, suitable for the woman taking it and has reversible effects. No contraception to date satisfies all these requirements. When considering contraception, the best place to seek help is either the local family planning clinics (listed in the local telephone directory) or from your general practitioner (he or she should be trained in most aspects of family planning).
5 Methods that women with vulval pain avoid
1 Natural methods
With this method, a woman keeps a daily record of her body temperature, changes in cervical mucus and other signs of ovulation. These signs can tell her when she is fertile so she avoids sex at that time or she uses barrier contraception. The advantages of this method are that it has no side-effects and involves no drugs or creams which would come into contact with the vulval area. The disadvantages are that the technique should be learnt from a specially-trained teacher who will sometimes charge a fee. The success rates are lower than for other methods.
2 Barrier methods
Condoms
Condoms form a barrier against the passage of sperm between partners. They can be either for men or women (Femidom). The advantages of condoms are that they can be used at any time during sex and can protect against sexually-transmitted diseases. The disadvantages of the male condom relate to splitting and interruption of sex. For women with vulval pain, many condoms are scented and may contain the spermicide Nonoxynol-9 which can aggravate symptoms. Low-allergy condoms are available and may help symptoms and be less irritating; however, they are expensive.
Diaphragm or cap
This is a flexible rubber device which is used with a spermicidal cream to cover the cervix. It must stay inside the vagina for six hours after sex. The advantages of diaphragms or caps are that they can be put in any time before sex and may protect against some infections. Unfortunately they must be used with a spermicidal cream which can aggravate vulval symptoms. Some diaphragms are available which use more natural products (e.g. honey) and are less irritating (contact VPS for information). Inserting the device may be tricky and should be taught by a trainer.
Sponge
This is a disposable piece of foam which can be bought over the counter. It acts as a barrier to the passage of sperm and contains the spermicidal Nonoxynol-9. The advantages are that it can easily be used and requires no special fitting; however, the Nonoxynol-9 content can cause irritation (see below).
3 Hormonal methods
Combined pill
This is taken daily and works by stopping the release of eggs. Many women with vulval pain notice that their symptoms are worse premenstrually, in addition to other symptoms of breast tenderness, bloating etc. These premenstrual symptoms are often better when on the pill; however, the effect of the pill on vulval pain remains unknown. The combined pill also is known to reduce menstrual blood loss and period pains. The disadvantages are that it may not be suitable for some women and many women experience minor temporary side-effects.
Mini-pill
This pill is taken daily and contains the hormone progestogen which prevents sperm from entering the womb. Its advantages are that it is useful for older women who cannot use the combined pill; however, there may be temporary side-effects such as irregular periods and breakthrough bleeding.
Injectable contraceptives
These are a hormone injection given once every two to three months which slowly release progestogens. The injection works by blocking the release of eggs and stops periods until the next injection is due. The advantages are that the woman has no periods; however, a minority of women experience initial irregular bleeding and regular periods and fertility may take some time before returning to normal.
Implants
Hormonal implants are soft tubes which sit beneath the skin of the upper arm which steadily release progestogen into the circulation. They are inserted under local anaesthetic. The advantages are that once the implant is in, it can last up to five years and once taken out, fertility will return to normal immediately. However, periods can be irregular for the first year with either breakthrough bleeding or missed periods.
4 The coil
The intrauterine device (IUD) or system (IUS)
The intrauterine device is a small plastic and copper device that sits within the womb to prevent eggs from implanting. The advantages are that it is immediately effective and can stay inside the womb for five years. Some women do experience a slight increase in pain just after insertion and periods can be heavier. The new intrauterine system is a coil which contains progestogen hormone which is as effective as the IUD and causes shorter, lighter periods.
5 Methods that women with vulval pain avoid
Women with vulval pain do notice an increase in sensitivity when any creams, medication or toiletries come into contact with the vulval area, therefore the use of spermicidal creams, condoms and sponges all might aggravate symptoms. Many of these products contain Nonoxynol-9, a spermicidal (sperm-killing) agent, which can cause vaginal irritation and make vulval symptoms worse. Using the sponge has been linked to increased chances of developing thrush which clearly won’t help your symptoms.
The final choice lies with you and what is acceptable to you with regards to failure rates and side-effects. If your symptoms are worse when you have periods then you can try the injectable contraceptions or the implant. If your symptoms are worse just before a period (and also you suffer from premenstrual symptoms) there is some benefit from starting the combined oral contraceptive pill. If you prefer to avoid hormone treatments then you could try the IUD, barrier methods or natural methods. If a barrier method suits you then low-allergy condoms can be used together with a water-based lubricant (with or without a local anaesthetic).