Many members have written to us requesting advice on vulval pain during pregnancy and shared with us their personal experiences. This is very useful because to date there is little in the medical literature on the subject of vulvodynia in pregnancy. We hope in this article to shed some light on the problem and to give you an overview of the subject, drawing information from the medical literature. If you have any advice for other members please email us at firstname.lastname@example.org or write and tell us.
Changes of the vulva in normal pregnancy
During normal pregnancy the levels of the female hormone oestrogen rise as it is produced by the placenta. This often causes an increase in the amount of normal vaginal discharge. This is white and does not cause itching or irritation. Do not think this is thrush, because the presence of a white discharge without symptoms is not normally infectious or of concern. Women who are pregnant are more prone to thrush infections and this is by far the commonest infection in pregnancy. If you develop a vaginal thrush infection, then itching followed by soreness and discharge (white — like milk curds) is what normally follows. A swab from the vagina is usually taken to confirm its presence and treatment is necessary with an anti-yeast cream or pessary. Beware! This can make symptoms worse through irritancy. Unfortunately, treatments like fluconazole are not licensed for use in pregnancy and should be avoided.
Repeated attacks of thrush may occur and can cause symptoms like vulvodynia. Avoid over-treatment with these anti-yeast creams and seek help!
Effects of pregnancy on vulval pain
Women can develop vulvodynia during or just after pregnancy. However, some women with vulvodynia who get pregnant can notice their symptoms get worse or better! It is possible that repeated attacks of thrush in pregnancy can make symptoms worse and obviously irritation from creams applied to the vulva can make things even worse. Remember, everyone’s pain is individual; what will happen to one woman will not necessarily happen to another.
Effects of vulval pain on pregnancy
To our knowledge there are no effects of vulvodynia on the outcome of your pregnancy and your baby. This is with particular regard to the growth and overall health of your baby. There is no evidence that women with vulvodynia have a lower normal delivery rate or are more likely to need forceps. Some women choose to have a Caesarean section before labour starts and this is discussed later.
This area is probably the greatest area of concern for most women with vulval pain, as the fear is that natural delivery will worsen the symptoms that already exist. Some studies have suggested that among women with a diagnosis of vestibulodynia (vulval vestibulitis), one fifth of women noticed their pain started following delivery. However, it is not clear whether this was true vestibulodynia or pain from other causes (e.g. vaginal stitches or lack of oestrogen whilst breast-feeding). Vulval pain has even been reported when the delivery was by Caesarean section and among women who have had more than one child there appeared to be variable amounts of pain after the delivery of different children.
Remember that vulval pain can occur following delivery for other reasons, and if you have vulvodynia beforehand, then you may feel that it has ‘flared up’ after delivery. Other causes of vulval pain after delivery include:
- Pain from stitches
- Oestrogen deficiency whilst breast-feeding (usually causes painful sex)
- Stitches healing too tight (again usually causes painful sex)
- Vaginal infections (e.g. thrush, discussed above)
Many women need stitches following a vaginal delivery, either because of a cut (episiotomy) or because of a tear or break in the skin. Stitches are necessary because they restore the anatomy of the skin and stop bleeding. All stitches used these days are dissolvable with time, and the outcome is almost always normal. Stitches do cause pain in the vulval area if they are too tight or if they become infected. Simply seeing your midwife or doctor will soon help diagnose these uncommon complications. Immediately following delivery ice-packs or frozen pea packets can help soothe the swelling. Avoid antiseptics, e.g. Dettol, and follow strict hygiene practices. Sometimes local anaesthetic sprays and gels on the vulva can help reduce pain in the short term, but they can irritate. The use of these can be discussed with your doctor.
If you are breast feeding, then there is a high chance that you will not be ovulating due to the breast milk hormone prolactin. If you are not ovulating, then temporarily your oestrogen levels will be low until your periods return. As a result of the low oestrogen levels, you may notice vaginal dryness or, more commonly, painful sex. (Painful sex is one of the main symptoms experienced by women with vestibulodynia.) If this occurs then seeing a doctor may help in order to exclude other causes of painful sex. Water-based lubricants (with or without local anaesthetic) can help.
Stitches too tight
If you have had stitches within the vagina, then it is a possibility that they can be too tight with the swelling that accompanies tissue healing. This can cause pain. See your midwife/GP and they can look to see if this is the problem. Stitches that are too tight on the vulval skin can be released.
In the long term once the vulval skin has completely healed, occasionally a bridge of skin can occur across the lower part of the vulva, which can then be responsible for painful sex. This skin bridge is an unusual complication of childbirth and usually requires the skin to be released under general anaesthetic by a gynaecologist as a day case. This is called a Fenton’s procedure.
You and your maternity doctor
The majority of women in this country have ‘shared care’ between the hospital and their midwife and GP. More and more normal, healthy mothers are being seen in the community. Each woman should, however, have a consultant obstetrician who should be in charge of overall care should there be any problems. You may or may not see this person if everything remains normal. Most obstetricians are gynaecologists as well so it is likely that they have some understanding of vulval pain and vulvodynia. If you are pregnant you might want to mention this condition to the hospital doctor when you initially visit.
We have had some members who have been so concerned at the thought of a vaginal delivery and its effects on the vulvodynia that they have opted for Caesarean section. This is no simple decision and should be fully discussed with your doctor. Having a Caesarean section will obviously avoid a vaginal delivery and may possibly (but not totally) prevent a flare-up of your vulvodynia. However, the great disadvantage is that you will have to undergo an operation and recovery from this procedure can take six to eight weeks. Caesareans are carried out for many reasons and most doctors are agreeable to a Caesarean section for good, valid reasons. Although vulvodynia is not a common reason for a Caesarean section, it has been heard of among the women we hear from. The advantages and disadvantages need to be raised at the hospital and discussed with your doctor. Unfortunately there is very little in the literature relating to vulval pain and pregnancy.