Gynecologic Symptoms

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Although men and women can both be affected by fibromyalgia, it is well-established that women are disproportionately affected by the condition at a much higher rate than men. In fact, approximately 85% to 90% of all fibromyalgia cases occur in women. It is not surprising, therefore, that women with fibromyalgia experience a number of gynecologic comorbidities, including severe premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), vulvodynia, and vaginal yeast infections. A brief review of each is detailed below, followed by a summary of the scientific literature for each topic and its relationship to fibromyalgia.

Vulvodynia

Vulvodynia refers to chronic pain around the opening of the vagina (known as the vulva). Symptoms of vulvodynia include burning, soreness, throbbing, itching, stinging, or an overall “raw” feeling to the affected area. In addition, intercourse may be painful. The pain can be so severe at times that some women may be unable to sit for long periods. In addition, pain can be constant or intermittent, and can last for weeks, months, or even years. The pain may be localized to one specific area of the vulva, or it may be more widespread and affect the entire vulva. In most cases, the vulva appears normal although it may on occasion appear inflamed or swollen.

The cause of vulvodynia is unknown. It may result from injury or irritation of the nerves that surround the vulva, or be a complication of prior vaginal infections. Vulvodynia may possibly arise from allergies or a localized allergic reaction, or result from hormonal changes within the body. A large number of women who develop vulvodynia report a history of treatment for recurrent vaginal infections, including yeast infections. Others have a history of sexual abuse. However, most women who develop the condition have no known causal factors in their history.

Vulvodynia can lead to emotional problems, including anxiety and depression. Due to its ability to interfere with sexual activity, vulvodynia may also create relationship problems for some women. In addition, the pain may also negatively impact sleep quality. Overall, women with vulvodynia can experience a noticeably decreased quality of life as a culmination of these factors.

Vulvodynia can be treated with tricyclic antidepressants or anticonvulsant medication to help control the pain, and antihistamines may be useful to relieve itching. Biofeedback therapy may help to train women to relax their pelvic muscles in order to decrease the pain sensations that they feel. Lidocaine, which is a topical lotion or ointment that temporarily numbs the skin, may be applied to the vulva in order to provide symptomatic relief prior to sexual activity. Nerve blocks (local injections of medications that block the transmission of particular nerve signals) may also help women who have long-lasting pain and who have not responded to other methods of treatment. Surgical interventions may also be beneficial to women who have localized vulvodynia.

Vaginal Yeast Infections

Vaginal yeast infections, or candidiasis, are a type of vaginal inflammation characterized by irritation, extreme itchiness, and vaginal discharge. Vaginal yeast infections may affect the vagina as well as the vulva. These infections are very common, with as many as 75% of women experiencing one at some point in their life. Most women will experience two or more such infections.

Vaginal yeast infections are caused by the fungus Candida. This fungus is normally present in the healthy vagina, along with certain bacteria. Under normal conditions, there is also a natural balance between yeast and bacteria in the vagina. In addition, certain bacteria regularly produce an acid that keeps the yeast from overgrowing. Any time this balance is disrupted and the acid is unable to regulate the growth of yeast, it can build up and result in the classic symptoms of a yeast infection. These symptoms can be mild to severe and may include any of the following: itching and irritation of the vagina and vulva, burning sensations, redness and swelling of the vulva, pain and soreness of the vagina and vulva, and a thick, white, odorless discharge.

The overgrowth of yeast that leads to a vaginal yeast infection can result from any number of factors. A common cause is the use of oral antibiotic medications. These medications can decrease the amount of bacteria in the vagina and facilitate conditions that promote the growth of yeast. Vaginal yeast infections occur more often in individuals with uncontrolled diabetes, as well as in women who have increased estrogen levels, such as those who are pregnant, taking high-estrogen birth control pills, or those who are taking estrogen for hormone replacement therapy. In addition, people with impaired immune system functioning (due to illness or the use of certain medications) also may experience vaginal yeast infections more frequently than those who have normal immune functioning. Finally, anything that changes the amount of bacteria in the vagina (or that may introduce new bacteria into the vagina) can also lead to the development of a yeast infection. This includes activities such as douching. Although yeast infections are not considered a sexually transmitted infection, they can be transmitted during sex, in particular through oral-genital contact.

The treatment for a vaginal yeast infection varies depending on whether the yeast infection is considered “complicated” or “uncomplicated.” Uncomplicated yeast infections involve mild to moderate symptoms and affect women who do not have an extensive history of yeast infections. For these infections, short-term vaginal therapy using antifungal cream, ointment, or a suppository is usually sufficient. These therapies may be administered in a one-time application, or in multiple applications over a three to seven day period. Medications known as “azoles” are the preferred class of drugs used to treat vaginal yeast infections. Examples of these drugs include clotrimazole (Lotrimin), miconazole (Monistat), and butoxonazole (Gynazole). Another potential treatment option is a one-time dose of an oral antifungal medication known as fluconazole (Diflucan). With the exception of Diflucan, many common treatments for vaginal yeast infections are available over the counter.

Treatment for complicated yeast infections is slightly different. Complicated yeast infections include those are those that have extensive symptoms (extreme itching, swelling, and redness, or the development of sores on the affected areas), or those that are caused by a type of Candida that is resistant to conventional antifungal treatments. In addition, women who are pregnant, those who have uncontrolled diabetes, and those who have a compromised immune system are considered to have complicated yeast infections. Treatment for these infections includes long-term (seven to 14 days) vaginal therapy with an azole drug, multiple doses of Diflucan, or maintenance therapy in the case of recurrent yeast infections. Maintenance therapy usually involves a six-week course of Diflucan after the completion of initial therapy to treat the infection.

Premenstrual Syndrome (PMS) and Painful Menstruation (Dysmenorrhea)

PMS is frequently associated with moodiness, irritability, fatigue, and menstrual cramping prior to the onset of menstruation. Since fibromyalgia is characterized by an increased sensitivity to pain, it is not surprising that the physical pain associated with PMS is often greater in women with fibromyalgia. Premenstrual dysphoric disorder (PMDD) is a severe form of PMS, and is characterized by severe depression, irritability, and fatigue. Research suggests that women with fibromyalgia may be more susceptible to the psychological symptoms associated with PMDD, although further studies are needed. Finally, painful menstruation, also called dysmenorrhea, is also commonly reported by women with fibromyalgia, despite a lack of scientific research regarding the relationship between the two conditions. For a detailed review of PMS, PMDD, and dysmenorrhea and their relationship to fibromyalgia (including a summary of selected research studies), please refer to the following articles.

Heightened PMS

Menstrual Pain

 

Research

Limited research has been conducted regarding the association between vulvodynia and fibromyalgia. No studies were identified that discussed a relationship between fibromyalgia and vaginal yeast infections; however, the 2007 study Arnold et al. described below did note that women with a history of recurrent vaginal yeast infections were much more likely to have vulvodynia than those who did not have such a history.

Nguyen et al. recently published a study examining the prevalence of co-morbid pain conditions among women with physician-diagnosed vulvodynia. This study used the results from a survey that was administered by the National Vulvodynia Association, and included data from 1,847 respondents. In the study, 45% of the women who were surveyed reported having one of the following conditions: fibromyalgia, chronic fatigue syndrome, endometriosis, interstitial cystitis, or irritable bowel syndrome. In addition, the study found that those women who had both vulvodynia and one (or more) of these chronic pain conditions experienced significant feelings of invalidation and isolation, as well as decreased psychosocial wellbeing (Nguyen et al., 2012).

A smaller, earlier study published in 2007 used telephone surveys to identify 100 English-speaking women who reported symptoms consistent with vulvodynia. The survey also identified 325 women without such symptoms to serve as control subjects for comparison. Each woman completed a 30 minute questionnaire and those with vulvodynia symptoms provided a history of their pain. The survey found that 14.1% of the women with vulvodynia symptoms also reported having a diagnosis of fibromyalgia. Much like the study by Nguyen et al., other chronic pain conditions reported included irritable bowel syndrome (24.5%) and chronic fatigue syndrome (13%) (Arnold et al., 2007).

Another survey-based study by Arnold and colleagues obtained data from 77 women with diagnosed vulvodynia and 208 control subjects without a diagnosis. This study found that women with vulvodynia had three times the rate of fibromyalgia (as well as irritable bowel syndrome) than control subjects (Arnold et al., 2006). Other studies have also reported similar co-morbidity between vulvodynia, fibromyalgia, and irritable bowel syndrome (Gordon et al., 2003).

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References

1.        Nguyen RH, Ecklund AM, Maclehose RF, Veasley C, Harlow BL. Co-morbid pain conditions and feelings of invalidation and isolation among women with vulvodynia.

Psychol Health Med. 2012 Feb 13. [Epub ahead of print]

2.        Arnold LD, Bachmann GA, Rosen R, Rhoads GG. Assessment of vulvodynia symptoms in a sample of US women: a prevalence survey with a nested case control study. Am J Obstet Gynecol. 2007;196(2):128.e1-6.

3.        Arnold LD, Bachmann GA, Rosen R, Kelly S, Rhoads GG. Vulvodynia: characteristics and associations with comorbidities and quality of life. Obstet Gynecol. 2006;107(3):617-624.

4.        Gordon AS, Panahian-Jand M, Mccomb F, Melegari C, Sharp S. Characteristics of women with vulvar pain disorders: responses to a Web-based survey. J Sex Marital Ther. 2003;29 Suppl 1:45-58.

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