Birth-Control-Recall-In-US-300x300Vulvodynia is a chronic pain condition of the vulva that affects between 3 and 15% of women. What makes vulvodynia particularly challenging is the cause is unknown and even the mechanism of the pain itself has not been well elucidated. For that reason, like many inadequately studied conditions, there are a myriad of therapies and recommendations that are based more on opinion, and often what amounts at best to be quasi-science. One example, which I have posted about before, is the low oxalate diet. This diet is recommended by many providers and has been turned into a veritable cottage industry all based on a single case report. It has been disproven by several other studies, but still I am asked about it on a regular basis. That is sad.

Suffice it to say good, prospective data on vulvodynia is needed.

One vulvodynia myth/idea/hypothesis that has been floating about for years is that it related to birth control pills. However, I have always had a lot of issues with this concept as:

A) The studies are often underpowered or otherwise not well designed to answer the question. They are also conflicting.

B) If you have sex you are more likely to be diagnosed with vulvodynia as a percentage of women with this condition only have pain with sex. If you have sex you are more likely to be on the birth control pill.  Controlling for this confounder is hard.

C) I have never seen anyone improve when they stopped the pill and I see a lot of women with vulvodynia (although granted, if they improved they probably wouldn’t be seeing me).

D) Women with vulvodynia are more likely to have other pain conditions, such as painful periods, so may be more likely to be on the pill on the pill for pain before they even initiate sex thus skewing the stats

E) I have a hard time with the biologic plausibility.  While hormones definitely have a role in pain for women (the increased incidence of chronic pain for women vs. men starts with puberty and ends with menopause), but women are exposed to far more estrogen during pregnancy than the pill can ever hope to introduce and we certainly don’t see an increased incidence during pregnancy. While it s possible that the progesterone in pregnancy, different from progestins in the pill, might have a protective role it’s all so “possible” and “maybe” that, well, it’s just a hypothesis and not a robust one at that.

However, a new study gives us more information. Reed et. al, (her group is a veritable power house of vulvodynia publishing) looked at oral contraceptive use and the risk of vulvodynia in a longitudinal population-based study published in BJOG.  They evaluated 906 women, just over 8% were found to have vulvodynia and almost 21% had a history of vulvodynia. They looked at contraception use, reasons for starting and stopping, and a host of other demographic variables. They also looked at the timing of oral contraceptive initiation and the onset of vulvodynia symptoms.

There was no association between vulvodynia symptoms and oral contraceptives, not even for women who took the pill for 10 or more years.

The study is large and uses validated questionnaires. It also gathered a lot of data that simply had not been addressed in previous studies. The 2 biggest issues with the study are the diagnosis of vulvodynia was based on a survey (albeit a validated one) and it wasn’t prospective, meaning women were not followed over the years so there could be some recall bias about pill use.

The study can’t prove cause and effect, but it does provide the most evidence to date regarding oral contraceptives and vulvodynia and the two do not appear to be related. A prospective study would be ideal, but this study is better than the current literature.

Stopping pills can lead to other medical concerns (irregular bleeding, painful periods, and of course pregnancy) and it is hard enough to have a difficult to treat medical condition, never mind someone feel that you are somehow responsible because of a medical that you took.

Unless other evidence arises, women and their providers should not be concerned that vulvodynia is associated with contraceptive pills.

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  1. Hi there, I just looked at the study and I am curious to hear your thoughts on this point. It seems worth noting that Reed et al. were investigating only the question of oral contraceptive use as a risk factor for *developing* vulvodynia. The findings certainly seem to suggest that previous oral contraceptive use is not associated with the development of vulvodynia (“the Cox regression analysis identified no association between vulvodynia and previous OC use (HR 1.08, 95% CI 0.81-1.43, P = 0.60)”). These results fail to demonstrate, however, that *current* OC use is not associated with *current* symptom exacerbation (in already existing vulvodynia).

    Unless I have misinterpreted the study (which is quite possible!), it seems that the researchers asked only the narrow question: “does prior OC use increase the risk of developing vulvodynia?” This very different from asking whether current OC use tends to worsen the symptoms of an already existing disorder. Again, this study tells us that prior OC use is not a risk factor for developing vulvodynia, but it doesn’t tell us anything about current OC use as a risk factor for symptom exacerbation in already existing vulvodynia. I wonder, then, if your conclusion is too broad. You suggest that “women and their providers should not be concerned that vulvodynia is associated with contraceptive pills.” Demonstrating that OC is not a risk factor for developing vulvodynia is dfferent from demonstrating that there is no association of any kind between vulvodynia and OC. Perhaps we should continue to exercise caution until future research demonstrates that there is no association between current OC use and current symptom exacerbation in already existing vulvodynia?

    Thanks for reading, and curious to hear your thoughts!

    1. I’m years late to the party here, but I agree with this. I have no idea what caused my vulvodynia to begin with, but after years of trying every treatment under the sun, a specialist finally suggested that I go off the pill. I did, and within a few months I was able to have pain-free intercourse. Now, some years later, I’m largely pain free all the time. Can I prove conclusively that this is a result of going off the pill? No, but nothing else changed at that time, so it seems likely to me. I’ll be interested to see what future studies reveal.

      1. I’m also a bit late, but I was wondering how long you had been on the pill when you stopped it? I recently went off the pill because I suspect it might be the cause of my vulvodynia, and I hope it will get better. My only concern is that I have been on the pill for 12 years and I’m afraid by body won’t be able to bounce back so easily..

  2. I developed severe vulvodynia while on Nuvaring. It got continually worse despite trying several topicals, such as lidocaine and capsaicin, and even a vulvar vestibulectomy did not help much. The pain got so bad that I couldn’t wear jeans, and it hurt to sit down. Then I switched from Nuvaring to Mirena (I have heavy periods so didn’t want Paraguard). Over the course of 3-6 months, the pain decreased dramatically, almost to zero. Now I just put on a little lidocaine to the affected area before sex, and I am almost completely pain free. Before this switch, my husband and I went long stretches, one was 7 months, without vaginal intercourse. So, from my anecdotal experience, I believe Nuvaring greatly exacerbated my vulvodynia, and I credit my recovery to switching to a lower hormone contraception.

    I just wanted to interject my story, and I have enjoyed your blog!

  3. I think after all this time that vulvodynia is a type of CRPS (a milder one of course)
    I have lost respect for all doctors apart from my first pain consultant since developing this
    Not because they don’t know what causes it, I don’t care about that
    But the fact that they keep trying to get rid of me as a patient. They only want to deal with standard health issues not nerve pain

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