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6. How is vulvodynia/vestibulitis treated?

Unfortunately, for most women with VVS, there are no magic cures. Sometimes an infection that will respond to medication is found, such as ureaplasma, candida, or strep. In a lucky few, it clears up on its own after 6 - 12 months. Some women develop vulvar pain as part of the hormonal changes of menopause. This particular problem often responds to estrogen creams or estrogen replacement therapy.

But for many women, the treatment is symptomatic, to try to reduce the pain. A prescription anesthetic, xylocaine (available both as a jelly and a liquid solution), may be helpful if applied directly to the sore areas. Unfortunately, the effects last only for a couple of hours and repeated applications can cause damage to the underlying skin. Xylocaine can very useful for intercourse, however, and also during pelvic examinations and sometimes during tampon changes.

Some physicians are injecting xylocaine directly into the affected area to create a nerve block. The effects of a nerve block can last from a few hours to a couple of days. Unfortunately, the more often you inject a nerve, the less responsive it becomes to the anesthetic.

Topical corticosteroids are often prescribed for vulvar itching, but seem to be of little help in VVS.

If the vagina is too acidic, one doctor recommends baking soda douches. This appears to help a few women, is inexpensive and non-toxic.

Several studies have treated women who show also signs of HPV infection with interferon, (which strengthens the immune system), with some success.^(17,18,19) However, the relapse rate is apparently quite high, and at least one study suggests that interferon may work better on women who do *not* have signs of HPV infection.⁽¹¹⁾ These researchers suggest that interferon may work, not by killing HPV, but by a general anti-inflammatory property.

Some gynecologists are treating VVS with hormones applied topically to the inflamed area. Usually, these doctors are prescribing estrogen, but some are also using progesterone or testosterone which are accepted treatments for another vulvar pain condition called lichen planus.

In the Fall 1994 issue of the Vulvar Pain Foundation newsletter, Dr. John Willems reports that he is having success with a kind of topical estrogen cream called Estrace. Estrace is a 0.01% solution containing a particular estrogen called estradiol. Willems works with many patients who have had laser excision of the vestibule with poor results. Willems believes that Estrace thickens or toughens the skin, and increases blood supply. He emphasizes that the patients he treats do not have clinical estrogen deficiencies nor are they menopausal.⁽²⁵⁾ Because many women with VVS find vaginal creams to be painful (possibly because the cream base contains compounds like parabens and alcohols), some physicians are mixing a 10% solution in a petroleum gel base instead of using the standard preparations. Some women find even this to be too painful; however, the petroleum gel preparation can be diluted to a 5% solution using heavy mineral oil, which may be more easily tolerated. Injection of hormones directly into the inflamed tissues should be avoided because most women find this to be too painful. Some women also find compresses made from prophyllin powder (a prescription medication) to be soothing.

Solomon and Melmed advise patients to try a diet low in oxalate. ⁽¹⁶⁾ It's not possible to completely eliminate oxalate from the diet and still obtain all the necessary nutrients. However, there is no reason to believe that harm will result from avoiding foods very high in oxalates, either. A list of high oxalate foods, along with their other dietary recommendations, is attached in Section X: List of foods high in oxalates. These doctors have been giving patients calcium citrate to see if neutralizing calcium oxalate helps vulvodynia. They are using a complicated method of charting the woman's peak times of oxalate production, and emphasize that patients should not try calcium citrate as a home remedy on their own, since it can be hazardous.

The Vulvar Pain Foundation reports that the two most consistently effective treatments, as reported by their members, are estrogen creams and/or the low oxalate diet/calcium citrate regimen.

Another thing consistently reported by women with vulvar pain is that it helps to keep the urine diluted by drinking large amounts of liquids. It's not clear whether this helps by reducing the amount of oxalates in the urine, or if it's simply helpful because urine itself is irritating and dilute urine is less painful to inflamed tissues.

Fibromyalgia researchers suggest that certain anti-depressant drugs may be of benefit to those women who also have FMS or who have vulvodynia involving neuralgia of the pudendal nerve. This is because these drugs have pain controlling properties independent of their antidepressant effects (via blocking pain impulses high in the spinal cord) and are therefore sometimes of value in pain of neurogenic origin. However, no controlled studies have been done of antidepressants for vulvar pain. Commonly used antidepressants include amitriptyline, nortriptyline, imipramine (all tricyclic antidepressants) and fluoxetine (Prozac - an SSRI). There is also an anecdotal report that paroxetine (Paxil) is helpful with vulvar pain. Marinoff, however, believes that SSRIs are not particularly effective in treating vulvodynia. ⁽³⁶⁾ Some people with vulvodynia who do not respond to low dose tricyclic antidepressants may improve with high doses.

Some physicians are experimenting with certain anticonvulsants known to work in other neurologic conditions involving shooting pains, such as trigeminal neuralgia (a pain disorder of the face), herpes related ("herpetic" neuralgia) and phantom limb pain. The most effective drugs for these conditions are carbamazepine (Tegretol), gabapentin (Neurotonin) and clonazepam (Klonopin).

Another approach some doctors are trying for neurologic vulvodynia is the use of capsaicin. Capsaicin is an extract of red pepper that destroys certain peripheral nerve fibers. It's commonly used for neurologic pain from diabetes, HIV infection, herpes infection and other disorders that damage nerve tissue. It is also used in the treatment of interstitial cystitis. The NVA News mentions an ongoing study of capsaicin by Dr. Hylina Zycznski of McGee Women's Hospital. Nine patients who applied capsaicin topically to the vulva for 6 weeks reported "significant relief". This study does not appear to have been published but it was presented at the first NIH Symposium on Vulvodynia. However, capsaicin also produces a significant burning sensation when applied to the skin. It may not be appropriate for patients with vulvodynia due to inflammation. ⁽³⁸⁾

Physical therapy may be of some help: not only do women often develop problems from the alterations of posture needed to avoid putting pressure on the vulva during walking and sitting, but it may be helpful by relaxing chronic tension in the pelvic muscles as well. ⁽²¹⁾ Many researchers believe that women develop chronic muscular tension in the vaginal area as a result of pain and that this can lead to a cycle of pain --> tension ---> more pain. Dr. Howard Glazer, a psychologist in New York, claims that biofeedback and pelvic muscle exercises involving relaxation and muscle strengthening are helpful to some women with VVS. He proposes that vulvodynia may persist after an initial infection that has resolved. He believes that some women develop unconscious muscle tension in the pelvis and that this contributes to muscle spasm and pain perception. He has published a study of 28 patients. ⁽³⁷⁾ Even though the study sample was small, his findings are in keeping with findings in other chronic pain syndromes.⁽²²⁾

Opiate and other standard pain relief drugs do relieve vulvar pain in high doses, according to Dr. Marinoff.⁽³⁶⁾ The latest opinion of pain management specialists is that these drugs do not cause addiction when used for legitimate pain conditions under the supervision of a physician.

Unfortunately, one effective treatment for neurologic pain cannot be used in vulvar pain: cutting the nerve causing the problem. The nerves that innervate the vulva also play a key role in bladder control. Cutting the pudendal nerve results in urinary incontinence.

However, the vulvar vestibule CAN be removed without causing incontinence. There are two main surgical procedures, which can be done either with laser or by traditional means: perineoplasty and vestibuloplasty. In perineoplasty, the entire vulvar vestibule is removed, whereas in vestibuloplasty, the nerves that branch off the pudendal nerve directly to the vestibule are cut but most of the vestibular skin remains intact.

The most optimistic studies report that 60-85% of women respond to surgical excision of the affected area. ^(20,23) Other investigators have not found such encouraging results, and warn that approximately 10% of women may experience worsening of symptoms after surgery.⁽²⁴⁾ In one study, researchers found that of 11 women who underwent perineoplasty, 9 experienced improvement whereas none of 10 control patients experienced relief when only vestibuloplasty was performed.⁽³⁵⁾

Laser treatments burn off the affected tissue. There are reports that carbon dioxide laser causes bad burns and can worsen vulvodynia. For this reason, some physicians feel very strongly that carbon dioxide laser should NEVER be used as a treatment. However, certain other laser treatments, such as dye laser are OK. One study of dye laser found that 43% of 163 patients improved.

A recent study attempted to find out who were the women most likely to improve from surgery or laser. They found that women who had an acute onset, relatively mild pain and whose pain was clearly localized to one area were most likely to benefit. Women whose symptoms were of short duration (i.e. they had had vulvodynia less than 1 year) are also more likely to respond to surgical treatment. ⁽³⁸⁾ However, even these women may not respond well and a few worsen. Women with generalized vulvar pain are poor candidates for surgery or laser.

Other researchers have concluded that women who have vulvar vestibulitis associated with pain with intercourse since their first episode of intercourse and in those with associated persistent vulvar pain will have a poor response to surgery. They suggest that "treatment approaches other than surgery should be considered for such patients".⁽²⁸⁾

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7. Pregnancy and vulvar pain:
Pregnancy can impact on vulvar pain in several ways. First, there is the problem of getting pregnant. Then there is the impact of the pregnancy before birth on vulvar pain and vice versa. Next, there is the concern of pain relief during labor and delivery and finally, there is the impact of childbirth and vaginal delivery on the vulva in the postpartum period.


Before the Pregnancy:
Some of the medications women use to treat vulvar pain may cause birth defects. This is most true of the antidepressants. If at all possible, these should be discontinued before trying to become pregnant. However, it is very important that a physician be consulted before discontinuing any medications. Do NOT wean yourself off antidepressants without a doctor's supervision.


FDA Pregnancy Classifications:
The FDA classifies drugs into 5 categories of potential for harm to the fetus.⁽²⁷⁾ These are:

A: No risk demonstrated to the fetus in any trimester.

B: No adverse effects in animals, no human studies available.

C: Only given after risks to the fetus are considered: animal studies have shown adverse effects; no human studies available.

D: Definite fetal risks, may be given in spite of risks in life-threatening situations.

X. Absolute fetal contraindications, not to be used any time during pregnancy.

Pregnancy Classification of drugs commonly used to treat VVS:

Tricyclic Antidepressants:

Amitriptyline (Elavil): C
Nortriptyline: C
Imipramine C
Anti-neuralgia agents:

Gabapentin (Neurotonin): C
Carbamazepine (Tegretol): C
Clonazepam (Klonopin): C
Serotonin Reuptake Inhibitors

Fluoxetine (Prozac): B*
Paroxetine (Paxil): C*
Sertraline (Zoloft): B*

* note: we don't know long term effects of SSRIs on the fetus because no human studies are available. Physicians recommend that women discontinue Prozac, Zoloft or Paxil prior to becoming pregnant.

(Ratings obtained from _Nursing 99 Drug Handbook_ and _Mosby's 1993 Nursing Drug Reference_.)

In addition, women taking calcium citrate and following the low oxalate diet need to make some changes. Marinoff states that doses of 1200-1500 mg. of calcium citrate per day are OK for most women, and do not cause harm to the fetus. However, higher doses can lead to kidney stones in the mother.⁽³⁴⁾

More problematic is the low oxalate diet. This diet is lacking in many necessary nutrients for both fetus and mother. The mother may need to consult a registered dietitian for help in planning her diet.


Becoming Pregnant:
Next: how do you get pregnant if intercourse is too painful to tolerate? It's best if the woman learns to detect when she is ovulating so that she can maximize her chances of becoming pregnant from one act of intercourse. The most commonly used methods for this are taking basal body temperature and observing the vaginal secretions for changes in the cervical mucus indicative of ovulation.

Rather than launch into a detailed discussion of ovulation detection here, I refer people to the excellent FAQ put together by the alt.support.infertility newsgroup called "Low Tech Ways to Help You Conceive". This FAQ, along with another excellent FAQ on ovulation predictor kits, can be found at Fertile Thoughts.

Some doctors think it's all right to continue using small amounts of topical anesthetics such as xylocaine jelly while trying to get pregnant. If this doesn't work: well, intercourse is not the only way a woman can get pregnant. Some people have thought up very creative "sperm delivery systems".

Turkey basters have been used for years by lesbians attempting to become pregnant and can be helpful. One doctor even boasts about his "turkey baster twins". Basically you can use either sperm from a sperm bank or sperm from your husband, male lover or friend, put it in the baster and inject it. Probably, the smaller the injector used, the more comfortable it will be. For this reason, some women may wish to use 5 or 10cc syringes, which should be available from your doctor or local women's health clinic.


During the pregnancy:
Does pregnancy worsen vulvodynia either during pregnancy or after delivery? There are no studies on this subject. In an issue of the NVA News, Dr. Marinoff states that about 1/3 of his patients improve, 1/3 get worse and 1/3 stay about the same. The growing fetus definitely places more pressure on the pudendal nerve and thus may worsen vulvodynia of the pudendal neuralgia sub-type. There is also more pressure on the bladder and urethra, which may aggravate urinary symptoms. However, there is an increase in circulating steroid hormones during pregnancy, including estrogen and cortisol. This may cause some cases of inflammatory vestibulitis to improve. ⁽³⁴⁾

Dr. Marinoff notes that some women have their first onset of vulvodynia during or after a pregnancy. In that case, he believes that the vulvodynia is most likely to recur with subsequent pregnancies. ⁽³⁴⁾


The Delivery and Post-partum Period:
There is no medical reason why a woman with vulvodynia must have a Caesarean section, even if she has had previous vulvar surgery. Each case is individual: if the vulva is heavily scarred, an episiotomy may or may not be needed to prevent tearing. There are women with vulvodynia who go through labor and delivery without any anesthesia at all; however, many women do elect to have at least an injection of local anesthetic directly to the vulva for examinations to determine cervical dilation and for the delivery. Other women prefer to have epidural anesthesia. This type of anesthesia can make labor and delivery much more comfortable and the woman usually retains the ability to walk and does not have the severe headache associated with a full "saddle block". However, it can lengthen the time needed to push the baby out and, in the hands of an overly cautious or inexperienced physician, leads to an increased rate of Caesarean sections. Thus, the decision to have an epidural block must remain with the patient herself.

After the delivery, some women elect to go directly back on medications they had discontinued during the pregnancy. These women should not breast feed because most medications contraindicated in pregnancy can also be excreted in breast milk. Other women stay off medication and try to determine if pregnancy has caused their condition to improve. In some cases improvement is permanent; in others the woman returns to her previous level of pain and function within about 6 months after the delivery. Unfortunately, there is no good way to predict who will improve with pregnancy and who will not or who will become worse.


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8. Finding a physician who can treat vulvodynia
Unfortunately, many physicians are still not well informed about vulvodynia and a woman may find that she knows more about the condition than her physician! It's difficult to find a physician experienced in treating vulvodynia and some still cling to outmoded ideas that the pain is psychosomatic in origin. Vulvodynia can be treated by gynecologists; I have also found gynecologic urologists and pain management specialists to be better informed than most other physicians.

I recommend that people contact the National Vulvodynia Association at (301) 299-0775 for a referral. It may also be helpful to seek out physicians who have actually published on this disorder. All footnotes in this article include the names of the physicians who wrote various articles and the research institutions that they are affiliated with. The reader may want to contact the gynecology departments of the listed research hospitals to try to get a referral in her own geographic area.

Dr. Howard Glazer also maintains a list on the Internet of professionals who treat VVS at http://www.vulvodynia.com/vvpros_frm.htm.


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9. Coping strategies and self-help tips:
Support:
Obviously, vulvodynia can interfere drastically with a woman's life. Proper information and support are very important in coping with VVS. The Vulvar Pain Foundation (listed under resources in section VII) both publishes a newsletter and maintains a list of local support groups. I strongly recommend that women with this condition get in touch with them. They are in contact with physicians who are knowledgeable about vulvar pain and may be able to put women with VVS in touch with physicians in their local area. They may also know of a VVS support group in your community.

Women with VVS may also want to consider psychological counseling by a therapist experienced in chronic illness. VVS, like all chronic pain disorders, can be extremely debilitating. This illness, like any painful illness, can interfere with many of the person's usual responsibilities; family members or friends may become angry about having to compensate for this. In addition, VVS carries the problem that it is a disorder that is very intimate and personal; very often, women are reluctant to speak about it. Because it involves the sexual organs, a woman may feel great shame about it. Her self-image can be drastically affected. She may feel that she is "less womanly" or no longer sexually attractive. This can be quite exhausting and very demoralizing.


Sexual impact:
Vulvodynia can cause a terrible strain on marriages or other sexual relationships because it makes many forms of sexual contact difficult or impossible. It is very important for the medical practitioner to validate the woman's experience. There are some tragic cases where relationships have broken up because a physician suggested that the pain was psychogenic and due to the woman "subconsciously rejecting" her husband or lover. Good communication between sexual partners is essential and relationship counseling may be helpful. While vaginal penetration is often out of the question, some people find other methods of sexual expression that can take its place. Xylocaine applied to the sore areas can sometimes make intercourse possible again. However, this doesn't work for every woman.


In an issue of the NVA newsletter, Dr. Gae Rodke recommends the use of a 4% liquid solution of xylocaine before intercourse, rather than jelly. This is because the jelly tends to transfer to the male partner, decreasing his sensation and often prolonging penetration which can be painful to the patient, even with the anesthetic. She advises women to place the solution on a cotton ball and place it right at the vaginal opening for a period of 5 to 10 minutes before intercourse. She also recommends using a lot of lubrication and, after intercourse, placing a cold compress on the area to reduce any reflex redness or swelling. ⁽³⁵⁾

Important note: do NOT use oil or petroleum based lubricants such as Vaseline if you are also using latex condoms. They will eat right through the condom in a matter of minutes. Instead, either use a good water based lubricant such as For-play, or Astroglide (available at most places that sell sexual aids, or by mail order); or else use lambskin or polyurethane condoms. Also, many women with vulvodynia are sensitive to spermicides: it's necessary for these women to avoid not only contraceptive jellies and foams, but also certain lubricants that contain nonoxynol-9.

Menstruation:
Another little discussed factor is the impact vulvodynia can have on menstruation: what is a woman to do during her menstrual period if she finds inserting tampons and wearing menstrual pads to be very painful? Many women find that the tampon string is quite irritating but that they can tolerate the tampon if the string is either cut off prior to insertion, or pushed far up behind the pubic bone. Some women find that they can tolerate a brand of menstrual pad that has a cotton cover but cannot tolerate pads with the more "absorbent" synthetic surfaces. All cotton cloth menstrual pads are also available by mail order (details on how to obtain them are given in the resources section). Another alternative is to use a diaphragm or cervical cap to catch menstrual flow, although some women cannot tolerate the stretching of the vaginal opening necessary to insert them. Topical xylocaine may be helpful with insertion. The Vulvar Pain Foundation reports that rolls of absorbent cotton can provide a comfortable and highly absorbent alternative to menstrual pads. You cut the cotton into strips the size of regular pads, fold and place them in your underwear.

Difficulty with urination and other pain relief measures:
The most commonly reported helpful intervention is to keep the urine dilute by drinking lots of fluids.

A few women find that ointments such as A & D Ointment or Desitin are soothing. They can also be quite helpful, as can Vaseline, in protecting the inflamed tissue during urination.

Another way to help painful urination to pour a cup of water over the vulva while urinating: this dilutes the urine and helps to wash away any irritating residue.

It also helps to sit slightly forward when urinating, as this directs the stream straight down and it does not touch the skin.

Rinsing the vulva with plain water several times a day helps some women. A special bidet, that removes the need to wipe with toilet paper and which delivers both a rinse and an air dry, is available from Lubidet USA. Their phone number is in the resource section.

Carefully avoiding all potential irritants on your underwear, such as laundry soaps and bleaches, may help. Some women find that they can tolerate underwear washed with a mild, non-perfumed soap such as Castile Soap, and run twice through the rinse cycle. Others simply do without.

It may be possible to relieve pressure on the vulvar area when sitting by placing a notepad under yourself, in such a way that the edge elevates the pelvis. A type of pressure relief cushion called an Isch-Dish may be helpful. (Source is listed in the resources section.)

Many women who must wear pantyhose or stockings for work, wear brands with a cotton crotch over all-cotton underwear. They then slit the pantyhose crotch to relieve binding. Other women rely on old fashioned garter-belts and stockings. A product called Scantihose was designed to avoid bumps or ridges in clothing, and comes completely up the leg, unlike older stockings that can't be worn with shorter skirts. Ordering information is in the resource section.

Many women find that perfumed soaps, or even completely plain soaps, aggravate the irritation. This may also be true of colored or scented toilet paper as well. Some women find tub bathing to be possible if they avoid all bath oils or perfumes; others find that any tub bathing worsens the situation and only take showers. A hand held shower massager is preferable to an overhead nozzle; it makes it much easier to wash away any soap residue that may remain after washing. Natural glycerin soap may be helpful, as it has no residual drying effects. One woman I know discovered that using distilled water to wash the vulvar area rather than tap water relieved some of the irritation. She speculated that perhaps the chlorine in the tap water contributed to her condition. One gynecologist advises his patients to keep the vulva very dry: he tells women to first wash with distilled water and pat the area dry; to then use a hand held blow dryer (on cool please!) to further dry the skin and to then apply cornstarch.

The Vulvar Pain Foundation mentions that some women find applying warm soaked tea bags to the vulva to be soothing. Some women put the tea bags on menstrual pads to hold them in place. Others take sitz baths in which tea bags have been soaked. Many women report cold compresses to be helpful.


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10. List of Foods High in Oxalates
Solomon and Melmed recommend complete avoidance of all foods high in oxalate. These include:

Beer, berry juices like raspberry juice, tea, cocoa, Ovaltine, beverage mixes, baked beans in tomato sauce, peanuts and peanut butter, pecans, soybean curd (tofu), all berries, concord grapes, citrus peel, rhubarb, tangerines, chocolate, vegetable and tomato soups, fruit cake, grits, wheat germ, black pepper (beyond a teaspoon a day), beans of all kinds, beets, celery, chard, collards, dandelion greens, eggplant, escarole, kale, leeks, mustard greens, okra, parsley, green peppers, sweet potatoes, rutabagas, spinach, summer squash and watercress.

They recommend that foods with a moderate amount of oxalate should be eaten in moderate amounts, no more than two half-cup servings a day. These include:

Coffee, cranberry, grape, orange and tomato juices, sardines, apples, apricots, black currants, sour cherries, oranges, peaches, pears, pineapple, plums, Italian prunes, chicken noodle soup (dehydrated), cornbread, sponge cake, canned spaghetti in tomato sauce, asparagus, broccoli, carrots, corn, cucumber, green peas, iceberg lettuce, lima beans, parsnips, tomatoes and turnips.

In addition, they recommend that women with VVS take no more than 250 mg of Vitamin C a day, because it is a chemical precursor of calcium oxalate. They also state that there is some evidence that drinking small amounts of milk or eating dairy products *with meals* (emphasis in the original) helps in reducing the amount of calcium oxalate to the body.


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11. Books that may be helpful:
Alas, there are no books written on this illness. However, women with vulvodynia may find the following books of interest:


The Low Oxalate Diet Book
General Clinical Research Center (H-203)
The University of California
San Diego Medical Center
University Hospital
225 Dickenson Street
San Diego, CA 92103
USA
Cost: $5 each plus postage and handling. Make checks payable
to the Regents of the University of California

Overcoming Bladder Disorders by Rebecca Chalker and
Kristine E. Whitmore, M.D. HarperPerennial Press, 1990
ISBN # 0-06-092083-1 Cost: $9.95 US
Contains good information about interstitial cystitis and
urethral syndrome.

Pain and Its Relief Without Addiction: Clinical Issues in the Use of Opioids and Other Analgesics
Barry Stimmel, M.D., Haworth Medical Press, (1997)
ISBN # 0-7890-0126-8 Cost: $24.95 (softcover)

Our Bodies, Ourselves; by the Boston Women's Health Book
Collective. New York: Simon and Schuster, 1984
Good general information on women's health care.

A New View Of A Woman's Body: A Fully Illustrated Guide
by the Federation of Feminist Women's Health Centers.
Touchstone Press, 1981. ISBN # 0-671-41215-9
Best illustrations of female reproductive anatomy *ever*.
Can be ordered through:
Feminist Health Press
8240 Santa Monica Blvd
West Hollywood, CA 90046
(213) 650-1508
Cost: $19.95 plus tax and S& H. Call for shipping information.

Sexuality And Chronic Illness: A Comprehensive Approach
by Leslie R. Schover and Soren Buus Jensen. New York: The
Guilford Press, 1988. This book does not deal directly with
vulvodynia, but contains helpful information for
psychotherapists, physicians and others who treat and counsel
people suffering from sexual dysfunction as a result of
chronic illnesses.

Living With Chronic Illness: Days of Patience and Passion
by Sheri Register. New York: The Free Press/Macmillan, 1987.
Contains information based on interviews with people suffering
from chronic, often painful, illnesses. Smashes some myths
about long-term illness.

The Honest Herbal by Varro Tyler, Ph.D. New York: The
Haworth Press, 1993 ISBN # 1-56024-287-6
Because there is not yet a reliable cure for vulvar
vestibulitis, many vulvodynia sufferers are exploring herbal
or other alternative medical treatments. This book is based
completely on scientifically validated studies and discusses
contraindications and adverse effects of herbs at length.
Cost: about $20 US for the softcover edition.

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