Yoga: Proven Benefits for Anxiety, Depression & Adrenal Dysregulation

If you practiced yoga daily, you wouldn’t need us doctors at the Gottfried Center to help you feel optimized. Yoga will change your life, for the good, but only if you commit deeply. You cannot proceed casually and expect transformation. Part of my job is to provide evidence to you – evidence that, in this case, yoga heals and transforms. What follows is the science supporting yoga for anxiety, depression and adrenal dysregulation, conditions that affect 100% of you. Please also keep in mind the wise words of BKS Iyengar:

“Words fail to convey the total value of yoga. It has to be experienced.”

Anxiety. There is 100% incidence of anxiety in our culture. There is a broad spectrum here from a little worry to the more debilitating problems such as obsessive thinking, insomnia, migraines, panic attacks, shortness of breath and palpitations. Excessive worry blocks healing. Simple tools such as deeper, belly breathing can help. Specifically, deep, slow breathing activates the Parasympathetic nervous system and releases the body’s own valium – GABA. Generally, we know that yoga increases our GABA levels. Other scientific evidence? Two studies show that yoga is as or more effective than tranquilizers such as Xanax or Ativan. In Germany, a group of 24 women with anxiety were randomized to two 90-minute yoga classes per week for 3 months or a waitlist. Significant reductions in both anxiety symptoms and salivary cortisol levels were found in the yoga group. Also interesting was that the women who reported headaches or back pain noted marked relief from pain.

Depression. Don’t co-opt the message from your conventional doctor that the answer to your sluggish mood and lack of joy can be found in a pill. Here’s the science: (1) A randomized trial from UCLA of 28 women with mild depression were treated with yoga twice/week compared to a control group placed on a waitlist. The yoga group had significant improvements in mood and anxiety, after only 2.5 weeks in class. (2) Another study of 80 people found that yoga for 3 to 6 months was as effective as a older treatment for depression – a tricyclic antidepressant (TCA), imiprimaine. Both yoga and the TCA raised serotonin and resolved symptoms, and while yoga took a little longer to have a significant effect, the effect lasted longer when patients stopped the therapies. Another randomized trial of Mindfulness-Based Stress Reduction showed it cut the recurrence rate for depression in half.

Adrenal dysregulation. If you have high cortisol levels, yoga has been shown to lower cortisol. High cortisol can cause depression, bone loss, poor memory and thick waistlines. Yoga activates the parasympathetic nervous system, which balances our chronically-activated sympathetic nervous system, or “fight or flight.”

Many of us look for a quick fix for depression, anxiety, fear, insecurity, stress, relationship problems, feeling numb, and emotional immaturity. Go with the long view: figure out what's not working for you and slowly manifest what would suit you better. Yoga helps you cultivate joy, peace, radical self-acceptance and vibrant health. It's proven.

Clearing Negative Beliefs

Just reading Shakti Gawain’s Reflections in the Light, and found this “Clearing” exercise to be very helpful for myriad issues: establishing a home yoga ractice, reigniting your spiritual path, cutting out sugar, getting a new job that aligns better with your values, etc.

This is quoted directly from Shakti’s book.

Here is a basic clearing process that you can use to clear out negative beliefs in order to attain a goal. First, state your goal in the form of an affirmation. Second, write “The reasons I can’t have what I want are:” and then start listing every thought that comes into your head. Third, decide which of the negative statements have the most power over you, and make a mark by those. Write an affirmation to counteract each one. Meditate on these affirmations every day along with your original goal.

I am now clearing my negative beliefs.

Click here for more info on Shakti’s inspirational and original work. We’re working on incorporating some of her processes into our next round of yoga and integrative medicine workshops. Sign up here for our newsletter for more info.

A+ Vacation: How to Recharge the Batteries

My husband and I just returned from Vancouver where we had four blessed days, sans kids. David was there to give his “New World of Green” speech – and if you don’t know the man, here’s his claim to fame: he’s done more than any individual to reverse climate change over the past 15 years through his visionary leadership and founding the world’s fastest-growing nonprofit, the USGBC, and the World GBC.

Here’s what we found in Vancouver: the best battery recharge ever. We arrived Friday to extraordinary weather, and a gorgeous hotel room overlooking the water and Stanley Park.

We dined Friday at Radha and ate scrumptious, lovingly prepared raw and cooked vegan food. Radha is a revolutionary spot that has manifested my long-held vision of combining yoga with extraordinary food and community. Add some integrative physicians and you have my vision.

I’ve noticed recently that vegan and raw food both deepen my meditation experience profoundly – I don’t fidget, I don’t get distracted, I stay on task.

Saturday, after researching every yoga teacher within a 10-mile radius, I settled on Christine Price Clark at YYoga in Yaletown. She is an Anusara teacher, and the class was for intermediate-advanced folk.

I walked into a densely filled, sweaty room tense with the anticipation of students devoted to their teacher. In walks guru Christine, singing “Business Time” by Flight of the Conchords. When I did my teacher training in 2002, we were taught to set carefully a healing container at the beginning of class, a vessel to hold the energy and emotion of our students during class. Christine claimed her container as loving, playful, irreverent and totally original.

Class was intense. She set an intention of us all getting connected to our Grand Vision. She told a story of her family member’s lukewarm enthusiasm for her own Grand Vision to step away from an unsatisfying job and into the flow of yoga teaching.

Class was outstanding. Intense, meaningful, the right mix of artful language and creative sequencing. I walked home to the hotel, inspired and connected to my Grand Vision – you know, the one about being a High Priestess of Energy and Libido, helping women connect to their inner priestess and deep well of vibrant energy and vitality. I found David finishing up the refinements to his speech, and we walked together in the sunshine to the Vancouver Art Gallery to learn about Emily Carr and be transported by her vivid charcoals of the British Columbia forests.

I won't give you all the details, but suffice it to say I went to every class Christine taught, bought some gold lame hot pants, and we arrived home yesterday flush with energy, love and vitality. The formula for this vacation worked.

Are Those Pearls on your Ovary?

Polycystic Ovarian Syndrome (PCOS) is a problem of hormonal imbalance that creates sputtering ovulation and hyperandrogenism (too much male hormones, which causes increased male-pattern hair growth and acne). Most important in the diagnosis is exclusion of other causes, as no single lab result leads to the diagnosis. Over 6-10% of women have PCOS.

Other findings include multiple cysts on the ovary (called the “string of pearls” sign on ultrasound - see image below), overweight or obesity, high blood pressure, and acanthosis nigrans – a weird skin finding of darker, velvety skin on the back of the neck.



While the cause is unknown, we mostly consider PCOS to be a metabolic problem. About half of women with PCOS have high insulin levels (or hyperinsulinemia). Lowering insulin levels with exercise, eating low-glycemic foods, and other measures can correct erratic ovulation. Some of the natural therapies that have been shown to be helpful in PCOS include bioidentical progesterone use and cinnamon. Tieraona Low Dog, MD, showed in a small study published in Fertility and Sterility in July 2007 that cinnamon (0.5 teaspoon per day) lowers insulin resistance in PCOS.

I want to emphasize the role of exercise – it’s essential in PCOS, no exceptions! I recommend 30 minutes per day, 4 to 5 days per week, of cardio exercise at a minimum as the primary treatment.

One of the findings of PCOS is estrogen dominance – too much estrogen versus progesterone. Reducing estrogen levels can be very effective and I suggest the following measures:

• Meat/Dairy: avoid conventionally raised meat and dairy products, which contain growth promoters that act as xenoestrogens - these stimulate estrogen receptors in the body and disrupt normal hormonal signaling. Omnivores should choose organic products.

• Cruciferous Veggies: increasing consumption of cruciferous vegetables, such as broccoli and brussel sprouts, which increase metabolism of estrogens.

• Gluten-free: reducing gluten lowers your estradiol levels by 30% or more.

Finally, natural progesterone, prescribed and monitored by a knowledgeable provider, can also help balance estrogen dominance.

Women with PCOS are at greater risk of type 2 diabetes and metabolic syndrome, and should be additionally screened with glucose testing and a full fasting lipid profile.

Adrenals Burned Out?

Adrenal fatigue or dyregulation is the change in the ability of the adrenal glands to carry out their normal job. The main symptoms is fatigue, or in the case of hyperadrenalism, feeling tired but wired.

In response to chronic stress, many folks suffer from adrenal dysregulation, which can be either low production of adrenal hormones (hypoadrenalism) or high production, or a combo of the two. Many of my patients wake up in the morning with low cortisol, drink a cup of coffee to wake up, and then have high cortisol (coffee raises cortisol) and feel wired. Then they’re exhausted when the caffeine wears off by 2-4pm.

What causes adrenal fatigue? At Gottfried Center for Integrative Medicine, every case is individualized, but there are four common causes as identified by Dr. James Wilson:

• Disease that overwhelm the body such as auto-immune conditions or cancer;
• Physical stress such as poor nutrition, addiction (especially to sugar and/or flour), injury, exhaustion;
• Environmental stress, e.g., toxic chemicals in air, water, clothing or food;
• Emotional stress – usually arising from relationship, work or psychological sources.
  

Overlap with other hormone systems
Over 80% of people with adrenal dysregulation suffer from some type of decreased thyroid function. We often find that people who have both adrenal dysregulation and hypothyroidism do not get relief from thyroid replacement alone, and need adrenal support to get better. Dr. Marsha Nunley, MD, and Dr. Charlotte Massey, ND, L.Ac., are especially good at addressing both simultaneously. Dr. Nunley is available to coach patients who live outside of California, but you must visit her in Oakland to receive prescriptions.

Testing
We recommend saliva or blood testing to check your adrenal function. For your adrenal home test, order a diurnal cortisol test. Alternatively, ask your doctor to order a morning cortisol level in your blood. For your thyroid, we recommend TSH, free T3 and free T4 tests.

Weight Gain in PeriMenopause & PostMenopause

Good post on how estrogens, when they are reduced by perimenopause and menopause, lower your metabolic rate. Unfortunately, this can start at early as age 35-40. Welcome to Perimenopause, My Friends! But there are things we can do about it. Read on....

Question: Does exercise attenuate or prevent the weight gain that occurs during peri- and post-menopause?

Commentary from:
Wendy M. Kohrt, PhD
Professor of Medicine
University of Colorado, Denver
in Menopause E-consult by the North American Menopause Society

The short answer is, yes, exercise can attenuate
or prevent weight gain during peri- and
postmenopause. The prevention of weight gain
at any age requires only that energy intake not
exceed energy expenditure. Thus, it is possible
to maintain body weight by modifying exercise
and/or eating habits. However, although simple
in theory, there are physiologic changes that
make it particularly challenging for middle-aged
women to maintain energy balance (ie, intake =
expenditure). Because the menopause transition
occurs over a number of years, it is difficult to
determine whether the increased propensity for
weight gain at midlife is primarily a
consequence of the menopause transition or of
advancing age. Both involve factors that make
weight maintenance a challenge.

Menopause-related factors that promote weight
gain. Studies of laboratory animals provide
compelling evidence that estrogen plays an
important role in the regulation of body weight.
Oophorectomy has consistently been found to
cause excess weight gain, and this is prevented
by estrogen replacement.1 There appear to be
multiple mechanisms by which estrogen
deficiency leads to weight gain in animals,
including increased food intake, decreased
spontaneous physical activity, and a suppression
of metabolic rate. If such effects of estrogen
deficiency also occur in humans, this would
suggest that there is a “biological drive” around
the time of menopause toward weight gain.

In fact, there is evidence that estrogen regulates
body weight in women. A number of large,
randomized, placebo-controlled, and open-label
trials of estrogen-based hormone therapy (HT)
have provided strong evidence that weight gain
and, more specifically, fat gain, is attenuated in
women on HT when compared to women on
placebo or no HT.2 Suppressing sex hormone
levels in premenopausal women with
gonadotropin-releasing hormone (GnRH)
agonist therapy also causes fat gain. For
example, women treated for 16 weeks with a
GnRH agonist gained 1.0 kg of fat, which
equates to an energy excess of about 80 kcal per
day.3 Because it is difficult to accurately
measure changes in energy intake and
expenditure of this magnitude in humans, it is
not clear whether the suppression of sex 2
hormones influences eating and/or exercise
habits. However, short-term hormone
suppression has been found to cause a decrease
in resting metabolic rate of 40 to 70 kcal per
day.4 This reduction in metabolic rate would be
expected to cause weight gain if not
accompanied by a compensatory decrease in
energy intake or increase in physical activity.

Aging-related factors that promote weight gain.
Even if the menopause transition does not alter
bioenergetics in a way that promotes weight
gain, there are unavoidable factors related to
aging that do so. Two important factors are the
loss of muscle mass and the decline in maximal
aerobic power. Lean body mass is an important
determinant of resting metabolic rate. As lean
mass declines with aging, there is a decrease in
metabolic rate and, therefore, daily energy
expenditure. The decline in metabolic rate will
result in weight gain unless appropriate
behavioral changes are adopted (ie, decrease in
energy intake or increase in physical activity).

Maximal aerobic power, also referred to as
aerobic capacity or VO2 max, is a direct index of
the rate at which an individual can expend
energy during exercise. For example, a healthy
young woman with an average VO2 max for her
age can easily increase her energy expenditure
by 8 to 10 kcal per minute during exercise.
However, there is a decline in VO2 max with
aging that cannot be avoided, due in part to the
inevitable decrease in maximal heart rate (ie,
maximal heart rate = 220 minus age).
Accordingly, with advancing age there is a
decline in the rate at which energy can be
expended during exercise, even in people who
maintain a vigorous level of physical activity.5
Rather than being able to increase energy
expenditure by 8 to 10 kcal per minute during
exercise, middle-aged women may be able to
burn only 6 to 8 kcal per minute. This has an
important impact on how women can use
exercise to maintain body weight as they age.
Because the rate at which energy can be
expended decreases gradually with aging,
maintaining the same level of total exercise
energy expenditure may require an increase in
the amount of exercise time.
Do physically active women gain less weight
than sedentary women during peri- and
postmenopause? Exercise can prevent weight
gain in peri- and postmenopausal women, but
factors related to menopause and aging make
weight maintenance a challenge. Even though
regular exercise does not come with a guarantee
against weight gain, prospective studies of
perimenopausal women indicate that the most
active women gain the least weight.6,7 Most
important, women should not abandon their
exercise habits if they become discouraged by
what they perceive as a lack of effectiveness of
exercise to prevent weight gain. Exercise has
numerous health benefits that are independent of
its effects on body weight regulation.8

Disclosure: Dr. Kohrt reports: Research support—
National Institutes of Health.

References:
1. Shi H, Clegg DJ. Sex differences in the regulation of
body weight. Physiol Behav 2009 Feb 27. [Epub ahead of
print]
2. Lobo RA. Metabolic syndrome after menopause and
the role of hormones. Maturitas 2008;60:10-18.
3. Yamasaki H, Douchi T, Yamamoto S, Oki T,
Kuwahata R, Nagata Y. Body fat distribution and body
composition during GnRH agonist therapy. Obstet
Gynecol 2001;97:338-342.
4. Day DS, Gozansky WS, Van Pelt RE, Schwartz RS,
Kohrt WM. Sex hormone suppression reduces resting
energy expenditure and beta-adrenergic support of resting
energy expenditure. J Clin Endocrinol Metab 2005;90:
3312-3317.
5. Hawkins SA, Marcell TJ, Victoria JS, Wiswell RA.
A longitudinal assessment of change in VO2 max and
maximal heart rate in master athletes. Med Sci Sports
Exerc 2001;33:1744-1750.
6. Sternfeld B, Wang H, Quesenberry CP Jr, et al.
Physical activity and changes in weight and waist
circumference in midlife women: findings from the Study
of Women’s Health Across the Nation. Am J Epidemiol
2004;160:912-922.
7. Macdonald HM, New SA, Campbell MK, Reid DM.
Longitudinal changes in weight in perimenopausal and
early postmenopausal women: effects of dietary energy
intake, energy expenditure, dietary calcium intake and
hormone replacement therapy. Int J Obes Relat Metab
Disord 2003;27:669-676.
8. Haskell WL, Lee IM, Pate RR, et al. Physical activity
and public health: updated recommendation for adults
from the American College of Sports Medicine and the
American Heart Association. Circulation 2007;116:1081-
1093.

Vulvodynia: Natural Approaches

This is a great intro to vulvodynia, which is a common syndrome affecting up to 15% of women and causing pain, burning or irritation of the vulva. Tori Hudson did a fine job in this essay, and rather than re-invent the wheel, I thought I'd post her work. -- SG

Vulvodynia: Diagnosis and Treatment

by Tori Hudson, ND

Vulvodynia or vulvar pain syndrome is a multifactoral clinical syndrome of vulvar pain, sexual dysfunction, and psychological distress. Recognizing the four specific subtypes of vulvodynia is important in the management approach. The most common four subtypes are vulvar vestibulitis syndrome, cyclic vulvovaginitis, dysesthetic vulvodynia, and vulvar dermatoses. Simple clinical guidelines can be developed to improve the evaluation and treatment of these often long-suffering patients.

Vulvodynia is different from itching or vulvar pruritus. Vulvodynia actually precludes itching because the burning and pain cause an intolerance to scratching. Over the years, the terminology used to describe vulvodynia has varied. The term vulvodynia has now been recommended by the International Society for the Study of Vulvar Disease (ISSVD) to describe any vulvar pain, regardless of etiology.

Vulvar pain usually has an acute onset. The onset can be associated with vaginitis (yeast, bacterial), changes in sexual activity (new sexual partner), or medical procedures on the vulva (cryotherapy, laser). In most cases, the vulvar pain then becomes a chronic problem varying in length from months to years. The intensity of the pain can vary from mild to disabling. It can be burning, stinging, irritating or raw. Most women with vulvodynia have been to many physicians either with inaccurate diagnoses or unsatisfactory treatment. Many women have been left feeling especially frustrated and at times mistreated because they have been told that their problem is purely psychological and there is nothing physically wrong with them. Because of the dramatic impact on their lives these women continue to seek help, and can become increasingly fearful and anxious about cancer or sexually transmitted diseases.

The incidence of vulvodynia is not known but it is clearly more common than is generally thought. In a general gynecological practice the prevalence can be as high as 15% when actively looked for.1 Characteristics of the patients with vulvodynia are nonspecific. The age distribution ranges from mid-20s to late 60s. Their Ob/Gyn history is unremarkable. They generally do not have other chronic health problems, and rarely have a history of sexually transmitted diseases. Sexual promiscuity is generally not a factor in these cases. Often, women with vulvodynia do report depression, but it is just as easily a result of the condition as it is a cause.

The pain reported can be in the general vulvar area, but is typically located in the vulvar vestibulum. The vestibule comprises the area between the labia minora and the hymenal ring, anteriorly from the frenulum of the clitoris, and posteriorly from the fourchette to the vaginal introitus. The urethra, Skenes glands, Bartholins glands and the minor vestibular glands are all located in the vulvar vestibule.

Only minimal findings are detected on the physical examination and most of the time there are not physical findings at all. The cotton tip applicator is used to determine the location of the pain. Touching the vestibulum lightly with a moist cotton-tipped swab reveals a sharp pain most often in the posterior vestibule, anterior vestibule or both. Occasionally red spots of inflammation can be detected at 5 oclock and 7 oclock or in a U-shaped area at the posterior fourchette.

Classification of Vulvodynia
Vulvar Dermatoses
Vulvar dermatoses can often cause both itching or pain and can be acute or chronic. Dermatoses are also dissimilar to other causes of vulvodynia because there can be physical signs of erythema, erosion or blisters. A partial list of vulvar dermatoses includes psoriasis, seborrheic dermatitis, tinea cruris, contact dermatitis, lichen simplex chronicus, lichen planus, lichen sclerosus, pemphigus, and erythema multiforme. Many dermatoses can be difficult to diagnose and may require a biopsy for a definitive diagnosis.

Cyclic Vulvovaginitis

Cyclic vulvovaginitis (CVV) is probably the most common cause of vulvodynia. The pain is typically cyclic and specifically worse during the luteal phase of the cycle. Symptoms are characteristically aggravated by vaginal sexual activity with the pain being usually worse the next day.2,3 CVV is thought to be caused by a hypersensitivity reaction to Candida antigen. If Candida cannot be detected during the symptomatic phase by culture, due to the bodys immune response, then culture specimens during an asymptomatic phase.

Conventional treatments include antimycotics for temporary relief, but symptoms recur soon after the treatment. Boric acid suppositories twice daily for 4 weeks and then once per day for 5 days during the menses only, for 4 more months is generally more successful for chronic yeast vaginitis than conventional antifungal agents. Boric acid suppositories were effective in curing 98% of the patients who had previously failed to respond to the most commonly used antifungal agents.4 However, many women do not tolerate the boric acid that leaks out of the vagina and further irritates the tissue. Lanolin or vitamin E oil or petroleum jelly or some other ointment (calendula) can be used to coat the vulvar tissue at the posterior fourchette where the irritation would be greatest. Other alternative treatments include local treatments such as lactobacillus suppositories, tea tree suppositories, garlic suppositories, herbal combination suppositories or douches (berberis hydrastis, usnea); systemic immune support (A, C, E, Zn, Glycyrrhiza glabra, Allium sativum, Hydrastis canadensis). Swabbing the vagina with genitian violet has been a longstanding specific treatment for candida, as has iodine douching (one part iodine in 100 parts water, twice daily for 14 days). Reinoculation from the anus requires attention to hygiene and possibly an approach that also addresses the gastrointestinal tract. Dietary considerations include a diet low in simple carbohydrates and refined foods, low in alcohol, and low in fats.

Vulvar Vestibulitis Syndrome
Vulvar vestibulitis syndrome (VVS) is characterized by dyspareunia, severe point tenderness on touch (positive cotton swab test), and erythema. The etiology of VVS is unknown. Some cases are aggravated by yeast vaginitis. Other suspected causes include chemical sensitivities, other irritants, a history of laser or cryotherapy, and allergic drug reactions. Some studies have suggested that VVS may be associated with human papillomavirus (HPV).5,6

Treatment of VVS is difficult and can require great patience and persistence on the part of both patient and practitioner. Conventional treatment is often fraught with overtreatment using antimicrobials and destructive or ablative therapies for suspected HPV. Conventional treatment can escalate to include interferon injections and vestibulectomy for severe incapacitating cases. The most promising alternative treatment that I have experienced in my practice is the use of calcium citrate. In patients whose urine shows evidence of excess oxalate, epithelial reactions similar to those found in vulvodynia are observed. Women have periodic hyperoxaluria and pH elevations related to the symptoms of vulvar pain. 1000mg of calcium citrate daily, in divided doses, is given to modify the oxalate crystalluria. A low oxalate diet is an additional cornerstone to managing these cases.7

In addition, I can cite cases in my private practice where an eclectic treatment plan of a topical ointment (vitamin A, tincture of thuja and lomatium isolate), oral beta carotene (75,000IU to 150,000/day), eliminating food intolerances, and a constitutional homeopathic remedy, have yielded anywhere from 50% improvement to 100% improvement. Unfortunately, I can also cite cases where there was only minimal improvement. I have heard anecdotal reports using elaborate chemical desensitizing methods and dramatic improvements, but I have not personally investigated these cases. Psychological intervention must always be considered for assistance in dealing with the illness, and perhaps therapeutic intervention can then allow the immune system to adequately address the chronic syndrome.

Dysesthetic Vulvodynia
This subtype of vulvodynia is more common among older women who are either perimenopausal or postmenopausal. Patients have constant noncyclic vulvar or perineal discomfort. These women have less dyspareunia and less point tenderness than the women with VVS. No significant changes are observed on the physical examination except diffuse hyperaesthesia which occurs on a wider area compared to VVS. Sharp pain can also be elicited with light touch. The hyperaesthesia is thought to be a result of an altered sense of cutaneous perception. A neurological basis is probably the explanation for the nonspecific burning. The sensation mimics the neuralgia associated with herpes. Urethral or rectal discomfort is often associated with their vulvar pain.

Conventional medicine often prescribes tricyclic antidepressants8 for dysesthetic vulvodynia. Side effects are a common problem with tricyclics, and occur in up to half of the patients. Theoretical nutritional and botanical alternatives for dysesthetic vulvodynia include Folic acid, B12, Piper methysticum (kava-kava), Ginkgo biloba, Hypericum perforatum (St. Johns Wort).

Physical Therapy for Vulvar Pain
The use of physical therapy to relieve vulvar pain should not be overlooked. Spasm of the inner thigh muscles or hip muscles can be a result of guarding against the pain of weight resting directly on vulvar skin while sitting. There are specific devices for removing pressure from the vulvar area when sitting. Manual therapy techniques can also be used to relieve pain by releasing severe muscle spasms. Trigger points in the pelvic floor muscles from fibromyalgia can refer pain to the vulvar skin and the vagina. Trigger point therapy and pelvic floor muscle strengthening and relaxation can also relieve pelvic floor muscle spasms.

Vulvar pain syndromes provoke psychological as well as physical distress. Sexual relationships become seriously strained in women with vulvodynia. Women tend to feel defective, less womanly, less sexually attractive ashamed and embarrassed. Dealing with spouses and partners who are having difficulty coping is an additional stress. Anxiety and depression set in with unsatisfactory visits to their health care practitioners and unsatisfactory results. Hopelessness can become the greater illness but practitioners should be cautioned against being overly optimistic in encouraging them to try another promising treatment. If it fails, it further escalates the hopelessness.

Knowledge of the specific subsets of vulvodynia is extremely important in improving the diagnosis and treatment of this complex multifactoral syndrome. Simple guidelines and recommendations augment the evaluation and management.9

Rule out underlying problems
Biopsy suspicious lesions
Do not overlook cervix
Use a multidisciplinary approach
Differential diagnosis of vulvar dermatoses
Differential diagnosis of vulvar erosions
Provide empathy and support
Educate the patient in their understanding of the problem
Help the patient to cope with the problem
Inform them that symptoms fluctuate
Best questions to be asked
Are there any days without burning?
Is the pain related to menses?
How is the pain associated with vaginal penetration?
Set simple goals
Less bad days, more good days
Getting better takes some time
Coach them to stick with the treatment

References

1. Goetsch MF. Vulvar vestibulitis: Prevalence and historic features in a general gynecologic practice population. Am J Obstet Gynecol 1991; 164:1609-16.

2. McKay M. Vulvodynia: a multifactorial clinical problem. Arch Dermatol 1989; 125.

3. McKay M. Subsets of vulvodynia. J Reprod Med 1988; 33:695-8.

4. Jovanovic R, Congema E, Nguyen H. Antifungal Agents vs. Boric Acid for Treating Chronic Mycotic Vulvovaginitis J Reprod Med 199;36:593-597.

5. Turner MLC, Marinoff SC. Association of human papillomavirus with vulvodynia and the vulvar vestibulitis syndrome. J Reprod Med 1988; 33:533-7.

6. Umpierre SA, Kaufman RH, Adam E, Woods KV, Adler-Storz K. Human papillomavirus DNA in tissue biopsy specimens of vulvar vestibulitis patients treated with interferon. Obstet Gynecol 1991; 78:693-5.

7. Sollomons C, Melmed M, Heitler S. Calcium Citrate for Vulvar Vestibulitis. J Reprod Med 1991; 36:879-882.

8. McKay M. Dysesthetic (essential) vulvodynia. Treatment with amitriptyline. J Reprod Med 1993; 38:9-13.

9. Paavonen J. Diagnosis and Treatment of Vulvodynia. Ann Med 27:175-181, 1995. Resources The Vulvar Pain Foundation, P.O. Drawer 177, Graham, North Carolina 27253; 910-226-0704.