The debate about the role of oral contraceptive pills (OCPs) in vulvodynia has been underway for almost two decades. More than a dozen different research articles have been written on the topic, both supporting and refuting the association.
The vulva and vagina can be thought of as three separate and distinct organs due to their embryological (prenatal) development. Very early after conception the cells divide into three tissue types- ectoderm, endoderm, and mesoderm. The ectoderm forms the tissue of the outer vulva, which includes the labia majora, the interlabial sulcus, the outer labia minora, the hood of the clitoris, the clitoris, and the perineum. The vulvar vestibule, which starts at Hart’s line on the inner aspect of the labia minora and extends to just inside the hymen, is derived from the endoderm. The vagina is mostly comprised from tissue coming from cells of medodermal origin. Because these tissues are derived from three different origins, it is logical they would respond differently to different hormonal states (such as too much, too little, or an imbalance in hormones) and to specific insults such as infections, allergic reactions, chemical irritation, and trauma. A recent study presented by the International Society for the Study of Women’s Sexual Health (ISSWSH) Annual Meeting showed that more than 90% of women with vulvodynia have pain confined to the tissue of the vulvar vestibule, and not the outside vestibule or inside the vagina. The historical name for this pain, vulvar vestibulitis, has been more recently discarded, as we now understand that there are several causes of this localized pain, and most of them are not due to inflammation- an “itis.” The new name “vestibulodynia” is a more inclusive term, literally meaning and abnormal pain sensation confined to the vestibule but it still does not address the issue of the cause or causes of the pain.
Almost all OCPS that are currently being used contain a combination of two synthetic hormones, a synthetic estrogen, and a synthetic progesterone (a progestin). All pills contain the same synthetic estrogen- Ethinyl Estradiol (EE). The primary ways in which the dozens of brands of OCPs differ is that they contain varying types of progestins, and have variable amounts of EE. The OCPs that have come to market in the last 15 years typically contain “3rd generation” progestin such as desogestrol, norgestimate, and drosperinone. In fact, OCPs containing drosperinone became so popular after the turn of the century that they comprised more than 40% of all OCPs prescribed in the United States. In addition, there has been a trend toward lower doses of EE. While any pill that contains 35 micrograms of EE is considered a low dose OCP, recent pills contain as little as 10 micrograms of EE. While this may seem like a good idea, we will soon discuss how OCPs with lower doses of EE and the progestin drosperinone significantly increase the risk of developing vestibulodynia. However, first we In a prospective study, Bazin et al. showed that women who started taking OCPs before that age of seventeen were 11 times (1100%) more likely to develop vestibulodynia in comparison to women who had never taken OCPs.4 In addition, a study by Bouchard and colleagues in Quebec showed that women who were examined in a vulvar specialty clinic and who were found to have vestibulodynia were 9.6 times (960%) more likely to develop vestibulodynia if they started OCPs prior to the age of 16, and showed an increasing risk of developing vestibulodynia with longer durations of OCP use.5
In addition, we recently published in Sexual Medicine a case series of 50 consecutive women who developed vestibulodynia while taking OCPs.6 Women with other potential identifiable causes of vulvodynia, such as tight pelvic floor muscles or pudendal nerve injury were excluded from this study. The women were treated by having them stop OCPs and by applying a compound that contained topical estrogen and testosterone to the vestibule. On average their vestibular pain dropped from 7.5 to 2 on a ten-point pain scale after three months of treatment. Although this was not a placebo controlled study, the results are so compelling that it is our opinion that women who developed vestibulodynia while taking OCPs should consider this treatment approach as first line treatment.
In addition, is it common practice, even among physicians, to consider all forms of OCPs as simply the “The Pill.” However, as discussed previously OCPs are a vastly heterogeneous group of medications with different synthetic hormonal components in different dosages. Therefore, in investigating the relationship between vulvodynia and OCP use, it is crucial to distinguish between pill types in order to not miss important associations. While Reed and colleagues did not differentiate between pill types in their study, Greenstein and colleagues showed that women taking OCPs containing only 20 micrograms of EE were more likely to develop vestibulodynia than women taking OCPs with higher doses of EE.
For the full article please go to: http://www.pelvicpain.org/Professional/Blog/IPPS-Blog/June-2014/Do-Oral-Contraceptive-Pills-Cause-Vulvodynia-Time.aspx#.U5YZyGJCZ4c.mailto
1 Battaglia C, Battaglia B, Mancini F, et al. Sexual behavior and oral contraception: a pilot study. J Sex Med 2012;9:550-7.
2 Johannesson U, Blomgren B, Hilliges M, Rylander E, Bohm-Starke N. The vulval vestibular mucosa-morphological effects of oral contraceptives and menstrual cycle. Br J Dermatol 2007;157:487-93.
3 Bohm-Starke N, Johannesson U, Hilliges M, Rylander E, Torebjork E. Decreased mechanical pain threshold in the vestibular mucosa of women using oral contraceptives: a contributing factor in vulvar vestibulitis? J Reprod Med 2004;49:888-92.
4 Bazin S, Bouchard C, Brisson J, Morin C, Meisels A, Fortier M. Vulvar vestibulitis syndrome: an exploratory case-control study. Obstet Gynecol 1994;83:47-50.
5 Bouchard C, Brisson J, Fortier M, Morin C, Blanchette C. Use of oral contraceptive pills and vulvar vestibulitis: a case-control study. Am J Epidemiol 2002;156:254-61.
6 Burrows LJ GA. The treatment of vestibulodynia with topical estradiol and testosterone. Sex Med 2013;1:30-3.
7 Reed B, Harlow S, Legocki L, et al. Oral contraceptive use and risk of vulvodynia: a population-based longitudinal study. BJOG 2013.
8 Greenstein A, Ben-Aroya Z, Fass O, et al. Vulvar vestibulitis syndrome and estrogen dose of oral contraceptive pills. J Sex Med 2007;4:1679-83.
Lisa Edwards, MOTR/L, BSRS