Enhancement of the perception of systemic pain in women with vulvar vestibulitis Michal Granot a,b,c,d , Michael Friedman c,d , David Yarnitsky b,d , Etan Z. Zimmer c,d, * Objective The aim of this study was to determine whether the characteristics of systemic pain perception and anxiety differ between women with vulvar vestibulitis and healthy women. Design Case control study. Setting Tertiary care hospital. Population Forty-four women with vulvar vestibulitis and 41 healthy women participated in the study. Methods First, the women’s state and trait anxiety was evaluated. Thereafter, heat pain stimuli were applied to the women’s forearm and the pain and unpleasantness thresholds, as well as magnitude estimation of perceived intensity and unpleasantness of suprathreshold stimuli, were assessed. Finally, blood pressure was measured before, during and after a heat stimulus of 46jC. Main outcome measures Pain threshold and suprathreshold, and anxiety levels of women with vulvar vestibulitis. Results Women with vulvar vestibulitis had a higher anxiety state (40.0 [12.8] vs 34.1 [10.8], P ¼ 0.044), a higher anxiety trait (42.1 [10.2] vs 35.6 [7.5], P ¼ 0.005), a lower pain threshold (42.2jC [2.5] vs 43.6jC [1.9], P ¼ 0.006), a lower unpleasantness threshold (40.2jC [2.9] vs 41.7jC [2.3], P ¼ 0.023), a higher magnitude estimation of suprathreshold pain at 47jC (88.3 [14.9] vs 70.8 [14.9], P ¼ 0.0001) and at 48jC (96.1 [7.3] vs 84.6 [14.8], P < 0.0001), a higher scoring of tonic pain perception (65.2 [17.3] vs 53.0 [18.6], P ¼ 0.006) and a higher increase in systolic blood pressure during tonic pain stimuli (4.6 [9.6] vs 2.1 [8.7] mmHg, P ¼ 0.005). Conclusion Women with vulvar vestibulitis have an enhanced systemic pain perception and are more anxious. INTRODUCTION Vulvar vestibulitis syndrome (VVS) is characterised by severe pain on vestibular touch or attempted vaginal entry, tenderness in response to pressure localised within the vulvar vestibule and physical findings confined to vestibu- lar erythema of various degrees 1 . The aetiology of this chronic pain syndrome is still obscure. Various underlying disorders have been suggested such as infectious diseases (candida, trichomonas, bacterial vaginosis or papillomavirus), down-regulation of pro- inflammatory immune responses, altered vaginal acid – base balance, allergic reaction to various chemicals or psycho- sexual disorders 2–7 . In the absence of a clear underlying mechanism and facing failure of response to local treatments in some patients, it is possible that vulvar vestibulitis actually represents a generalised pain disorder and not only a local genital pathology 6,8 – 10 . The present study was con- ducted in order to determine if there is an alteration of pain perception at an extra genital site in women with VVS. Characteristics of systemic pain perception and autonomic nervous system response to painful stimuli were evaluated in these patients and were compared with healthy controls. The anxiety level was also evaluated because of the pos- sible association of pain syndromes and anxiety disorders. METHODS The study was performed during a six-month period and included Caucasian women from the clinic for vulvovaginal disorders who had a confirmed diagnosis of VVS according to the criteria of Friedrich 1 . Healthy employees and students from the Faculty of Health Science who had no gynaeco- logic complaints served as a control group. Women with a systemic disease or hormonal disorders were excluded from the study. The study was approved by the Rambam Medical Center Review Board in accordance with the Helsinki BJOG: an International Journal of Obstetrics and Gynaecology August 2002, Vol. 109, pp. 863–866 D RCOG 2002 BJOG: an International Journal of Obstetrics and Gynaecology PII:S1470-0328(02)01416-7 www.bjog-elsevier.com a Faculty of Health and Welfare Studies, University of Haifa, Haifa, Israel b Department of Neurology, Rambam Medical Center, Haifa, Israel c Department of Obstetrics and Gynecology, Rambam Medical Center, Haifa, Israel d Technion Faculty of Medicine, Haifa, Israel * Correspondence: Dr E. Z. Zimmer, Department of Obstetrics and Gynecology, Rambam Medical Center, Haifa 31096, Israel.