Western Diagnosis: vulvar vestibulitis
Medical History: My patient has had the condition for 7 years. It first started as pain only on intercourse, then 2 years ago it became pain on arousal, and when she first came to see me there was constant pain. She is 28 years old, married, and a final year law student. The pain is predominantly on the right side of the vulva, it is a sharp pain that occurs with skin redness and inflammation, after the menses the pain will occur with itching. She is unable to have intercourse but the pain that is experienced constantly is a 6/10. The vaginismus only occurs on intercourse, but because the pain is so intense on arousal, it is not the immediate concern.
Previous Treatments Laser surgery which was unsuccessful, immediately after the surgery there was some loss of sensitivity and then the pain sensation returned. Topical cortisone. Antidepressants amitriptiline 150 mg/day, no change in pain but constipation, dry mouth, insomnia, weight gain. Biofeedback 6-7 months, no effect Next suggested treatment, surgery moon shape cut to remove inflamed tissue
Energy: 6/10, could be better Sleep: 7 1/2 hours, would prefer to sleep 9-10, fall asleep easily, 2 times a week wake up during the night, over thinking, one time nocturia commonly has night-frights always associated with fear, running away
Emotional: erratic tend to worry, low self esteem, tend to keep emotions in, has a tendency to be irritable with a short temper, and then times of melancholy. Stress- medium, many exams, pressure to find a job.
Appetite: eat often, small meals, crave sweet, sometimes salty, well balanced, quite a bit of dairy, enjoy spicy foods and coffee every day.
Digestion: good except diarrhea 1/week no pain, but urgency, strong odour.
Thirst: yes enjoy cold temperature
Urinate: 12 times a day short stream, medium yellow, no odor sometimes burning sensation on urination washes with baking soda,
Body temperature: very cold hands and feet Pains: headache occur on vertex slight throbbing, no vision is affected.
low back pain: flares up, dull weakness, with radiating pain
Menses: on birth control pill, Triphasil regular 28 day cycle, 8 years ago ovarian cysts now undetectable, when off bcp, severe cramps, heavy long menses (10 days).
menses started at 13 yrs, on bcp for 8 years, no pain at beginning of menses, but flow is very heavy with very big clots, dark in color. discharge: thick opaque, whitish yellow
PMS: tend to be overly sensitive Experiences tightness in chest, ache deep
Skin: very dry, dandruff, previous problem with eczema
Pulse exam: Pulse: slippery, thready with a very weak kidney pulse on the left
Tongue exam: tongue: very red swollen sides, thick yellow coat on middle to root, no coat on sides, veins swollen
OM Diagnosis: Damp heat in the liver meridian, with an underlying qi and blood deficiency, kidney deficiency due to the chronic condition
Treatment Principle: Treatment: Even though the pulse was weak I used an aggressive treatment protocol, to drain the liver and relieve the pain.
Point Prescription: Stage 1: Combination of points: liv-3, li-4, sp-6, sp-10, sp-9, gb-34, rn-2, rn-4, li-11, rn-9, liv-2
The pain went to 3/10, but the discharge was worse I added gb-26, du-20. st-36
Stage 2:kid-3, liv-5, liv-8
stage three using the extroadinary vessels balancing right lu-7, left kid-6. right gb-41, left sj-5, and mostly tonifying points, du-20, st-36, liv-3, li-4, sp-6, rn-6, rn-4, kid-3
Stage 1: Long dan xie gan tang internally external wash of kushen, huang bai, huang lian, lian qiao, chi shao yao, dan shen, jin yin hua, mao she xiang
Stage 2: Formula Dan zhi xiao yao san ovulation to menses and liu wei di huang wan for 2 weeks after
Lifestyle Prescription: The patient eliminated dairy, sugar, coffee, and ate spicy foods in moderation Patient went off BCP Patient is practicing meditation
Results: The results were slow even considering how long the patient had the condition. She feels emotionally balanced, menses is regular off the bcp and comes so smoothly it is usually a surprise, the irregular bowel mvts have subsided, the headaches occur rarely usually at times of extreme stress. The day to day pain is 0/10. But the intensity of the pain on arousal is still there, and the strong desire to have a normal marriage and sex life is causing my patient frustration. The progress is now at a standstill. It has been 5 months.
Synopsis: I feel we have treated quite successfully with TCM but I now referred the patient out for counseling to address the psychological component.