Why does a postmenopausal woman have vulvar pain at age 58?

Question

Hello doctor,

I went to a primary doctor about two months ago. They said there was no urinary tract infection, but suggested trying Estradiol vaginal cream. The cream caused severe burning, so I was referred to a gynecologist. The gynecologist advised using the cream once a week, but it still burned. I then visited a urologist about three weeks ago, who performed a culture test and a CT scan and prescribed antibiotics about a week later. I have been off the cream for about a month.

I had been taking Macrobid for over ten years to prevent urinary tract infections and usually had about one infection a year. I typically took it after intercourse. I am 58 years old and postmenopausal.

Usually, I take Macrobid, but I had not taken any for about a month, and my burning mouth, which I have had for three years, improved. When I took one dose for a suspected urinary tract infection, the burning mouth returned, so the doctor changed the medication to Cipro. After four pills, I developed pins and needles and stopped it, then completed treatment with Keflex.

Tests done include yeast testing, bacterial vaginosis testing, urine culture, and a CT scan. One urine culture showed Escherichia coli, and another was negative.

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I have gone through your query and understand your concern.

Your symptoms are most consistent with vulvodynia (a type of long-term pain or discomfort around the outer part of the female genitals), specifically genitourinary syndrome of menopause (postmenopausal vulvovaginal atrophy) with nerve irritation.

Several clues in your history point toward vulvar nerve irritation rather than an active UTI (urinary tract infection):

Burning, raw, pins and needles feeling in the vulva or perineum.
Clitoral swelling and sensitivity.
Pain when sitting.
Symptoms started after using estradiol cream.
Negative urine culture from one test.
A long history of antibiotics (Macrobid, Cipro, Keflex), which can irritate tissues and alter vaginal flora.
Burning mouth syndrome, which is sometimes associated with nerve hypersensitivity conditions.

In genitourinary syndrome of menopause, the vulvar and vaginal tissues become thin, dry, and extremely sensitive after menopause due to low estrogen. When irritated by medications, infections, or creams, this can trigger chronic vulvar pain (vulvodynia). Other conditions doctors might consider

Contact dermatitis (irritation from estradiol cream or hygiene products).
Vulvar neuropathy (nerve hypersensitivity after inflammation).
Recurrent urinary tract infection, but your symptoms now sound more external than urinary.

These steps are commonly recommended for vulvar irritation:

Calm the irritated tissue by stopping all creams temporarily unless prescribed, using plain petroleum jelly or zinc barrier ointment, wearing loose cotton underwear, and avoiding soaps, wipes, fragrances, and hot baths
Reduce nerve irritation by doing sitz baths with lukewarm water, cool compresses for burning, and sometimes doctors prescribe gabapentin cream or oral nerve medications.
Re-evaluate estrogen therapy. Some people cannot tolerate estradiol cream. Alternatives include lower dose formulations, vaginal tablets or rings, and non-hormonal vaginal moisturizers.
See a specialist if symptoms persist. A urogynecologist or vulvar pain specialist can evaluate for vulvodynia or nerve pain. Get checked sooner if you develop:

Fever.
Worsening pelvic pain.
Blood in urine.
Spreading rash or sores.

Your symptoms sound less like an ongoing UTI and more like postmenopausal vulvar nerve irritation and tissue sensitivity, possibly triggered by the estradiol cream and repeated antibiotics.

I hope I have answered your question.

Let me know if I can assist you further.

Thank you.