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Vulvodynia

Chronic vulvar pain lasting 3+ months without an identifiable cause, reported by 7 to 16% of women at some point in population surveys1. Long dismissed as "in your head," now understood as a real neuro-immune-pelvic floor2 disorder, diagnosed only after other causes of vulvar pain are ruled out3.

Hormonal & Women's Health Evidence-Based

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Definition

What Is Vulvodynia?

Vulvodynia is chronic vulvar pain or discomfort (burning, stinging, rawness or stabbing) lasting at least 3 months, with no identifiable infectious, inflammatory, neoplastic or hormonal cause on standard workup.

The 2015 ISSVD, ISSWSH and IPPS consensus terminology defines vulvodynia as pain of the vulva that is idiopathic by definition, meaning every visible cause must be ruled out first. Proposed contributors include nerve changes, pelvic floor dysfunction, hormonal factors, inflammation and previous infection, and the cause is very likely multifactorial3.

Vulvodynia is sub-classified by location, timing and trigger pattern. The subtype identifies the treatment focus:

A front view of the vulva with the vestibule and the nerves around it marked, under the words chronic vulvar pain
๐Ÿ’ก Vulvodynia is a diagnosis of exclusion: infection, skin conditions such as lichen sclerosus, and other causes are ruled out first, and a woman can have one of those and vulvodynia too3. The American College of Obstetricians and Gynecologists advises an individualized, multidisciplinary approach3.

Provoked Vestibulodynia (PVD), most common

Sharp, burning pain localized to the vestibule (the area just inside the labia minora at the vaginal opening), triggered only by touch, tampon insertion, penetration, gynecologic exam or tight clothing.

  • โ†’Hallmarks: Provoked, localized, pain-free at baseline, positive cotton-swab test at the vestibule
  • โ†’Subtypes: Primary (since first sexual experience) vs Secondary (after a period of pain-free function)

Generalized Vulvodynia (GVD)

Diffuse, often unprovoked4 burning, rawness or aching of the entire vulvar area, sometimes including the perineum and inner thighs. Pain is often constant or near-constant, present even without touch.

  • โ†’Hallmarks: Diffuse, often unprovoked, "always there," waxing and waning intensity
  • โ†’Watch-out: Often co-occurs with other central sensitization conditions (interstitial cystitis, IBS, fibromyalgia)

Mixed Vulvodynia

Combination of localized provoked symptoms and a baseline of generalized burning or rawness.

  • โ†’Hallmarks: Both spot-pain at the vestibule and background burning across the whole vulva

Hormone-Related / Atrophic Vulvar Pain (Not Vulvodynia, Often Confused With It)

Burning, dryness and rawness driven by low estrogen at the vulvar tissue, common in postmenopause, postpartum, breastfeeding and after years of hormonal contraceptives. The 2015 terminology classes pain from hormonal deficiency, such as vulvovaginal atrophy after menopause or during breastfeeding, as pain with a specific cause rather than vulvodynia, and it is treated as such3.

  • โ†’Hallmarks: Burning + dryness + thinning/pale vestibular tissue on exam; often onset around hormone change
  • โ†’Watch-out: Postpartum forms and those linked to birth control pills (OCPs) often improve with hormone restoration5
By the Numbers

Vulvodynia by the Numbers

7 to 16%
of women report vulvar pain consistent with vulvodynia at some point, in large US population surveys1
60%
of women who sought care for chronic vulvar pain saw 3 or more doctors, and nearly 40% never sought treatment1
3 months
of vulvar pain with no identifiable cause is the threshold for the diagnosis, once other causes are excluded3
79%
felt much or very much improved after 10 weeks of physical therapy, against 39% with a topical anesthetic, in a trial of 212 women with provoked vestibulodynia6
~50%
remitted without relapse in a population study of women screening positive; about 40% relapsed after remission and about 10% had persistent pain7
60 to 90%
reported success rates for vestibulectomy, an operation kept for pain confined to the vestibule after other treatments fail; studies define success differently3
Signs & Symptoms

Symptoms of Vulvodynia

Vulvodynia presents as a pattern of vulvar sensory abnormalities plus the downstream consequences on pelvic floor, intimacy, mood and quality of life.

SymptomWhat happens
Vulvar & Sensory Symptoms
Burning Sensation at the VulvaThe hallmark symptom. Worse after sitting, exercise or fitted clothing.
Sharp Stabbing or "Knife" Pain on TouchIn provoked vestibulodynia, light contact (a cotton swab, a finger, a tampon, a speculum) triggers a sudden, sharp, knife-like pain at specific points around the vestibule. Pain is often greater than the stimulus would predict (allodynia, the hallmark of nerve sensitization).
Rawness or "Open Wound" SensationA constant feeling of being chafed or worn, as if the tissue is irritated even when no contact is happening. Examination usually shows normal-appearing tissue, a key clue.
Itching, Tingling & Pins-and-NeedlesNon-burning sensory abnormalities, itching that does not respond to antifungals, tingling, "crawling skin" and electric-shock sensations are common, especially in generalized vulvodynia.
Pain with Sitting or Tight ClothingMany women report needing to sit on a special cushion, avoiding jeans and avoiding certain chairs at work.
Dyspareunia (Painful Sex)Provoked vulvodynia often makes vaginal penetration impossible or excruciating.
Pelvic Floor, Systemic & Quality-of-Life Symptoms
Pelvic Floor Muscle Tightness & SpasmOveractive, guarded pelvic floor muscles are common, particularly in provoked vestibulodynia2. The muscle tension both contributes to and is reinforced by the pain. In a trial of 212 women, physical therapy reduced pain during sex more than a topical anesthetic6.
Urinary Urgency, Frequency & Painful UrinationPelvic floor dysfunction and shared nerve pathways often produce symptoms like those of interstitial cystitis (urinary urgency, frequency, burning with urination and postvoid discomfort) without infection.
Constipation & Painful Bowel MovementsA tight pelvic floor often produces difficulty emptying, the sensation of incomplete evacuation and painful defecation.
Anxiety, Depression & Pain CatastrophizingLiving with chronic genital pain produces high rates of anxiety and depression, made worse by years of dismissal from providers.
Sleep Disturbance & FatiguePoor sleep then amplifies pain perception the next day. Sleep restoration is an important part of any vulvodynia recovery plan.
Avoidance, Intimacy Loss & Identity StrainAvoidance of sexual activity, romantic relationships, certain clothing, certain workouts and even gynecologic care is common. These are real consequences that require their own care, often with a trauma-informed sex therapist.
โš ๏ธ Pattern to watch for: Vulvar burning or rawness lasting > 3 months + normal exam + multiple negative yeast/UTI cultures + pelvic floor tightness points toward vulvodynia once infection and skin conditions such as lichen sclerosus have been ruled out3.
Causes

Causes of Vulvodynia

The exact cause of vulvodynia is not known, and it is diagnosed only after other causes of vulvar pain have been ruled out; several factors probably act together83.

CauseHow It Contributes to VulvodyniaWhat Helps
Nerve changesDamage, irritation or over-sensitivity of the nerves in the vulva is one of the suggested causes8Treatment for nerve pain from a specialist: numbing creams or nerve-pain tablets, as the treatment section describes8
Pelvic floor muscle problemsThe NHS lists weak pelvic floor muscles8, and ACOG advises assessing every woman with vulvodynia for pelvic floor dysfunction, including muscle overactivity3. In vulvodynia the muscles are more often too tight than too weak2, so do not start strengthening exercises on your own; a pelvic floor physical therapist assesses which appliesPelvic floor physical therapy; in a trial of 212 women with provoked vestibulodynia it reduced pain during sex more than a topical anesthetic6
Previous vaginal infectionsPrevious vaginal infections are one of the suggested causes8Swabs and cultures to confirm an infection before it is treated, rather than repeated treatment without testing3
Hormonal changesChanges in hormone levels, such as estrogen, are among the suggested causes3Assessment, and estrogen cream where your clinician advises it; ACOG lists it among the commonly prescribed topical treatments3
Other pain conditionsIn a population study, screening positive for fibromyalgia was linked to both relapse and persistent pain, and interstitial cystitis to relapse7Care from more than one specialist, such as a gynecologist, physical therapist, psychologist and pain specialist8
Irritants on the vulvaPerfumes, dyes, shampoos, detergents and douching irritate the vulva and can add to the pain3Cotton underwear, water only on the vulva, no scented products and an emollient instead of soap8
Diagnosis

How Vulvodynia Is Diagnosed

Vulvodynia is a clinical diagnosis of exclusion, made when chronic vulvar pain persists 3+ months with no identifiable cause. The workup is mostly about ruling things out, not in.

TestWhat it shows
At-Home Screening
These steps cannot make the diagnosis, but they prepare you for a more useful visit:
The 3-⁠Month Rule + Symptom ChecklistScore 1 point for each: vulvar burning > 3 months, sharp pain on touch at the vestibule, pain with intercourse or tampon insertion, pain with sitting or tight clothing, multiple negative yeast/UTI cultures, pelvic floor tightness or constipation, co-occurring IBS, interstitial cystitis or fibromyalgia, history of recurrent yeast/BV/UTI treatments. This is not a validated score; see your doctor if vulvar pain does not go away or keeps coming back8.
Pain Diary & Trigger TrackingTrack for 2 to 4 weeks: pain location (vestibule vs full vulva), severity (0 to 10), triggers (touch, sex, sitting, foods, stress, cycle day), relievers and discharge changes.
Self-Inspection & Sensitivity MappingUsing a hand mirror, identify whether tissue looks normal (typical for vulvodynia) or shows redness, fissures, white patches or atrophic thinning (suggesting a separate diagnosis such as lichen sclerosus, lichen planus, eczema or atrophic vaginitis).
Clinical & Specialist Tests
Cotton-Swab TestThe key bedside test for provoked vestibulodynia. A moistened cotton swab is gently touched at the 1, 3, 5, 7, 9 and 11 o'clock positions around the vestibule.
Microbiology & Infection Rule-OutVaginal pH, wet mount, yeast culture, NAAT for chlamydia, gonorrhea, M. genitalium, trichomonas. HSV serology and culture if blistering ever occurs.
Vulvar Dermatology ExamDetailed inspection (ideally with a colposcope and biopsy as needed) to rule out lichen sclerosus, lichen planus, lichen simplex chronicus, vulvar eczema, plasma cell vulvitis and atrophic changes9. In one review of biopsies from women with hard-to-treat vulvodynia, 61% showed a relevant skin condition3.
Pelvic Floor Muscle AssessmentExternal and internal palpation by a pelvic floor PT or trained provider identifies hypertonic muscles, trigger points and asymmetric tone. Surface EMG biofeedback may quantify resting tone.
Hormonal & Endocrine PanelEstradiol, free testosterone, DHEA-S, SHBG, especially in women on OCPs, postpartum, breastfeeding or postmenopausal.
Specialty Imaging & Nerve StudiesPelvic MRI is rarely needed but useful if pudendal neuralgia or pelvic congestion syndrome is suspected. These are tertiary tests, not first-line.
Treatment Comparison

Conventional and Holistic Treatment for Vulvodynia

Vulvodynia responds best to layered, multidisciplinary care that addresses every contributing system.

๐ŸŒฟ HOLISTIC
๐Ÿ’Š CONVENTIONAL
๐ŸŒฟ

Holistic / Functional Approach

Address every contributing layer simultaneously: pelvic floor, hormones, mast cells, gut, nerves and nervous system

Primary Treatment
Pelvic floor PT + topical hormones + anti-inflammatory nutrition + mast-cell stabilization + nervous system desensitization
Duration
3 to 6 months for noticeable change; 9 to 18 months for substantial recovery in chronic cases
Effect on Underlying Disorder
Aims at each contributing factor; sustained improvement is possible, though evidence for most nutritional parts is limited
Sexual Function
Gradual restoration of pain-free intimacy for most; partner-inclusive sex therapy supports the process

Full Holistic Approach Includes

  • Pelvic floor physical therapy with internal manual release, dilator program and home practice
  • Topical estradiol/​testosterone compounded cream applied to the vestibule nightly for atrophic / OCP-induced cases
  • Anti-inflammatory diet emphasizing colorful vegetables, wild fatty fish, bone broth
  • A short low-histamine eating trial only if symptoms clearly flare with histamine foods; diet studies in vulvodynia are lacking10
  • Nerve-supportive nutrients: methyl B12, alpha-lipoic acid, magnesium glycinate, palmitoylethanolamide (PEA)
  • Pain education and graded exposure to reduce central sensitization (the "neuroscience of pain" model)
  • Trauma-informed sex therapy and partner education when appropriate
  • Sleep optimization (7 to 9 hours), daily walking, breathwork for vagal tone
  • Cotton underwear only; eliminate fragranced products, panty liners, dyes, harsh soaps from vulvar contact
  • If your clinician finds a hormonal cause, ask whether to change or stop the birth control pill, and agree on other contraception before stopping it
โš ๏ธ Side effects: Mild local irritation in first week of topical hormones; transient soreness as pelvic floor PT releases trigger points; emotional challenges as long-held patterns shift, often the hardest and most important part.
Supplement Protocol

Evidence-Based Supplements for Vulvodynia

Few randomized trials of any vulvodynia treatment exist, and none of the supplements below has one showing it treats vulvodynia; they are optional additions to the treatments above3. Start one at a time so you can identify what is helping (or not).

Supplement What it is for Typical range Timing Notes & cautions
Magnesium GlycinateRelaxes the pelvic floor, supports GABA synthesis, dampens nerve excitability, improves sleep quality.300 to 400 mg elemental per dayEvening, 30 to 60 min before bedIn pregnancy, check the dose with your midwife or doctor. Avoid magnesium oxide (poorly absorbed, laxative). The top of this range is above the 350 mg/day upper intake level for supplemental magnesium; above that, diarrhea is common. With kidney disease, take it only on your clinician's advice.
Alpha-Lipoic Acid (ALA)Antioxidant with RCT evidence mainly in diabetic neuropathy; it has not been tested in vulvodynia. Supports nerve regeneration and reduces oxidative damage to small fibers.600 to 1,200 mg per day30 minutes before meals on an empty stomachCan lower blood sugar; monitor it if you have diabetes. If you are or may become pregnant, check with your midwife or doctor first. Often takes 8 to 12 weeks for full effect.
Palmitoylethanolamide (PEA)Endogenous fatty acid amide with RCT evidence in pelvic pain, neuropathic pain and mast cell activation. Evidence in vulvodynia itself is limited to small studies.600 to 1,200 mg per day, micronized or ultramicronizedWith meals, split twice dailyIf you are or may become pregnant, check with your midwife or doctor first. Effects build over 8 to 12 weeks.
Vitamin B12Essential for myelin repair and small-fiber nerve regeneration.1,000 to 5,000 mcg per dayMorning, sublingual preferredTest B12 and MMA first if possible.
Omega-⁠3 EPA/DHAAnti-inflammatory, supports nerve membrane health and dampens central pain amplification.2 g combined EPA+DHA per dayWith mealsChoose a product with independent third-party purity testing. In heart trials, fish oil supplements raised the risk of atrial fibrillation, an irregular heartbeat, more so above 1 g a day15, so check this dose with your clinician first.
Vitamin D3 (with K2)Modulates immune and mast cell function, supports nerve health. Deficiency is common in chronic pain populations.D3: set the dose with your clinician; most adults need no blood test first; K2 (MK-⁠7): 100 to 200 mcg per dayWith a fat-containing mealIf you take warfarin, clear any vitamin K supplement with the clinician managing your anticoagulation before starting or stopping it: vitamin K antagonizes warfarin, and changing your intake destabilizes the INR. Consistency matters more than avoidance. This does not apply in the same way to direct oral anticoagulants such as apixaban or rivaroxaban, but tell your prescriber about any supplement you take.
Curcumin (Turmeric Extract)Reduces NF-ฮบB-mediated inflammation, mast cell activation and central pain sensitization.500 to 1,000 mg curcumin per dayWith a fat-containing mealTurmeric supplements may be unsafe in pregnancy16. Unenhanced curcumin is poorly absorbed; liver injury has been reported mainly with high-dose, high-absorption formulations such as those with piperine, so stop and seek advice if you notice dark urine or yellowing skin17.
Topical Estradiol/​Testosterone Cream (Rx)For hormone-related vulvar pain (postmenopausal, postpartum, OCP-induced atrophy). Restores tissue thickness and reduces vestibular pain.Compounded per providerApplied to vestibule nightlyRequires prescription from a vulvodynia-aware provider.
Lactobacillus crispatus + rhamnosus (Vaginal)Restores protective vaginal flora, especially valuable after recurrent yeast or BV treatments.Vaginal suppository, 2x/week long-termAt bedtimeLook for L. crispatus CTV-⁠05 or rhamnosus GR-⁠1 strains with RCT data.
What to Expect

What to Expect Over Time

Treatment aims to manage the pain; no single treatment works for everyone, and several may need trying8.

Treatment and supportive care, together
First Weeks

Examination, a cotton-swab test, swabs for infection and a biopsy of any abnormal-looking skin come first3. Gentle vulvar care starts now: cotton underwear, no scented products, lubricant for sex8.

Months 1 to 3

Pelvic floor physical therapy, psychological therapies such as CBT, and medicines for nerve pain are the main options8. In one trial, 79% felt much improved after 10 weeks of physical therapy, against 39% with a topical anesthetic6. Nerve-pain medicines take up to 3 weeks to work3.

Months 3 to 12

In trials, group CBT reduced pain, and at 6 months did better than a topical steroid on pain and sexual function18. Improvement may take weeks to months and may not be complete. Surgery is considered only after other treatments fail3.

Long Term

In a population study, about half of women remitted without relapse and about 10% had persistent pain7.

When to Seek Care

See a doctor for an examination if you have a new sore, lump or ulcer, bleeding from the vulva that is not a period, itching that does not get better, or new red, white or dark patches19. Never stop a nerve-pain medicine suddenly; your prescriber reduces it gradually3. See your doctor too if vulvar pain does not go away or keeps coming back8.

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Next Steps

Vulvodynia Is Real and Common

Other causes must be ruled out first, so a proper examination comes before a pain diagnosis. What works is usually a combination, with pelvic floor physical therapy among the best evidence, alongside psychological therapies and nerve-pain medicines. Improvement may take weeks to months, and several treatments may need trying.

Explore Menopause โ†’ Explore Fibromyalgia โ†’

References & Evidence Notes

Each numbered entry below is either a source you can follow or a note setting out what the evidence does and does not support. Both are numbered together so the markers in the text line up.

Last reviewed October 20, 2026. Supplement entries are cross-checked against the NIH National Center for Complementary and Integrative Health and the Linus Pauling Institute Micronutrient Information Center.20 Vulvodynia is real, it is common, and being told that nothing is wrong because the examination looks normal is the standard experience rather than the exception. A normal-looking vulva is part of the definition: vulvodynia is diagnosed when pain persists for three months or more without an identifiable cause, and that means other causes must actually be looked for first. Infection, lichen sclerosus, lichen planus, dermatitis, hormonal atrophy and neurological causes all mimic it and are treated differently, so a proper vulvar examination, and biopsy of anything that looks abnormal, comes before a pain diagnosis. What works is usually a combination rather than a single remedy, and pelvic floor physical therapy has among the best evidence of anything on this page.

  1. On how common vulvodynia is: a Boston population survey of women aged 18 to 64 found that about 16% had a history of chronic vulvar burning, knife-like pain or pain on contact lasting at least 3 months, and nearly 7% had it at the time; nearly 40% never sought treatment, and 60% of those who did saw 3 or more doctors, PubMed 12744420. A later survey of over 19,000 women aged 18 to 40 in two US regions found that 7 to 8% reported pain consistent with vulvodynia by age 40, PubMed 24080300. ↩
  2. On pelvic floor physical therapy in vulvodynia: pelvic floor muscle overactivity is present in a large proportion of women with vulvodynia, particularly provoked vestibulodynia, and physical therapy including manual therapy, biofeedback and graded desensitization has good supporting evidence. It is frequently the highest-yield intervention and is frequently not offered. ↩
  3. On diagnosis and treatment: the American College of Obstetricians and Gynecologists defines vulvodynia as vulvar pain of at least 3 months without an identifiable cause and calls it a diagnosis of exclusion, to be made only after infection, inflammatory skin conditions such as lichen sclerosus and lichen planus, neoplasia and neurologic disorders are excluded, with biopsy where needed. It advises assessing every woman for pelvic floor dysfunction. It lists physical therapy, cognitive behavioral therapy, topical treatments (including estrogen cream) and oral nerve-pain medicines, which take up to 3 weeks to work and should not be stopped suddenly. It notes that few randomized trials exist and that improvement may take weeks to months and may not be complete. It reserves vestibulectomy for pain localized to the vestibule after other treatments have failed, with reported success rates of 60 to 90% and no standard definition of success, ACOG Committee Opinion 673. ↩
  4. On definition and subtypes: vulvodynia is vulvar pain of at least three months' duration without a clear identifiable cause. It is described by location (localized, such as vestibular, or generalized), by provocation (provoked, spontaneous or mixed) and by onset (primary or secondary). These distinctions matter because they predict which treatments help. ↩
  5. On hormonally associated vestibulodynia: combined hormonal contraceptives and other causes of low local estrogen and testosterone can produce vestibular pain that improves with topical estradiol (sometimes with testosterone) and with stopping the causative agent. This subtype is worth identifying because it responds specifically. ↩
  6. On pelvic floor physical therapy: in a randomized trial of 212 women with provoked vestibulodynia, 10 weeks of physical therapy (education, pelvic floor exercises with biofeedback, manual therapy and dilation) reduced pain during sex more than a nightly topical anesthetic, with results maintained at 6 months; 79% against 39% reported being much or very much improved, PubMed 32818475. ↩
  7. On the course over time: in a US population study of 239 women who screened positive for vulvodynia and completed follow-up, 50.6% remitted without relapse, 39.7% relapsed after remission and 9.6% had persistent symptoms; screening positive for fibromyalgia was linked to relapse and persistence, PubMed 26752153. ↩
  8. On causes, treatment and self-care: NHS guidance says the exact cause of vulvodynia is not known and may relate to nerve damage, irritation or over-sensitivity, previous vaginal infections, changes in hormones such as estrogen and weak pelvic floor muscles. Treatment aims to manage the pain, often with more than one specialist. It can include numbing creams, nerve-pain tablets, pelvic floor exercises, vaginal dilators, cognitive behavioral or psychosexual therapy and, occasionally, surgery; no single treatment works for everyone. It advises loose cotton underwear, lubricant for sex, no scented products and an emollient, and seeing a doctor for vulvar pain that does not go away or keeps coming back, NHS, vulvodynia. ↩
  9. On excluding other causes first: recurrent candidiasis, bacterial vaginosis, herpes, lichen sclerosus, lichen planus, contact dermatitis, genitourinary syndrome of menopause and pudendal neuralgia all cause vulvar pain and have specific treatments. Vulvar biopsy is indicated for any abnormal-appearing lesion. Empirical antifungal treatment repeated without confirmation is a common source of years lost. ↩
  10. On diet more broadly: a 2024 systematic review found that studies of dietary patterns in vulvodynia, other than the low-oxalate diet, are lacking, PubMed 37856898. ↩
  11. On medical and psychological treatment: topical agents including lidocaine and compounded preparations, low-dose tricyclics and gabapentinoids for neuropathic pain, and, for localized provoked vestibulodynia refractory to everything else, vestibulectomy. Cognitive behavioral therapy and sex therapy have randomized evidence, and pain education addressing central sensitization is a genuine treatment rather than a way of saying the pain is psychological. ↩
  12. On oxalate and calcium citrate: no controlled trial has tested a low-oxalate diet in vulvodynia. The idea began with a single case report of a woman treated with calcium citrate, PubMed 1816400; in a later series, 24-⁠hour urinary oxalate was almost identical in 130 women with vulvodynia and 23 controls, and of 59 women given a low-oxalate diet and calcium citrate for 3 months, 24% improved and 10% could have pain-free sex, PubMed 9322615; a case-control study of 242 women with vulvodynia and 242 without found no link with dietary oxalate, PubMed 18441720; and a 2024 review concluded the few data do not support prescribing a low-oxalate diet, PubMed 37856898. ↩
  13. On the low-oxalate diet and calcium citrate, since it circulates widely: the evidence is limited to case reports and small uncontrolled series, and controlled evidence is lacking. It is a demanding diet with real social cost, and it should not displace treatments with better support. Avoiding irritants (soaps, fragranced products) and using a bland emollient is low cost and reasonable. ↩
  14. On liver and vitamin A: NHS guidance advises not eating liver or liver products more than once a week, not taking supplements containing vitamin A if you eat liver every week, and avoiding liver altogether in pregnancy, because its high vitamin A content can harm a baby, NHS, vitamin A, NHS, foods to avoid in pregnancy. ↩
  15. Gencer B, Djousse L, Al-Ramady OT, Cook NR, Manson JE, Albert CM. Effect of long-term marine omega-⁠3 fatty acids supplementation on the risk of atrial fibrillation in randomized controlled trials of cardiovascular outcomes: a systematic review and meta-analysis. Circulation. 2021;144(25):1981-⁠1990. PubMed 34612056. Seven trials with 81,210 people followed for about 5 years: omega-⁠3 supplements were linked to a higher risk of atrial fibrillation (hazard ratio 1.25), more so in trials of more than 1 g a day (1.49), and the risk rose with each additional gram. ↩
  16. On turmeric in pregnancy: the NIH National Center for Complementary and Integrative Health states that the use of turmeric supplements during pregnancy may be unsafe, and that little is known about amounts above those in food while breastfeeding, NCCIH, turmeric. ↩
  17. On curcumin and the liver: in a case series and systematic review of acute hepatitis linked to Curcuma longa supplements, every case in the Tuscany series involved high-bioavailability, high-dose formulations, PubMed 32656820. ↩
  18. On psychological therapy: in a randomized trial of 97 women with provoked vestibulodynia, both group cognitive behavioral therapy and a topical steroid reduced pain, and at 6 months the therapy group had more pain reduction on one pain scale and better sexual function, PubMed 26727408; an earlier trial of 78 women found pain reductions with group therapy, biofeedback and surgery, PubMed 11275387. ↩
  19. On signs that need examination: NHS guidance lists a lump, a sore, growth or ulcer, bleeding from the vulva that is not related to periods, itching that does not get better, red, white or dark patches or thickened skin, a mole that changes and burning pain when peeing as symptoms to have checked by a doctor, noting that they are common and usually have other causes, NHS, vulvar cancer symptoms. ↩
  20. National Center for Complementary and Integrative Health (NIH), nccih.nih.gov, and the Linus Pauling Institute Micronutrient Information Center, lpi.oregonstate.edu/mic. ↩