A Team Approach: The Parallels of Severe Asthma and (Apparently) Chronic Pain: Part 2

Editor's Note: This is the second article in a 2 part series. Read the first article here.

In my early days of asthma in Winter 2008, I no longer had a family/primary care doctor to coordinate my care as I learned my pediatrician had recently retired. In April of 2021, when the beginning of my chronic pain, also known as vulvodynia developed, my family doctor had recently shared she was moving out of province and closing her practice.

After several months of self-treatment and virtual care, I had her run some tests (ordered wrong, which provided no answers) and then was left without a doctor to coordinate my care...hmm, sounds like my asthma experience.

Fortunately, I got a new (incredible) family doctor within 6 weeks, who identified my symptoms before I mentioned them during a routine Pap test, and quickly referred me to the appropriate care. In this case, my amazing gynecologist.

Referrals to the appropriate care

Now admittedly, asthma is much more common in a family medicine practice than what I would learn to be chronic vulvar pain, or vulvodynia, is. However, it took at least 18 months of asthma medication trial and error back in 2009/2010 to convince my doctor I needed a specialist on my case. I really had to make the case, despite that I was on over the maximum approved amount of Symbicort every day, and still really struggling.

I am fortunate in 2 things with my new family doctor. He showed me how attentive and thorough he is on my very first visit, and he has never hesitated to make a referral, going back to the third time I saw him. (Oh, and third, he has a great sense of humor!)

Taking a team approach: Parallels in my asthma story and vulvodynia story

While bringing a care team into my asthma journey was slow, and I was not a well-versed self advocate yet in 2009-2010, I was fortunate that once I got sent to respirology, an allergist referral soon followed. Eventually I would see a different respirologist, who would later send me to an ENT to ensure my sinuses were not impacting my breathing. This is a common set of doctors to be consulted for people with asthma, especially when it is more severe.

My vulvodynia story is unfolding with similar challenges. I have been so lucky my pain has been taken seriously by each new doctor who has cared for me since Fall 2021. It was just weeks between my new family doctor running tests and attempting treatment, to when he referred back to my gynecologist (who I had not seen for 8 years).

Similarly, after trying just 1 treatment, my gynecologist referred me to a specialist clinic, assuring me I would get the best possible care in the province. In truth, after the first 6 months, once I got a new family doctor, I absolutely have. Not everyone with pelvic pain is taken this seriously.

Finding the causes of symptoms

Again, just like asthma has many triggers, some easier to identify than others, figuring out what is causing my pain has taken a startlingly similar approach, involving different focuses.

While asthma has clear criteria, vulvodynia is known as a "wastebasket diagnosis," used where a specific cause cannot (yet) be identified --technically it is a symptom rather than a disease itself. However, the pain can have various causes: allergic, dermatologic, neuropathic, or even myopathic (caused by musculature), or a combination of factors.

Interestingly, when we read about asthma, we read about red, inflamed airways with tightened surrounding muscles. Somehow, it did not surprise me when my second gynecologist noted erythema (swelling) during my exam, and suggested my symptoms could be dermatological. More recently, my pelvic floor physiotherapist noted redness and muscle tightness. It is interesting to consider a similar process could be at play.

We are not yet sure the cause of my symptoms: we are taking all the routes. She started treatment with, you guessed it, daily steroids (topical rather than inhaled) to manage inflammation, and moisturizer, as my specialist initially thought it could be dermatological but was not sure. We later added a compounded cream to provide short-term pain relief, address nerve pain, and protect the skin.

Knowing my symptoms could have one of many causes, my gynecologist has been incredibly open to possibilities and suggestions I have brought in.

Growing the team

In a meandering path that feels much like my long journey of combinations of inhalers, asthma symptom tracking, and various specialists, more team members have come into my orbit as I navigate vulvodynia--both intentionally and by fortunate circumstance.

As noted above, I recently begun pelvic floor physiotherapy, moving forward on a thought spurred by a single journal article that my congenital hip dislocation and musculature may be a factor in my vulvodynia, which my doctor thought was insightful.

So far, on visit 1, I have alarmed my PT with how bad my skin looked (prompting an email to my gynecologist) and she has identified both muscular tightness AND weakness we are working on—clearly, there may be multiple causes at hand.

Recently, my asthma specialist sent me back for allergy testing for asthma-related reasons, and while outside of the scope of the initial referral, I realized meeting a new allergist was a great opportunity to dive into vulvar irritation causes related to allergens and irritants.

He was knowledgeable about vulvar dermatitis (while maintaining he was not an expert), and enthusiastically dove in even after my skin tests were negative. He headed off to prepare a contact dermatitis patch testing panel for me with a list of all the ingredients of the allegedly hypoallergenic topical medications, hand soap, and laundry/dish detergents I am using. He also mentioned possible referral to dermatology based on how things go, trading me for a lab requisition for environmental inhalant blood allergy tests.

Too many similarities to ignore

Of course, the underlying causes of asthma and my chronic pain could be entirely different, there are far too many similarities to ignore—potential overlapping pathophysiology, various allergic and non-allergic causes, and the variety of team members who are helping me figure things out.

It is completely possible and perhaps even probable they are 2 different sets of problems with 2 entirely different causes or contributing factors. But, we will never know unless we explore all the options.

If you see more than one doctor, do your doctors take a team approach when it comes to your asthma and/or other conditions? Share your story with the community.