Q. Could my old episiotomy scar be causing me pain?
A. It would be very, very unusual for an old episiotomy scar to become problematic. You say you experience dryness, irritation and a "tearing feeling," which sounds to me entirely consistent with vulvodynia (also called vestibulodynia or provoked vulvodynia). Other ways the pain has been described are "sandpaper," "cutting" or "ripping."
The most common experience with vulvodynia is pain with intercourse and usually not with other activities (although sometimes women have sensitivity when wiping after urination). There may or may not be vaginal dryness.
If the pain you're experiencing is related to atrophy, which is very common and usually evident by vaginal dryness, Premarin vaginal cream should be quite effective for that. A topical steroid, which can be prescribed, would be helpful if there's an identified vulvar skin condition or dermatosis, but, from your descriptions, I'm not sure that the steroid is beneficial. You also asked about the Mona Lisa Touch, which has been shown effective for atrophy, but not for vulvodynia, at least thus far.
For patients with vulvodynia, I use a compounded prescription of low-dose estrogen plus testosterone applied to the opening of the vagina (the introitus) two times a day for 12 weeks, tapering to once a day or less.
Another option might be Intrarosa, a relatively new treatment for vulvovaginal atrophy, which I've begun using with some vulvodynia patients. Intrarosa is a vaginal insert, used nightly. It's metabolized to testosterone (and estrogen) in the vagina, so I think this is going to help vulvodynia.
Note that vulvodynia can be difficult to diagnose, because the vulva and vagina may look normal. Describing your symptoms accurately will be extremely helpful.
Barb DePree, MD, has been a gynecologist for 30 years, specializing in menopause care for the past 10. Dr. DePree was named the Certified Menopause Practitioner of the Year in 2013 by the North American Menopause Society. The award particularly recognized the outreach, communication and education she does throughMiddlesexMD, a website she founded and where this blog first appeared. She also is director of the Women's Midlife Services at Holland Hospital, Holland, Michigan.
