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Let’s talk about sex-things I learned at the ‘International Society for the Study of Women’s Sexual Health’ annual conference

At the recent ISSWSH www.isswsh.org conference in San Diego there was a lot of talk about sex. Psychologists, physical therapists, researchers, sexual medicine doctors and a spine surgeon presented on insights and medical advances to improve women’s sex drive (hypoarousal no more!); reducing pain during/following sex; balancing hormones (estrogen is good!); post menopause in the bedroom (women in their 60-70’s have sex!) transgender information (3% of highschool students in a major US city say they are transgender). Today’s blog is about the big insights in treating vaginal pain.

Many women still think that it’s normal to have vaginal pain during and following intercourse.  Some experience vaginal burning, itching, pain and feel raw in this area 24/7 and sex increases their pain.

Women may be embarrassed, think this experience is normal, some even feel guilty so they don’t tell their doctors. Unfortunately, many doctors do not ask 3 important questions:

  1. Do you feel pain during/after intercourse?
  2. Are you happy with your sex drive?
  3. Can you achieve orgasm and if yes, are you satisfied with the quality?

 

 

Women with persistent pain can get stuck in a cycle of pain. Vaginal pain causes tension of the pelvic floor/abdominal muscles which can lead to depression, anxiety and catastrophizing behavior. If not treated effectively, they can develop a hypersensitive central nervous system and overprotective brain which worsens pain.  To break this cycle, it’s crucial to find out what type of vaginal pain she has, as each requires a completely different medical approach.

 

The following is a general information guide – see your doctor to get your specific diagnosis!

 

After taking a good history and listening to your symptoms, your doctor that specializes in sexual medicine will do a physical exam, using a Q-tip to gently press against each point of the Vestibule (see image below)

The vestibule is divided like a clock, the top portion, 9 to 3 o’clock is considered the “anterior vestibule” and contains Skenes glands.  The lower 4 to 8 o’clock are considered the “posterior vestibule” contains Bartholin glands and reflect how tense or relaxed are the pelvic floor muscles. Redness of the vestibule is not always an easy way to determine pain because it’s naturally red due to lots of blood vessels.

Complete Vestibulodynia

The whole vestibule, anterior and posterior portions are super sensitive to the Q-tip touch.

This is due to a dominance of estrogen (the pill, acne medicine, facial hair medicine all contains estrogen). These women are not getting enough androgen and testosterone, male hormones that the vestibule needs to be balanced.  Treating this type of vaginal pain is challenging because the woman on the pill has to discontinue and find alternate birth control methods. Teenagers being treated for acne will have it return, so coming off estrogen is a challenge yet once done, this type of vaginal pain will completely heal.  The time it takes to heal – in 6 months she is 50% better and in a year, she is  100% better.  While waiting for the body to balance, doing some healthy mental and physical exercises from the relieve program (link) can also help.

Inflammatory Vestibulitis.

If a woman has a history of chronic infections or if she is one of the 3-4% of American woman who is allergic to propylene glycol which is found in all vaginal gels, yeast creams, steroid creams such as the over the counter Monistat.  Woman may have been incorrectly diagnosed with a yeast infection and given creams (that contains propylene glycol) which causes more sensation of rawness, burning and cutting. What’s happening is that the inflammatory cells, called Mast cells, actually signal nerve endings to grow into the vaginal tissue which makes women feel more pain.

How to treat? If women can be seen within 6 months of symptom onset, they’ll be started on Interferon, a medicine which stops the production of mast cells.

If the woman is seen after 6 months, then treatment is more challenging. Either they use of a capsaicin crème (hot pepper component which removes “Substance P” of the nerve ending or desensitizes the nerve). Treatment is for 12 weeks of use of nightly cream – doable, but painful. Other option is surgery (vestibulectomy) to remove the affected tissue.

Congenital Neuroproliferation.

There is an increased amount of nerve fibers in the vestibule since birth.  These women could never use a tampon. A quick test is to touch your inner belly button and gently press inward. If you feel increase pain/sensitivity in your vagina, then this may be the cause for your pain. How can this be? The umbilicus shares the same embryonic tissue as the vestibule – so they are connected and have the same increased nerve fiber growth.

Treatment is surgical removal of the vestibular tissue (which healthily heals without the extra dense nerve fibers) resulting in no pain.

Overactive Pelvic Floor

Women who experience vaginal pain and have pain with the Q-tip test at the 4-8o’clock region, the posterior vestibule, with no sensitivity in the anterior vestibule. These women have overly tense pelvic floor muscles and this is the most common cause for vaginal pain.  Women can also experience symptoms of urinary frequency, urgency, sensation of incomplete emptying, constipation, rectal fissures, hemorrhoids.

This condition can be effectively treated by pelvic physical therapy. Pelvic PT includes releasing tension in the muscles of the lower back, sacrum, inner thighs, pelvic floor, teaching breathing techniques to relax the pelvic floor muscle, biofeedback, use of dilators and bladder and bowel retraining exercises.

Biopsychosocial Approach for Chronic Pain

Over the last 10 years, we also are now understanding why people stay in chronic pain for months, years, even decades.  Once an injured or chronically inflamed tissue has healed, why is there pain?

 

The answer is that they have developed an overprotective brain and hypersensitive nervous system. Without being aware of their habits developed due to social norms, family history, past experiences with pain, some people learn to be in a pattern of pain. Once the tissue issue has been healed, yet there is still pain, pain is the brain’s way to protect your body.   Ongoing negative experiences like a fight with your partner, stress at work, abuse at home, loss of a pet, saying non-loving, fear-based statements to yourself all day, not having or doing something that gives you joy  (even for a few minutes) can make the brain feel you are always in danger and send pain to protect you.

 

The Doctors of Physical Therapy at EMH are well versed in helping women heal from chronic pain using the biopsychosocial approach as well as our pelvic floor physical therapy for vaginal tissue based pain.  Our e-Book, re.lieve Solutions for Chronic Pain can help you learn self-help techniques to lower chronic pain.  Here’s the link: http://emhphysicaltherapy.com/product/re-lieve-solutions/

 

In summary, women can have a healthy fulfilling sex life – to find a provider, go to isswsh.org.

 

Chronic Pain: New Science provides Solutions for Complete Recovery (Part 1)

Chronic pain is a worldwide epidemic, affecting 1.5 billion people1.   In the USA we spend over $635 BILLION dollars treating chronic pain, visiting multiple medical practitioners, getting  tests, injections, prescription medications, and surgeries2.     With all the amazing advances made in treating cancer, diabetes and heart conditions, the numbers of people suffering with chronic pain has not lowered; in fact it’s increasing.

The good news is that we have learned more about pain in the past 10 years than ever before. The fields of neuroscience, physical therapy, psychology and nutrition have unearthed a treasure trove of knowledge to help people truly heal from chronic pain. There are a number of non-invasive, low risk self-help treatments that people with chronic pain can do simultaneously while they receive treatments by their doctors, physical therapists and other health practitioners to achieve total chronic pain relief.

Chronic Pain Defined

Chronic pain is pain that lasts longer than the normal tissue healing time of 3-6 months. Note: this blog does not include the pain caused by active cancers nor end of life pain issues. So, by the end of 6 months all tissues (skin, muscles, fascia, tendons, ligaments, nerves and bones) should be completely healed barring no major complications such as infections, disease processes or re-injuries.

3 Phases of Healing

Below is what our body does after getting a physical injury:

Inflammatory phase 3-7 days from original injury: when you feel most pain or see redness and swelling. Swelling shows that your body is doing an excellent job of healing and prevents further injury to the area.

Repair (Proliferation) phase 2-6 weeks from original injury: depending on the tissue (skin heals faster than bone). New collagen is laid down, like weaving a basket or sewing up a hole in your socks. Collagen replaces the torn, strained, or fractured tissue.

Remodeling phase 3-6 months from original injury: this phase starts when production of new collagen stops. New collagen is usually stiff, inflexible and needs to be remodeled, lengthened, and strengthened to your pre injury state and function. This is best achieved by going to physical therapy and doing your exercises.

Acute Pain Process

If the normal healing timeline takes 6 months at most, why do so many people experience chronic pain for years, sometimes decades past the original injury? Before we can understand how pain becomes chronic, here’s how our nervous system and brain works when we are experiencing acute injury pain.

When we first sprain our ankle, specialized sensors in our skin called “nociceptors” are activated (see red “Nociceptive Information” ).  Nociceptors are not pain sensors- rather pressure sensors, chemical sensors and stretch sensors. In fact, we don’t have actual “pain sensors” in our bodies. Nociceptors sense that your ankle ligament is overstretched or your muscle fibers are torn and sends this information to the brain.

 

Brain is our Protector

Your brain’s main role is to protect your body, so when your brain receives the nociceptive signals about the overstretched/torn tissues, it also checks your surrounding environment and assesses the situation to decide how best to protect.

Let’s say you twisted your ankle in a pothole while crossing a busy NYC street. You need to run quickly or you may be hit by oncoming cars. The brain decides that you need to get to safety first so it allows you to run on your injured ankle WITHOUT PAIN by sending pain reducing chemicals to the area. Once you are safely on the sidewalk, the brain sends pain signals to your ankle so you immediately take your weight off your foot. Your brain has effectively protected you from harm both by decreasing and increasing pain. This whole process happens in milliseconds.

 Brain is the Boss of Pain

Our brains are capable of learning and creating new nerve pathways throughout our whole lifetime. This is called “neuroplasticity”3.  Areas of the brain that are used very frequently show high levels of activity (as seen in brain MRI scans) and may actually increase in size4.  Before iPhones and Google Maps, London cab drivers had to memorize the whole intricate street map of the city before they could get their licenses. Studies show that they actually have enlarged areas in the brain associated with memory. The brain changes based on how we use it.

The brain is the center where the actual sensation of physical pain originates from and gets relief. People who experience chronic pain have a brain and nervous system that has learned to be in a heightened state, always on guard awaiting the next danger signal. What leads to this “faulty wiring” of our brain and nervous system?  Some factors include:

  1. Childhood and early social experiences – did you suffer loss/lack of love or did you feel safe and supported? These experiences affect how we respond to both physical and emotional pain.
  2. Daily thoughts and self-talk – are they positive or tend to be negative/fear based?
  3. Current social interactions – are they mostly supportive, like seeing a good friend, petting your cat or stressful, like fighting with your spouse/children?
  4. Your Expectations- are you afraid of bending forward because years ago a doctor said it could flare up your back pain? 5,6

Nutrition, exercise, restful sleep plays just an important role in total healing which we will discuss in the next few blogs. While we can’t change what happened to us in the past, the good news is that our brains can relearn healthy patterns to lower/stop chronic pain.

While receiving medical care from your doctor, you can simultaneously  retrain your brain to learn healthy processes, decrease fear based movement patterns, use mindfulness to stop negative catastrophizing thoughts, breathing techniques to lower fear/anxiety and much more.

At EMH Physical Therapy, we offer a chronic pain recovery program, called re·lieve, which educates patients in the new science of pain and teaches them a scientifically proven self-help program along with providing any needed manual and movement therapies.

Stay tuned for Part 2 of  “Solutions for Complete Recovery of Chronic Pain”.

References

1.Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, D.C.: Institute of Medicine of the National Academies; 2011.

2.Darrell J. Gaskin, Patrick Richard. The economic costs of pain in the United StatesThe Journal of Pain 2012;13(8):715

3.Draganski B, May A. Training-induced structural changes in the adult human brain. Behav Brain Res 2008;192:137-42

4.Johansson BB. Brain plasticity in health and disease. Keio J Med 2004;53:231-46.

5.Seifert F, Maihofner C. Functional and structural imaging of pain-induced neuroplasticity. Curr Opin Anaesthesiol 2011; 24: 515-523

6.Sandkühler J. Learning and memory in pain pathways. Pain 2000; 88: 113-118

7.Jensen M. Magnetic resonance imaging of the lumbar spine in people without low back pain. New Eng J Med. 1994;331: 69-73.

8.Katharina A. Schwarz, Roland Pfister, Christian Büchel. Rethinking Explicit Expectations: Connecting Placebos, Social Cognition, and Contextual Perception. Trends in Cognitive Sciences, 2016