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.

 

Painful sex? Check out our helpful tips about what you can do to help!

If you’re having pain during sex, try the following tips:

You should have a consult with a pelvic floor physical therapist for training on positioning and how to use a set of vaginal dilators:

They are used to stretch the vaginal tissue, facilitate pelvic muscle relaxation and prepare for intercourse.

If you are able to have penetrative sex:

  • Practice breathing techniques or stretching prior to intercourse
  • You may want to begin with clitoral stimulation to increase natural lubrication and vaginal expansion prior to insertion
  • You can use the dilator with your partner if you feel comfortable as a way to transition from medical to sexual use of dilator. This practice can help prepare you for engaging in sexual intercourse and help you both come to understand the challenge of the healing process and develop skills for working together as a team
  • The transition from plastic dilators to a partner’s penis is often an exciting step for a couple. To make the transition, your partner has to learn a passive role, letting you control the insertion and then just resting inside the vagina for a while. In time you can expand this exercise to permit insertion by the male of his own penis, clitoral stimulation, some thrusting and experimentation with different positions.
  • Use plenty of lubricant and use one that is water soluble
  • Apply ice or frozen blue gel pack wrapped in one layer of a hand towel to relieve burning after intercourse. Frozen peas or corn in a small sealed plastic bag mold comfortably to vulvar anatomy.

Keep in mind that intercourse isn’t always 100% comfortable. Temporary tugs and pressures are often just part of getting started. If some minor discomfort exists, try moving ahead anyway – but if obvious pain persists, don’t ignore it, stop. If you encounter unexpected difficulty, you may want to practice with the dilators some more before attempting intercourse again. Continued dilator use may be necessary from time to time, to keep the vaginal area relaxed and comfortable.