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.

Don’t miss your chance to listen to Evelyn Hecht, PT, ATC speak about modern pain science and how she’s been using it to help heal chronic pain

 

Follow this link to listen to Evelyn’s episode of the Healing Pain Podcast: listen to podcast here

Chronic Pain Solutions for Complete Recovery Pt. 2: Movement

In Chronic Pain Solutions for Complete Recovery Part 1, we discussed “neuroplasticity”, the ability for the amazing brain to change and grow for the better.  For a quick review, check out this cool, short YouTube video  on neuroplasticity. Part 2 Movement will focus on how and why movement is crucial to help decrease chronic pain.

Motion is lotion.

The body and brain loves movement.  A sedentary lifestyle associated with fear of movement or lack of motivation to move leads to weakened muscles, stiff joints, weight gain, increased inflammatory cells, brain atrophy and… more pain. Movement grows new neuronal connections within the brain, basically rewiring the faulty circuitry associated with our internal pain alarm. Remember the burglar and alarm analogy from Part 1?

Use it or lose it

Above is an illustration of our brain. The region highlighted in rose color is the called the motor cortex, which basically  is a map of our body located on the brain, our virtual body. Each body part is represented on a specific region of our motor cortex. The tongue and hands have a lot of real estate on the brain compared to the knee because the tongue & hands are critical for survival.

For example, when you speak, the tongue section of the motor cortex is activated.  When you turn your head to look at an attractive person passing by, the neck and upper back  on your brain’s map light up like a Christmas tree.   However, if  you have chronic neck pain and can’t rotate your neck fully, your “virtual neck” doesn’t fire as quickly or intensely and can even atrophy.  The good news is that we can retrain our brain, restoring these lost connections which reduces pain because of the brain’s neuroplasticity.

No Brain, No Pain

OK, so we know that without a functioning brain, we cannot feel pain. With chronic lower back pain, patients have a smaller “virtual lower back” on their motor cortex as compared to healthy subjects.1, 2, 3. The good news is that no matter how long you have experienced chronic pain, with consistent practice of various techniques including daily movements we’ll discuss here, the brain can learn healthier patterns which results in 1) reactivation of the motor cortex and 2) less pain.

A study in 2010 looked at motor cortex activation of patients who had 4+ years of low back pain who either participated in a  walking program or a core exercise program4.  The group who participated in the deep core exercise program gained more lower back “real estate” on their motor cortex (ie showing more brain activation) and they reported a significant decrease in lower back pain.

The group who did the walking program showed no changes in pain nor brain activation. Walking can be very helpful for the joints, muscles and heart, but specific exercises targeting the area in pain can improve brain activation and lower pain.

Core Training

Below are three videos on training the deep core muscles (Transverse Abs, deep lower back). These videos are not to be used in lieu of seeing your medical doctor or physical therapist.

Level 1 Core Video

Level 2 Core Video

Level 3 Core Video

What about other areas of the body in pain? Generally speaking, there are actually core muscles for your neck which are the deep cervical flexors; the core muscles for your arms are the scapular muscles and the core stabilizers of your legs are glutes and pelvic floor.  Exercising these muscles can help change the brain to look and act similarly to those without pain.

Strength Training

When you think of strength training what do you visualize?

 

 

 

 

 

 

 

 

 

 

 

Do you picture the bulky weightlifter power-cleaning hundreds of pounds? While this is technically strength training, so is lifting 1 lb. dumbbells for 3 sets of 5 reps.  Your “heavy” is not your boyfriends “heavy”, is not your mom’s “heavy” and may not be your ‘heavy” 2 months from today.

Strength training streamlines the body and can create a more toned, slim appearance. It helps breakdown fat up to 72 hours after a workout, stabilizes your spine so your posture keeps in good alignment and nerves can function more easily. Strength training also prevents osteoporosis by building bone density, decreases visceral (abdominal) fat linked to heart disease, helps control appetite and decreases inflammation throughout the body5. Most importantly, it can help rewire the brain and eliminate pain just like core training does.

Here are three strengthening level 1 basics for anyone. Remember these are suggestions and if you are having pain, best to first consult with your physical therapist to get tailored advice.

Squats

Region targeted: thighs and glutes Frequency: 2-3x/week
Joints stabilized: hips and knees Intensity: heavy with minimal discomfort
Helps with: bending, lifting, sit to stand 2-3 sets 8-12 reps, 30s rest -> 3-4 sets 6-8 reps, 1-2’ rest

Bent Over Rows

 

 

 

 

 

 

Region targeted: back, shoulders, trunk, arms Frequency: 2-3x/week
Joints stabilized: shoulder, elbow, spine Intensity: heavy with minimal discomfort
Helps with: pulling, lifting, carrying 2-3 sets 8-12 reps, 30s rest -> 3-4 sets 6-8 reps, 1-2’ rest

Push Ups

 

 

 

 

 

 

 

Region targeted: shoulder, chest, upper back Frequency: 2-3x/week
Joints stabilized: shoulder, elbow, spine Intensity: heavy with minimal discomfort
Helps with: pushing, carrying, lifting 2-3 sets 8-12 reps, 30s rest -> 3-4 sets 6-8 reps, 1-2’ rest

Daily Movement

Another great way to begin to counteract sedentary lifestyle, especially if you sit for work or school, is to track your steps via a pedometer or on your phone. Depending on your fitness level and pain levels, aim for 5000 steps every day and gradually increase to 8000 then 10,000 steps (over time). Research shows that doing high impact cardio workouts is too stressful for many people with chronic pain so walking can promote similar benefits6.

Even if you are house bound, taking a stroll around the house/apartment once an hour can start to add up your steps. Instead of going to the mall to shop, let it be a destination for a comfortable walk with plenty areas to rest anytime you need.  If you work, walk an extra few blocks to the subway/bus stop, or park your car farther away from your home.  Instead of taking an elevator to your exact floor, take it to the floor below.

Once walking becomes easier, begin a targeted core and strengthening program for all of the benefits listed above. There are so many! Move every day, avoid being too sedentary, get guidance to help you find your best exercise plan and most importantly keep practicing this for at least 3 months. You’ll be amazed to feel less pain by that time.

References

  1. Strutton PH, Theodorou S, Catley M, McGregor AH, Davey NJ. Corticospinal excitability in patients with chronic low back pain. Journal of Spinal Disorders & Techniques 2005;18(5):420e4.
  2. Tsao H, Galea MP, Hodges PW. Reorganization of the motor cortex is associated with postural control deficits in recurrent low back pain. Brain 2008;131(Pt 8):2161e71.
  3. Flor H, Braun C, Elbert T, Birbaumer N. Extensive reorganization of primary somatosensory cortex in chronic back pain patients. Neuroscience Letters 1997;224(1):5e8
  4. Tsao H, Galea MP, Hodges PW. Driving plasticity in the motor cortex in recurrent low back pain. European Journal of Pain, 2010; Feb 22
  5. Tatta J. Heal your pain now. Boston, MA: Da Capo Press; 2017.
  6. Kristen M. Beavers, Daniel P. Beavers, Sarah B. Martin, Anthony P. Marsh, Mary F. Lyles, Leon Lenchik, Sue A. Shapses, Barbara J. Nicklas; Change in Bone Mineral Density During Weight Loss with Resistance Versus Aerobic Exercise Training in Older Adults, The Journals of Gerontology: Series A, , glx048