 A summary of the Commentary by Melissa A. Farmer “What is special about the vulvar vestibule?” Copyright 2015 by the International Association for the Study of Pain, March 2015, Volume 156, Number 3 If you were to take a mirror and take a look at the opening of your external genitalia, you would be looking at your vulvar vestibule. The vulvar vestibule (or “entrance way” to the vagina) includes from the clitoris to the urethral opening (for urinating) to the vaginal opening as well as portions of the inner lips on either side of the vaginal opening. Many incorrectly refer to the whole area as “the vagina”. Actually the skin of the vestibule lies between the vaginal lining and the outside hair bearing skin. If you need a little help on vocab and anatomy - check out this blog.
It is also really important to realize that the most common reason for entrance pain with intercourse, tampon use, vaginal speculum or just light touch from clothing is the common condition known as vulvar vestibulitis or better called vulvar vestibulodynia. (“itis” means inflammation and “dynia” means pain). So back to looking in the mirror. You’ve probably never whispered “you’re special” to your vulvar vestibule. But it is. Not just for its role in the reproduction of life, but because the external tissues in that area are actually very different from other mucosal surfaces in the body. Mucosal surfaces are those bodily tissues that excrete mucus like the inside of your mouth and the inside of your nose. The difference is in the “profile” of the immune cells in that area, meaning the type and the amount of the cells of the immune system. Given how important the external genitalia is to the reproduction of life, we would suspect that it would indeed be a place that needs some extra immune system defense. This same observation holds true for other species as well, not just humans. We also know that one of the methods the immune system uses to attack what it identifies as a threat to the system is inflammation. And as a result of inflammation we often feel pain. It makes sense then that pain brought on by inflammation at the vulvar vestibule would be different than the pain brought on by inflammation at other mucosal sites. Recent research seems to indicate that pain felt in this area is determined by 1) the amount (not simply the presence alone) of low grade inflammation, 2) altered vulvar nerve innervations, meaning an abnormality in the distribution of impulses of the nerves in that area, and 3) genetic susceptibilities that contribute to abnormal inflammatory cascades (chemical messengers that ramp up the immune system and cause a domino effect). Vagina! (You are definitely more complicated than we thought!!!) Just making sure you’re still with me here, this information is dense but it’s how we know persistent genital, sexual, and pelvic pain has a MEDICAL and SCIENTIFIC explanation. Ok, back to the mirror. We know that the vulvar vestibule is derived (or made from) the endoderm. When we were just embryos in the womb, the inner-most layer of that embryo is called the endoderm. Do you know what else was derived from the endoderm? The bladder and urethra and also the gastrointestinal tract. It is possible that these other structures also have unique immune profiles, similar to that of the vulvar vestibule. Let’s briefly recap: The vulvar vestibule has a unique immune profile compared with that of other mucosal sites. An immune/inflammation response at the vulvar vestibule isn’t enough to cause pain. Pain is determined by the magnitude of the immune response/inflammation. The vulvar vestibule, the bladder, and urethral linings are all derived from the endoderm and could share immune profiles. One last piece of information that’s critical to note: the most recent research is finding that in the clinical setting, self-reported pain levels at the vulvar vestibule are closely connected with the release of an immune system messenger known as cytokine. That means when research study participants reported increased pain, the presence of cytokines in the examined vulvar tissue also increased. What does all of this really mean? It means that we know that chronic genital, sexual, and pelvic pain is real in a clinical and biological sense. We of course recommend treatment modalities that work from the top-down to address the mind-body connection and help turn the central nervous system pain ‘volume dial’ down. But we also want to highlight the science behind the pain and the need for bottom-up approaches in line with current research and the desperate need for earlier diagnosis and appropriate treatment modalities and medications to counter these inflammatory and painful processes.
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NUTRITIONAL THERAPY FOR PELVIC PAIN GUEST POST BY CERTIFIED WOMEN'S HEALTH AND NUTRITION COACH, SUSAN TESSMAN  “After years of working with thousands of women patients, I have found that no therapy can be fully effective without including beneficial dietary changes as part of the treatment plan." (1) Over 20 years ago those words in a book on endometriosis were my first introduction to the connection between food and pelvic pain. I had been diagnosed with uterine fibroids, ovarian cysts and advanced endometriosis earlier that year and was determined to try anything I could that might help to reduce the pain, and avoid having to undergo further surgery or deal with the emotional and physical side effects of hormonal treatments.
At that time there was much less access to information on complementary therapies for pelvic pain, but I learned as much as I could about a holistic approach for treating endometriosis and other pelvic pain issues that I developed. I followed specific dietary recommendations along with addressing other lifestyle factors like exercise, sleep, and mind-body practices and had regular treatment with pelvic floor physical therapy, acupuncture and massage therapy. It took trial and error to learn what worked best for my body, but I had great results in managing my health outcome. Most of the time there’s not a magic bullet cure for pelvic pain - it takes an integrated and multi-disciplinary approach to support sustained healing. Whether you suffer with painful bladder syndrome, pelvic floor dysfunction, endometriosis, irritable bowel syndrome (IBS), vulvodynia, or other sources of chronic pelvic pain, nutrition can be used as an additional therapeutic tool to improve these conditions, and to heal co-existing health issues that can increase pelvic pain. NUTRITION AND ROOT CAUSES OF PELVIC PAIN When working with nutritional therapy for pelvic pain we want to consider what some of the root causes and triggers might be. It’s estimated that the breakdown of sources of chronic pelvic pain are approximately 37% gastro-intestinal, 31% from urologic causes, 20% reproductive system, and 12% musculoskeletal. Studies have shown that chronic pelvic pain is frequently associated with systemic inflammation, including autoimmune diseases. (2) A 2002 study reported in the Sept. 27th issue of Human Reproduction (3) concluded that hypothyroidism, fibromyalgia, chronic fatigue syndrome, autoimmune diseases, allergies and asthma are all significantly more common in women with endometriosis than in women in the general USA population. Vulvodynia is associated with other chronic comorbid pain conditions such as fibromyalgia, interstitial cystitis and irritable bowel syndrome, individually and in combination, and the presence of vulvodynia or any of the other comorbid pain conditions increases the likelihood that a woman will have one or more of the other chronic pain conditions. (4) If you suffer with multiple health issues, nutritional therapy can not only address the pain symptoms, but can also support healing in other inter-related body systems that can be impacting your pelvic pain. The right nutritional shifts can correct digestive disorders, improve the healthy balance of gut microbiota and ability to absorb healing nutrients, bring hormones and blood sugar levels into better balance – all of which can impact pain levels, support your recovery from surgery and medical procedures, and help to down-regulate the nervous system so pain response is not as intense. ELIMINATION DIETS TO DECREASE INFLAMMATION AND PAIN To begin to address pelvic pain symptoms, a personalized elimination diet is an important tool. What exactly is an elimination diet and why do we use it? Most people are familiar with food allergies and how potentially deadly they can be. A food allergy reaction occurs when your body recognizes a certain food as harmful and produces an immune response to that food, which can result in severe symptoms. Antibodies produced in the allergic response (most commonly IgE antibodies) will show up on a food allergy test. 8 food groups have been identified as causing 90% of all IgE food allergies in the U.S.: Milk, eggs, fish, shellfish, wheat, soy, peanuts, and tree nuts. But many of these same foods also cause reactions that may not produce IgE antibodies, but do cause other immune responses, and these reactions are referred to as food sensitivities or intolerances. A common example of this would be having “lactose intolerance” where you’re lacking the enzyme needed to properly digest this milk sugar. These kind of responses are often delayed and not always as obvious to detect. Symptoms of food intolerances can include digestive problems like bloating, cramping, constipation, diarrhea; headaches; sinus problems; unexplained weight gain; fatigue; skin conditions; and increased pain anywhere in your body. You can imagine if you’re eating poorly tolerated foods over and over again, and each time your body is having a reaction, that this can lead over time to a chronic state of low-grade inflammation, as the immune system is always being activated. And once inflammation is ongoing, it can also lead to developing even more food intolerances, so a very negative cycle of inflammation is set up, and symptoms increase. Testing for allergies and food intolerances can be extremely helpful, but tests are not always completely accurate, and can be expensive, so using an elimination diet can be another effective method to help identify these possible food sensitivities. One of the main goals of using an elimination diet with pelvic pain conditions is to calm down and reduce the inflammation cycle and resulting pain and symptoms, and allow the body to rest and heal. ELIMINATION DIET BASICS The nutritional advice I followed over 20 years ago for my pain was to stop eating dairy, wheat and sugar (and processed foods in general) and focus on whole foods. I’ll admit it wasn’t a total breeze at first! Those three food groups are still considered top of the list to avoid to reduce many disease or pain states, including pelvic pain conditions. But in a full elimination diet protocol we include all of the main “allergenic” foods: dairy, gluten, corn, shellfish, soy, eggs, peanuts, tree nuts as well as alcohol and caffeine. Some people may also need to remove nightshades, citrus fruits and sometimes even non-gluten grains and/or legumes. These foods are removed for 3 to 4 weeks, and at the end of that time you add back only one of the eliminated food groups at a time, eating 2-3 servings per day for 3 to 4 days, making note of any symptoms that arise and then breaking from that food to let the symptoms resolve. The following week you try reintroducing the next food. For those foods you identify as having a reaction to, it’s a good idea to then stay off of them for at least 3 to 6 months, if not longer, to allow for full healing before trying to introduce them again. Many people choose to permanently remove certain foods because they experience such improvements in their health. When people first think about removing these foods from their diet, especially dairy, gluten and sugar, it can be overwhelming to say the least, because these foods have become such a huge part of the standard North American diet. It helped me stay motivated when I understood a little more of the “why” - Dairy: Lactose is a sugar in cow’s milk, and casein is the protein found in cow’s milk. People can be sensitive to either or both. Many people who are gluten intolerant are also casein or lactose intolerant. Gluten can damage the part of the intestine that is responsible for producing the enzyme lactase, which is necessary for breaking down lactose. About 75% of adults worldwide are lactose intolerant, and don’t have the digestive enzymes needed to digest this milk sugar, and that means digestive distress. Dairy products are also a dietary source of arachidonic acid, the fat used by the body to produce “bad” prostaglandins, localized hormones which can increase pelvic pain, cramps, and inflammation. Gluten: Gluten includes several related proteins found in wheat and other grains including spelt, kamut, triticale, barley and rye. It’s estimated that approximately 30 to 40% of the U.S. population has some sensitivity to gluten, in addition to those diagnosed with full blown autoimmune celiac disease. Non celiac gluten sensitivity can over time result in damage to the intestinal lining or mucosa, that then allows undigested food proteins to “leak” through the gut wall into the bloodstream, which can trigger pain, inflammation and autoimmune responses. Even among people who are not sensitive to gluten, eating it triggers the release of a protein produced in the small intestine called zonulin, which again can lead to damaged intestinal lining. Gluten expert Dr. Alessio Fasano has stated that nobody digests these proteins well, and because of this it tends to trigger an inflammatory response. Gluten intolerance has also been linked to altered estrogen levels. In a 2012 study on women with severe painful endometriosis-related symptoms over 12 months, 75% of the over 200 participants reported statistically significant improvements in painful symptoms when eating gluten-free. (5) Sugar: Sugar depletes the body’s B complex vitamins and minerals which can worsen muscle tension as well as nervous tension and anxiety. Lack of B vitamins can make it harder for the liver to handle estrogen (important with a number of pelvic pain conditions), and B6 in particular is required for production of good prostaglandins that have relaxant and anti-inflammatory effects. Too many simple carbohydrates and sugar can contribute to indigestion, leaky gut (damage to the lining of the gut), a suppressed immune system, and candida overgrowth. These all mean more inflammation, which can trigger increased pain or symptoms. FOCUS ON ANTI-INFLAMMATORY FOODS The good news is there are still lots of delicious, satisfying and nourishing foods left to eat – really! With the right guidance, you will find an elimination diet isn’t the imagined journey of utter deprivation, but leads to discovering and enjoying new foods, losing old cravings, and learning to easily make healthy substitutions. Foods that are well tolerated can be eaten again after only a few weeks. A focus on choosing mostly whole, nutrient dense, organic foods when possible reduces exposure to toxic chemicals, pesticides and added hormones, so the best choices are:
A basic elimination diet is a great start to tackling your pelvic pain. There are growing resources available via books, group programs, and personal nutrition coaching to lead you through the process, but it’s always best to work with someone who understands pelvic pain conditions and can develop your personalized nutrition plan based on your particular genetic makeup, pelvic pain symptoms, and other health conditions and treatments you’re undergoing, especially in working to identify any personal food sensitivities and recommendations that are outside of a basic elimination diet. A few examples of how we would tailor a pelvic pain nutritional program would be to also test removing additional foods that are known to increase symptoms for specific conditions:
Resources Cohan, Wendy, RN, The Better Bladder Book. 2011 Morrison, JA, Sullivan, J. A novel approach to treating endometriosis. Alternative & Complimentary Therapies, August 1999, p 225-229. Petrelluzzi KF, Garcia MC, Petta CA, et al. “Salivary cortisol concentrations, stress and quality of life in women with endometriosis and chronic pelvic pain.” Sep;11(5) (2008): 390-7. doi: 10.1080/10253890701840610. Segersten, Alissa and Malterre, Tom, MS, CN, The Elimination Diet. 2015 BIO Susan Tessman is a Certified Nutrition Coach, and Certified by the Integrative Women’s Health Institute as a Women’s Health and Nutrition Coach, with specialized training in chronic pelvic pain, hormone health and pre-conception health. She is dedicated to supporting women suffering with pelvic pain conditions, using a whole person approach that includes nutrition and lifestyle solutions. For more resources on endometriosis and pelvic pain please visit www.susantessman.com  Vaginismus is a condition that affects the muscles of the pelvic floor and involves involuntary spasming or clenching of the pelvic musculature. Typically this reactive tightening of the muscles is in response to insertion or the attempt of insertion of an object into the vagina, making vaginal intercourse painful and sometimes impossible. Thankfully, this condition is becoming more and more recognized by the mainstream media. But coming along with it are some misconceptions about vaginismus that we'd like to clear up. Myth #1: Kegels Cure VaginismusKegels, done correctly, are a great strengthening technique for the muscles of the pelvic floor for many women and men. However, someone who is struggling with vaginismus is not a good candidate to begin practicing kegels. While kegels may be introduced later on to help the overall pelvic and core musculature function together during certain body movements, they should be avoided at first. The focus of treatment should instead be on the ability to consciously recognize and relax the pelvic floor muscles. It is best to receive this treatment under the direction of a specialized women's health physical therapist who can guide you through imagery and biofeedback techniques. Also, consider our physical therapy digital download chapter packages to assist you at home. Myth #2: Vaginal Dilators are Used to 'Stretch' the MusclesDilators are an incredibly helpful tool for those with vaginismus. Their function in the treatment process, however, isn't so much to "stretch" the tight muscles of the pelvic floor. The pelvic floor muscles are already quite capable of stretching far beyond what is needed for sexual intercourse (think, delivering a baby). The problem with vaginismus is that the central nervous system (the brain and all its related systems including the spinal cord and nerves) is sending signals to the pelvic musculature to brace itself for what it considers or 'remembers' to be painful: vaginal penetration. So dilators work by desensitizing the central nervous system (see Myth #3 for more on this) and by providing trigger point release (intentional pressure to points of muscular tension for the relief of pain, much like in your neck or shoulders). To learn more about the science of chronic pelvic pain and the use of dilators in the treatment of vaginismus, purchase the DVD Healing the Pain Down There: A Guide for Females with Persistent Genital & Sexual Pain. We recommend dilators from Syracuse Medical Devices as they are made of medical grade material and have a consistent length. It is important to have a long enough dilator to be able to reach the second layer of the pelvic floor musculature even with the smallest dilator in diameter. Myth #3: You Just Have to Try to Relax and Keep Practicing SexIf you continue doing as you have been doing - having sex that is painful, then setting yourself up in that same environment with your partner will actually perpetuate or re-enforce the pain - because your mind is already anticipating the pain - it is a known response and you cannot just "force" a relaxation response instead. But if we remove the “red flags” from the brain and place YOU IN CONTROL using the dilators, we can re-train the brain to realize that there doesn’t need to be a “fight or flight response”, we can begin to “unwind” the nervous system. When you start with an extra small dilator and can insert and move it and do self stretches with low to no pain - then the brain starts to realize that - OK - that wasn’t so bad and the secondary responses of muscular tensions ease also allowing for less pain and your overall confidence level with repeated successful sessions with the dilator allows you to become ready for return to intercourse with low to no pain. It is important that you abstain from intercourse (not intimacy) during dilator sessions until you can progress to the proper size. So essentially what happens is you change the perception in your brain about the health of your vagina, decreasing the sensitivity of your nervous system to keep the muscle tension in check to help achieve a good end result. Content Providers of this Article, paindownthere.com, and video guide series for Healing the Pain 'Down There':
Robert Echenberg, MD Karen Liberi, MS, MPT, WCS Alexandra Milspaw, PhD, LPC  New to paindownthere.com this month: we've added digital chapter packages in our products page. There are five chapter packages, each include a unique set of specific chapters from the Video Series Healing the Pain 'Down There': A Guide for Females with Persistent Genital & Sexual Pain.
Each digital package is designed to address five main topics: 1. Explaining Pain: The science of pain and as it relates to chronic pain 'down there'. Everyone should know this information. Our team doctor uses these chapters to prep his patients before an appointment because everything he's going to tell them about pain science as it relates to Chronic Pelvic Pain disorders is in here. 2. Brain Neurobiology & Healing: Don't let the title scare you! Easily learn the basics of brain systems and strategies for healing the brain, including mindfulness-based stress reduction. 3. Physical Therapy (Breath, Posture, Stretching): Practicing appropriate breath, posture, and stretching techniques for pelvic floor and core functionality and health. 4. Physical Therapy (Relaxation and Strengthening): Practicing relaxation and strengthening techniques for the pelvic floor and hip musculature. 5. Physical Therapy (Dilator Use): Specific guidance and instruction in the use of dilators to desensitize pain responses in the pelvis for decreasing pain with sexual intercourse. Each digital package is priced individually so that if you're only interested in one or two packages you only pay for what you want, making our guide more accessible and affordable. Chapter 6: The Pelvic Floor: An OverviewWatch Chapter 6 of the Video Resource Series Healing the Pain 'Down There': A Guide for Females with Persistent Genital & Sexual Pain. This chapter introduces the physical therapy component of the DVD. Hear from Karen Liberi, a physical therapist specializing in women's health and pelvic pain for over 16 years. Learn how to view pelvic pain as a threshold of pain and how to affect and move this threshold through techniques we will teach you. What feels like "there is no rhyme or reason for my pain" will start to have a rhyme and a reason. The feeling of "I don't know where the pain is coming from" becomes "this is the reason for my pain and I can do something about it". The global feeling of pain in the pelvis becomes an identifiable, local area of pain that can be addressed with the strategies given. The psoas (said like so-az) is an extremely important muscle. It plays an important role in postural and structural stability as well as in respiration. This muscle attaches from the front part of your lower spine to the front part of your hip allowing you to bring your knee to your chest. Several interconnected factors going on in the psoas and surrounding areas can affect pelvic, genital and sexual pain. For instance, because there are nerves that run through the psoas, if the muscles are too tight they could be pressing on the nerves and contributing to pain. In another instance, if this hip musculature is too tight it forces the angle of the pelvis forward, causing excessive curvature of the lower back which affects our ability to regulate the tension of the pelvic floor. Therefore, a properly functioning, released, and relaxed psoas muscle is crucial in the process of healing the pain "down there" and maintaining health and functionality in the pelvis.   The long-awaited Video Guide Healing the Pain 'Down There': A Guide for Females with Persistent Genital & Sexual Pain is now available for purchase. Learn More: A woman with chronic pelvic pain brought together a team of multidisciplinary professionals to create this instructional and educational DVD guide for those suffering with “pain down there”. The team represents over 50 years of experience in women’s health related fields including OB/GYN, physical therapy, mindfulness techniques, and human sexuality with their focus being on the treatment of pelvic pain. This educational video is intended for women of all ages who are experiencing pain during intercourse who want to learn why they have their symptoms and learn strategies to improve them. This video is also for teens and young women who may be at risk for developing these symptoms, and for clinicians who are practicing in the field of women’s health. “Groundbreaking … “ Jill Osborne, MA ICN Founder & CEO “A well designed comprehensive view of pelvic pain from a multidisciplinary perspective and clear options for returning to health and well being.” Sandra Hilton, PT, DPT, MS “A very important resource for many women...” Frank Tu, M.D., MPH " Respected pelvic practitioners create a road map to navigate the challenging path of healing pelvic pain." Dustienne Miller PT, MS, WCS An important way to promote or restore function and control of the pelvic floor is through the breath. Clenched abdomen and habitual breathing from the chest directly affects the pelvic floor, making it too tight/tense and "turned on" which can contribute to sexual pain. Shallow chest breathing also cues our bodies into the tensing, fight or flight mode of the nervous system (see previous blog).
Breathing is meant to come from the abdomen/diaphragm, not from the chest. If you've been taught by sports or cultural influences to suck in your abs and breathe from your chest you may need to re-train your body to breathe appropriately. Musculoskeletally, the respiratory diaphragm and the pelvic floor work together. As you inhale .... the diaphragm lowers and the pelvic floor expands. As you exhale... the diaphragm and pelvic floor return to their elevated positions. Therefore, if you are constantly breathing from your chest, your pelvic floor never gets a chance to relax and expand. Mentally check into your breath pattern throughout the day to ensure proper breathing techniques. We go more in depth about how to do this in the DVD, Healing the Pain 'Down There': A Guide for Females with Persistent Genital and Sexual Pain.  Take a look at this image. The Autonomic Nervous System is responsible for managing our breathing, heart rate, and other basic survival processes. This system is not in our conscious control. There are two branches of the Autonomic Nervous System: Sympathetic and Parasympathetic. The Sympathetic branch initiates a fight or flight response. The opposite is the Parasympathetic branch: calming, relaxing, restorative. Both Sympathetic and Parasympathetic are phases of the Autonomic Nervous System. Remember, the Autonomic Nervous System is not in our conscious control.
Stick with me here. When signals from injury or previous injury are interpreted by our brain and our nervous system as painful enough, the Sympathetic branch of the nervous system (the fight or flight response) kicks in. It is an evolutionary response that is meant to be protective. It leads to physiological changes: muscle tension, increased heart rate, increased blood pressure, shallow and rapid breathing, sweating, dry mouth, slowed immune response, inhibited digestion. All this to give us the strength to either fight or run away. It is a stress response. This response could save our life in moments of real and imminent danger. But we want to stay out of this branch of the Autonomic Nervous System during the times we don't need it, which for many of us makes up the majority of our time. We don't want to 'hang out' here. The question you should be asking at this point is: but how can I help it, since it's not under my conscious control? GREAT QUESTION! Enter the Somatic Nervous System. The Somatic Nervous System is within our conscious control. It makes possible our body movements as well as how (not whether) we breathe. That means that through the conscious manipulation of breath we can cue into the Parasympathetic branch of the Autonomic Nervous System and induce a relaxation response. Deep, diaphragmatic breathing stimulates the Parasympathetic nerves, which has a calming effect on the entire body. This is where we want to 'hang out'. Shallow, chest breathing cues us right into the Sympathetic system - a tensing, fight or flight type breathing. Quiz: 1. Ask yourself "how do I breathe?" 2. Is the way that you breathe cueing you into the Sympathetic (fight/flight, tension, stress) system or the Parasympathetic (relaxing, calming) system?  So to recap:
The amount of danger signals that are sent up to the brain + The level of threat that is perceived by the brain = The amount of pain we experience In the context of chronic pelvic pain, the brain either perceives safety or danger. The more it perceives danger, the more pain we experience. It is important to note that chronic pain is not prolonged acute pain. "Chronic Pain" is the result of our brain interpreting signals through our nervous system, commonly long after the actual tissue damage has healed. Triggers of these signals in the pelvic region can include one or more of the following: 1. Functional Systems (bladder, bowel, uterus, prostate in male pelvic pain) 2. Structural Systems (muscles and ligaments, often in spasm) 3. Nerves firing (causing tingling, burning, itching, dryness, aching, or even stabbing of surface tissues) All of the signals from these triggers add up in our memories, emotions, and thoughts. These signals are also called "generators". When generators are sent up to the brain, the brain responds by sending down corresponding inhibitors. For example, when we stub our toe it really hurts for a couple of seconds! Until our inhibitors take over. Our brain immediately tells us that by all of our previous experiences, stubbing our toe is not dangerous. So the pain quickly fades away. But with chronic pain, the generators outweigh the inhibitors and the volume of our nervous system gets "turned up". Over time, the nervous system responds more and more strongly to a smaller amount of signals. This is one reason why sensitivity related to the external genitals and pelvic floor, for example, can increase over time when not treated and managed properly. The more we understand what is going on in the body, how pain is processed, and the more "tools" we have to temper these signals and how they are reacted to in the brain, the more we are likely to reduce the pain or "turn the volume dial down". Focused training can help us guide us in the process. These tools include: Mindfulness-Based Stress Reduction, diaphragmatic breathing techniques, and physical therapy. As well as other disciplines like medicine, psychological counseling, nutrition and dietary changes, yoga, and massage.  Pain is the alarm system in the body. So called acute pain is essential to our survival. We need to know that we have injured ourselves so that we can be properly warned and instantly make moves to protect ourselves. Signals from the injured area travel through our nervous system to our brain and trigger the alarms to go off. This happens instantaneously but it's not as simple as it sounds.
When signals from all the senses and from all parts of the body travel toward the brain they are influenced along the way at various levels of the nervous system before being processed and interpreted. For instance, we will feel a twist of our ankle in different ways under different circumstances because the "pain" signal travels to parts of the brain where previous experiences, memory, and knowledge about our bodies are stored. Think of it this way: If you trip on a curb and sprain your ankle will you feel pain? Yes. But if you sprain your ankle and you have a big bus coming at you will you feel pain? Probably not. Not until you've moved out of the way of the bus and are safe again. Recollections of all our senses including sights, sounds, touch, smells, and tastes are stored indefinitely in many locations in our nervous system and ultimately all of our ongoing experiences are therefore processed and interpreted by a vibrant and constantly changing network of connected combinations called "neurotags" that together form the overall concept known as the "neuromatrix". The neuromatrix can be conceptualized by functional MRI images. We can see all the different parts of the brain that light up in different colors and locations when there are signals and triggers being set off both from inside the body and from the outside environment. The nervous system is constantly checking in with the neuromatrix to decide how to react in any given situation, almost always to protect us. So, this neuromatrix of ours allows us to give variable meanings to pain and suffering - commonly determined by the accumulation of our past experiences (those that we remember and those that we do not remember) as well as our acquired beliefs, thoughts we focus on throughout the day, our emotional state, and our overall understanding and perception of the situation. Think again of spraining your ankle when you have a big bus coming toward you. You won't feel the pain of your ankle until you are out of the way of the bus. This is the neuromatrix at work. It perceives what is going on around us and determines what is more "dangerous" in the present moment. It is important to keep in mind that our brain's perception is not always accurate and not always in our control. How do these concepts help us understand chronic pain in the context of pelvic pain? To be continued...
Take a look at the image in the blog post just below. This image of the female pelvis is incomplete because there is a great deal more to the anatomy of the female pelvis that is just not shown in this image. The pictures in this blog post show much more of the complete anatomy of the pelvic region.
The actual causes of chronic, persistent pain itself are in all of these neuro-myofascial components: Nerves, Muscles, and Ligaments. Bladder, bowel, and reproductive organs are commonly acting as "triggers" that set off painful, but protective responses in the region. Just as in any other area of the body, the muscles, nerves, and ligaments go into a protective bracing mode as a result of current tissue injury, protecting against further injury, and even when the system is reminded of past injury. These structures are trying to immobilize the region in order to control the pain. Comprehensive assessment and treatment of chronic pelvic pain therefore will naturally include specialized pelvic floor physical therapy to rehab and release long term muscle spasming and trigger points, as well as a working knowledge of diagnosing and managing chronic nerve type pain in the pelvic and genital region.  Over the last several weeks I (Stephanie) have been busy trying to catch up at work, getting to my commitments on-time, and generally just trying to keep my head above water among all of life’s responsibilities. What typically is a low to no pain sexual experience for me one night turned out to be excruciating pain instead. I alerted my husband and we enjoyed other forms of intimacy (I never go through with painful sex, it only serves to heighten the fear of it next time). When we discussed it later I expressed my frustration: “I don’t know why it’s hurting, it doesn’t make any sense”. I set out my towel and pillows to use my dilators so I could get a sense for where the pain was and why. The smallest dilator was difficult for me, which is usually never the case. As I worked through the process it began to hit me. Of course it made sense!
In my constant rush I’d neglected to practice my massage techniques on my stomach and inner thighs for days. After my dilator use (I could only successfully use the smallest size without resistance) I immediately grabbed the lotion and sure enough, very tight, tense, and painful sections in both areas. I had multiple trigger points to release. As I practiced my relaxation breathing while holding pressure on the trigger points I realized I’d been holding my stomach tense and had slipped back into “chest breathing”. I also noticed areas of tension in my hips. So after my massage techniques I got my tennis ball and found these points of tension and pain in my hips. I then stretched my hip musculature and did hip strengthening exercises. I was reminded of the couple times over the week I had worked out. Maybe I had overdone it a bit, after all my inner thighs are touching so I could be getting fat. And in my morning and evening rush I’d forgotten my probiotics and hadn’t been very mindful during the day of drinking enough water. The recollection came to me that my stools had been hard to pass lately. I scolded myself that night for putting my pain on the back burner. If I had been mindful to check in mentally with my stomach, hips, legs and pelvic floor I would have caught the fact that they were holding tension. If I had sat down for a few minutes to participate in guided mediation it would have prompted me to notice these areas of tension I was holding in my body. If I would have taken my work out slower, not been so concerned with my body image, and more diligently drank water and remembered my probiotics I could have avoided this current predicament. Grateful for the reminders, I forgave myself and went to bed. The next morning I woke up with the image of the volume dial in my head. Over several weeks all of the combined factors added up and my pain volume dial got turned way up! Stress: notch up. Chest breathing: notch up. Muscle tension: notch up. Hard and big stool: notch up. Lack of water: notch up. And then I went into sex expecting a pain-free experience. With a new-found commitment I pledged to take the daily steps to turn that volume dial back down. Keeping this promise to myself might mean I don’t get as much done in a day. It might mean that I’m not as skinny as I’d like to be. It might mean asking for help more than I’m usually willing to admit I need so I have more space and time for healing and mindfulness. But I’ll do it. Whatever it takes. Because sexual pain is not acceptable. It’s not good for me. And It’s not good for my relationship with my husband. And those are the things that truly matter to me. * Caution Ladies: This is what my journey looks like right now. And we hope that it connects the dots for you on how inter-related factors can add on top of each other, causing the pain volume dial to get turned up. Not everyone, including me, can always take the time and effort to perfectly keep the pain volume dial turned down. Children, work, demanding partners all come into play. We encourage you to not let feelings of guilt creep in if you can’t keep up. Guilt and its side effects are counter productive in managing your pain. Give yourself lots of grace in this area and just do what you can, when you can.  Paindownthere.com and the educational/instructional videos Healing the Pain ‘Down There’ intend to explain, as best as possible, that there are many reasons in the pelvis for pelvic floor dysfunction and for genital and pelvic pain. One of these reasons may be hypertonicity (as posted about last time). Virtually everyone with pain, caused by all sorts of injuries to the body, has reactive hypertonicity in and around that injured area. The muscles around a knee injury or shoulder injury, for instance, always tighten to guard that area and stabilize or “splint” that area. Same in the pelvis. The way that pain is processed in the brain along with fear and anxiety factors can also continue to cause hypertonicity even after the initial injury has healed. Mind/body aspects of care become so important in this instance.
Other reasons or “triggers" in the pelvis for pelvic floor dysfunction and for genital and pelvic pain besides the implications of hypertonicity include: Somatic reasons: Current or previous injuries or stress on all of the surrounding structural entities. These structural entities include bone, muscle, fascia (connective tissue), ligaments, and nerves. Visceral reasons: Organ dysfunction like IC (Interstitial Cystitis or Painful Bladder Syndrome), IBS (Irritable Bowel Syndrome), Endometriosis, Prostatitis and others. We want to help “connect these dots” for all the potential and interconnected sources or “triggers” of chronic pain in the pelvic and genital area. |
AuthorStephanie Yeager: Passionate about spreading the word of hope and healing for those like her, influencing a paradigm shift in the medical community toward greater understanding of chronic pelvic pain disorders, and prevention initiatives that may protect young women before onset can occur. Archives
July 2018
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