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Pain 'Down There'
  • Welcome
  • Blog
  • Store
  • Contact Us
  • Resources
    • Resource List
    • Recommended Products
    • Sexual Partners Support
  • Donate
    • The Foundation for The Prevention of Chronic Pelvic Pain
  • Glossary
  • FAQs

Blog

WHY DO I HAVE VAGINAL PAIN? A SCIENTIFIC LOOK AT THE VULVAR VESTIBULE 

11/30/2016

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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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Provoked Vulvodynia  

9/30/2016

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​Provoked Vulvodynia
An Update from The Journal for Nurse Practitioners
Volume 12, Issue 8, September 2016
Page 530

Provoked Vulvodynia  An Update from The Journal for Nurse Practitioners Volume 12, Issue 8, September 2016  Page 530
Overview:
This article by the Journal for Nurse Practitioners focused on the holistic treatment approach to provoked vulvodynia, highlighting several recent research findings that we’d like to share. According to the International Society for the Study of Vulvovaginal Disease, provoked vulvodynia is pain localized to the vaginal vestibule when provoked (touched) that has been present for at least 3 months and does not have a clear identifiable cause. Provoked vulvodynia (PVD) you may have heard also referred to as vestibulitis or vestibulodynia.
 
Origin:
How PVD begins isn’t known, but likely it is a complex combination of factors involving genetics, musculoskeletal and neurologic mechanisms, and psychological factors, including the interplay between chronic stress and pain, leading to a sustained pain response. Research has also shown that low confidence about how to manage and cope with the pain is related to higher pain intensity. Depression and anxiety further complicate PVD. As we are already aware, providers are generally unfamiliar with this disorder. Women see up to 6 providers before being accurately diagnosed and treated.
 
Treatment:
Current recommendations call for the least invasive treatment options available. This article focused on two treatment options which are noninvasive and comprehensive, yet often only recommended as alternative options: Cognitive Behavioral Therapy (CBT) and Mindfulness. CBT is a multi-session practice that includes relaxation, self-management techniques, and restructuring thoughts and emotions that are maladaptive. While CBT is a change-oriented strategy, mindfulness seeks to create awareness of the body, thoughts, and emotions by simply noticing them rather than judging them.
 
In one study, CBT was found to be superior to surgical procedures in pain relief with intercourse at a 2 ½ year follow up. And CBT has been shown to be more effective in reducing pain and improving sexual function than topical steroids. CBT was also found to improve patient confidence in being able to manage and cope with the pain, along with significantly reducing depression and pain anxiety. At the 1 year follow up these findings had either been maintained or improved.
 
Current studies also suggest that women with PVD benefit from the practice of mindfulness. Women were found to have significant improvements in their own confidence to manage and cope with their pain, along with decreases in pain hypersensitivity and feelings of hopelessness. Women who participated in a mindfulness-based CBT program experienced decreased depression, anxiety, and fear. These findings were maintained at the 6 month follow up.
 
Conclusion:
CBT and mindfulness are noninvasive, effective long term, and provide an approach that factors in both mind and body, not just physical pain. Current research would suggest these options be recommended as a first-line treatment instead of an alternative therapy. More evidence-based guidelines are needed for PVD in tandem with increased provider awareness.
 
In addition, we at paindownthere.com would add that further research is needed in the multidisciplinary approach to treating PVD. We believe highly in “top-down” approaches such as mindfulness but also recognize the need for simultaneous “bottom-up” approaches that take into consideration biological/medical factors that may call for medication, physical therapy, and nutrition intervention as well.
 

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Sexual Abuse & Vaginal Nerve Pain 

12/8/2015

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Easing Vaginal Penetration PaiN 

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After our vaginal entrance pain vocab post last week, we got a good question about sexual abuse and pelvic, genital, and sexual pain. We'd like to address that in this blog post, as well as strategies for easing pain at the vaginal opening. 

Q: Can sexual abuse make nerves in the vaginal opening more sensitive? If so, how do you ease the pain?

A: 
Sexual, physical, and emotional abuses remain so prevalent in our society and are a tremendous burden. Like anxiety, depression, stress, genetic and hormonal influences, injuries, accidental traumas, pelvic surgeries, falls and straddle injuries, abuse is a predisposing factor for female pelvic and sexual pain. This means that all of these factors can make an individual woman more inclined to these conditions. Pain that results from sexual and/or physical abuse can absolutely contribute to an over sensitization of the pain receptors at the vaginal opening (the vestibule). The experience of this “bad” pain is "remembered" by the nerves. Our nervous system stores these bad memories chemically and awakens them when it is feeling threatened and trying to protect itself (when you’re attempting pleasurable, consented sexual intercourse for example). 

So sexual abuse is one of many possible traumas that can be precursors of pain and sensitivity of the vaginal opening.      Vestibular pain (vestibulodynia) is by far the most common reason for entrance pain and sensitivity in the vaginal opening in      reproductive aged women.  It is a common subset of a condition known as Vulvodynia (pain in the vulvar or genital region of women). It is estimated that about up to 15 million women suffer from vulvodynia in the United States alone.   All too commonly, even when young women are barely able to be touched by the use of tampons, having a Pap smear, or by any sexual activity, they can be diagnosed mistakenly with "yeast infections" and/or bacterial infections.  Those types of infections rarely cause the severe pain and inflammation experienced with those individuals suffering with vulvodynia or "provoked" vestibulodynia.  

Various oral medications to help quiet the nerves firing off in this very sensitive area are similar to medications used to quiet other hypersensitive nerves (neuropathies), in other parts of the body.  These may include combinations of low doses of tricyclic antidepressants such as imipramine, amitriptyline, and nortriptyline, as well as medications used in pain management for nerve related pain such as duloxetine, gabapentin, pregabalin and others. There are also various prescription ointments such as 5% Lidocaine ointment, and compounded ointments that can include medications such as amytriptyline, baclofen and gabapentin that can be helpful for some, but not all women. You can also find over the counter soothing creams, such as Medicine Mama’s V-Magic, Neogyn Cream, coconut oil, etc.  Find a specialist to assist you by visiting NVA.org the web site of the National Vulvodynia Association. 

In addition to medications to quiet the nerves, the brain also needs to be retrained to not perceive gentle touch as a threat.  You can accomplish this by use of vaginal dilators starting with a very small dilator to allow for touch and insertion and movement and gentle pressure in the vaginal canal with low to no pain.  We would recommend seeing a women's health PT to instruct you how to use the dilator to decrease the tension in your pelvic floor muscles as this can also play a role with your "ramped up nervous system".  Once your muscles are more relaxed and there is increased blood flow into the vaginal region and decreased pressure placed on the nerves, then the vestibule is allowed to be less sensitive. 

In addition to utilizing dilators and physical methods of retraining the brain and nervous system's responses, we recommend seeking psychotherapy with someone who specializes in treating trauma with neuro-therapies, such as EMDR (Eye Movement Desensitization and Reprocessing), EFT (Emotional Freedom Techniques), and Mindfulness-Based Stress Reduction. Neurotherapies help retrain the brain to get out of "fight, flight, or freeze" mode that is the body's normal response to stress and trauma. Addressing and healing past traumas are integral in the healing of the nervous and immune systems.


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Digital Chapter Packages to Heal the Pain 'Down There'

11/24/2015

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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. 



Take Me To the Digital Products Page
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Reducing Pain with Sex: Psoas Release 

9/3/2015

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Properly functioning, released, and relaxed psoas muscles are crucial in the process of healing the pain "down there" and maintaining health and functionality in the pelvis. See the previous blog post for a refresher. So how do we achieve (for lack of a better term, sorry yoga instructors!) released and relaxed psoas muscles for ourselves? 

Here are a few starting points:

1. Learn about the psoas from the point of view of Liz Koch at coreawareness.com. She has dedicated more than 30 years to this muscle. You may enjoy her Yoga Journal article here or if you learn better via video/audio check out her video segments. What I've gleaned from Liz so far is that our psoas muscles are primal muscles. So they are the "messengers" of the nervous system, holding trauma and emotion. As such, releasing the psoas should be a tender and gentle process, as she teaches through her articles, books, and videos. 

2. Consult a Women's Health Physical Therapist. They can evaluate for this and other areas of muscle tension that may be contributing to painful sexual intercourse one on one. Manual "trigger point release" of muscular tension can prove immediately relieving. If you find you identify with Liz Koch's view of the psoas, this myofascial release technique on the psoas in particular may be controversial. You'll need to balance the approaches for yourself. 


3. Learn safe and gentle stretches for the psoas muscle. Find stretches from sources you trust online or take a yoga class. Your Physical Therapist can also teach you stretches. We teach you how to stretch the psoas and other hip musculature in our DVD guide: Healing the Pain 'Down There'.

4. Take care of yourself. You can't expect your psoas to be happy and healthy if you treat yourself poorly. Maintain good posture and sit on your sits bones. Breathe from your belly and not from your chest, allowing your pelvic floor and core muscles to expand and relax as you breathe in. Eat natural, whole, nutrient rich foods. Drink plenty of water. Move and play. Keep your stress under control: practice guided meditation, see a therapist or spiritual advisor if you need support coping with painful or traumatic events or circumstances (past or present), be nice to yourself and treat yourself to cuddles with a furry friend, a hot bath, a massage, a cup of tea. 

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DVD Guide for Healing the Pain 'Down There' Available Now

8/12/2015

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BUY NOW
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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 

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Mindfulness Techniques Continued 

7/13/2015

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Remember, mindfulness is the practice of being in the present moment without judgment or the intention to change anything. This practice is actually a way of living, a way of being. We often go about our lives without living in the present moment. Either we are thinking about the past or worrying about the future. 

Through the practice of being present in the moment comes a quieting of the mind and calming of the body. And it offers us space to choose what our mind focuses on. When we have this choice, we can choose to focus on the things that feel better. 

When we stay in the "doing" mode for too long and live life on "automatic pilot" two things can occur:

1. Negative emotions and reactions can be triggered
2. It can jumpstart habitual coping patterns, such as mindless eating or biting our nails 

In the context of pain, we recognize signals being sent up to our brain from a certain part of the body and then our minds (depending on our neuromatrix) add meaning and assumption in interpreting these signals. If we don't know about our bodies and what is going on, the danger flags rise and our pain 'volume dial' gets turned way up. 

I hope I've convinced you to at least consider Mindfulness-Based Stress Reduction. If you're ready to give it a try, please first read the blog about the Mind's Error Detection System. And keep in mind that when you're first practicing mindfulness, it's normal for the mind to distract you, making you wonder if you're doing it right and telling you how hard it is to "not thinking about anything". It'll feel like a dance between the "doing" and the "being" mode. This is ok. Expect it. And it will get better. The more you practice, the more your mind will be quite and peaceful during this time.

There are two different approaches to mindfulness you may find helpful:
- An active way: "Google" search for Mindful Eating Script and have a partner read it out loud while you enjoy mindful eating
- A Meditative way: Using sensory awareness and using the breath as the main anchor to the present moment. 

Guided Meditation has been my method of choice because the "work" is done for you as you listen to the audio voice that is leading you into a peaceful place. Here's a 3-Minute Breathing Space MP3 that only costs .99, give it a try. And notice how your body feels after only three minutes of focusing on the breath. Purchase the whole album from our content provider, Alexandra Milspaw, PhD, LPG if you find this method works well for you! 

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Mindfulness Techniques & Chronic Pelvic Pain

7/8/2015

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Mindfulness techniques are particularly helpful in the management of chronic pelvic pain because it can help us become aware of the specific triggers that are being set off in that moment. The more we learn about our bodies and gain awareness of our organs, muscles, and nerves, the more we can decipher where the pain is coming from and consequently, what coping mechanisms to use. 


In other words, the more our brain understands where the pain is coming from, the less scary or threatening those signals are perceived and the more control we can have over managing how we respond to those signals. Mindfulness practice is ideal for cultivating greater awareness of the unity of mind and body, as well as of the ways unconscious thoughts, feelings, and behaviors can undermine our overall health.

Need help getting started? You're not alone! Mindful living doesn't come naturally in a society that trains us to race around. Have you ever tried just sitting still for a moment? You'll start to hear the judgment that you "should" be doing something. More to come next time. 

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WHAT IS PAIN? {CONTINUED}

6/8/2015

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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. 
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TURNING THE PAIN 'VOLUME DIAL’ DOWN

1/27/2015

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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. 

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    Stephanie 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. 

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