 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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Specialized Women's Health Physical Therapy: What ELSE to Expect on your First Visit Follow up video blog answering some questions from our first video post about what to expect at your very first pelvic floor physical therapy session. Individual experiences will vary. But listening to internationally recognized women's health physical therapist Karen Liberi, MS, MPT, WCS may help relieve some fears and anxiety, especially surrounding the pelvic floor muscle evaluation.
 If you're having difficulties with sexual pain then physical intimacy with your partner is likely a challenge. Here's a few tips for maintaining your sexual relationship even when intercourse may not currently be an option. Schedule Intimacy Schedule a weekly date with your partner to maintain emotional intimacy. Set aside a few hours to snuggle as you watch a movie or share an adventure together. Keeping emotionally connected with relieve the tension that can be caused by difficulties surrounding sex. Alternate with your partner to select activities you both enjoy. Experiment There are many exiting and fun ways to have sex even if you are unable to have intercourse. Set aside the idea that intercourse is the only "real" way to have sex and intimacy. Open your mind to sharing other types of sexual activity. Regularly Engage in Sexual Activity That Doesn't Cause Pain Once you together find several sexual activities you can share in that are fun and exiting but don't cause pain, engage in these activities regularly. Many women lose interest in sex due to the pain they experience. But chances are you will eventually enjoy sex again if you can relax and be willing to engage in sexual activity with your partner that does not cause genital pain, sexual pain, or pelvic pain. Realize That Intimacy is Two People Working Together to Please Each Other Intimacy is the result of two people working together to please each other. While some men may say that only intercourse is "real" sex, many admit that they get aroused by making their partner exited, with or without intercourse.
EXERCISE ROUTINE TIPS FOR THOSE WITH PELVIC PAIN
"Toning up" may actually be a "sexual downer" on body parts that need to be the most relaxed and comfortable for those intimate moments. 2. Seats and ClothingFind the softest, most pliable seat possible and wear loose-fitting clothes when riding a bicycle, motorcycle, or scooter. Better yet, consider giving up these activities. The pressure against your already sensitive genital area can cause symptoms to flare up. 3. Give Up the Attitude of "Playing Through the Pain"While coaches often urge athletes young and old to "play through the pain", it's vital to abandon this attitude when it comes to enduring painful sex as an adult. Please don't believe that you must have sex to please your partner despite the pain and if you don't something is fundamentally wrong with you. Nothing could be further from the truth. A loving partner would never want to cause such suffering. 4. See a Pelvic Floor Physical TherapistMore and more physical therapists (PTs) are incorporating pelvic pain treatment into their practice as the urgency of effectively treating sexual pain increases. A growing number of doctors consider pelvic floor physical therapy a vital component of a complete treatment plan for sexual pain. Specialized pelvic floor PTs utilize various methods to release trigger points in the body. Trigger points develop through contraction or spasms in the muscle groups surrounding the vagina, bladder, and lower bowel. Using manual pressure, biofeedback, and other techniques these health care providers can often aid sufferers. Patients are eventually given techniques to maintain wellness at home.
 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
"doing mode", you're operating almost exclusively in the sympathetic branch of your autonomic nervous system. This system is associated with the "fight or flight" response, shallow breathing patterns, muscle tension, and increased heart rate and blood pressure. These stress responses of the body not only negatively influence the pelvic floor muscles but also the overall pelvic region including bladder and bowel function, both common triggers of genital, sexual, and pelvic pain. 2. Pelvic Traumas, Injuries, or SurgeriesInjuries to the pelvic floor region caused by childbirth, previous pelvic surgeries, falls on the coccyx bone, and other accidental traumas to the region such as straddle injuries can all contribute to the development of chronic pain in the pelvis and genital area. Take for instance, the condition once known as "bikers syndrome" that affects long distance bike riders. Cumulative targeted pressure on the pudenal nerve overtime can cause damage to the nerve. This particular nerve branches out into the entire vulvar region and can therefore emit painful stimuli anywhere in the pelvic region, not just at the "sits bones". 3. Present or Past Physical, Emotional, or Sexual AbuseMemories from past (or current) abuses are stored in pathways along the central nervous system, and even in particular muscles, especially the psoas muscle. The psoas muscle has a direct and neurological connection to the pelvic floor muscles. These bad memories that are stored by the nervous system awaken when it is feeling threatened or when trying to protect itself. Even when attempting consented, pleasurable sex, the nervous system can interpret this environment as threatening. Protective measures include muscles tension and clenching (which leads to pain, which leads to the fear of pain, which leads to further clenching), and the over-sensitization of the pelvic nerves. 4. Participation in Competitive SportsMany popular sporting activities require tight, clenched body positions and breathing from the chest in order to perform. If we are taught by these sports (or cultural influences) to suck in our stomach and breathe from the chest and clench our buttocks at all times as a matter of "good posture" this can, over time, be detrimental to the health and function of the pelvic floor. In addition, young women who participate in sports are more likely to experience sports-related injuries such as injuries to knees, ankles, legs, and hips. If a knee, for instance, is favored for a long enough period of time the opposite pelvic area takes on more stress and can contribute to pain due to compensatory patterns. 5. Genetic, Hormonal, & Dietary InfluencesStructurally the body is not symmetrical and consequently curvatures of the spine, leg length difference, being left or right footed, all have a bearing on the long-term cumulative stress on one side of the pelvis or the other. Genetic and hormonal influences can also put us at risk for other triggers commonly associated with pelvic, genital, and sexual pain. For instance, endometriosis, irritable bowel syndrome, and interstitial cystitis (painful bladder syndrome or "IC"). The dietary decisions we make also influence how and when these triggers manifest in the body. Foods can promote the inflammatory responses contributing directly to pain, but also inhibit the immune system from functioning properly.
 Independent research findings from a randomized (participants chosen at random), double blind (neither the researchers nor the participants know if they are using the placebo or the magnetic dilator) study were released just last month on the VuVa magnetic vaginal dilators.
24 women with vulvar pain participated in the study. The women used both the Vuva magnetic vaginal dilators and the placebo vaginal dilators (looked and felt the same but didn't contain magnets) with a 7 day period in between in which no treatment was given. Women were asked to report their pain intensity levels before and after the use of each dilator. Women who used the VuVa magnetic dilator reported a decrease in pain levels twice that of the placebo dilator during a tampon test. Women using the Vuva magnetic dilators experienced an average 28% decrease in pain levels during a cotton swab test. And 40% of the women reported an increase in the frequency of sexual intercourse during the study while using the Vuva magnetic dilator as compared with only 10% using the placebo dilator. Based on these findings, the independent research study concluded that Vuva magnetic dilators are a safe and effective treatment of vulvovaginal pain, performing significantly better than the placebo dilators. Each Vuva magnetic dilator is created with soothing Neodymium magnets to increase blood flow and add elasticity to the tissues. The dilators, which come in graduated sizes, can be used 1-2 times per day by simply allowing the dilator to rest inside the vaginal canal for 20-30 minutes. For more information go to: https://www.vuvatech.com * Pain Down There is happy to report these findings as it provides another resource within the multi-disciplinary approach to treating genital, sexual, and pelvic pain. Not one single medical approach is likely to cure chronic pelvic pain. Please take into consideration the use of VuVa magnetic dilators along with and part of a team-based approach to pain management: physical therapy, pain science education, mindfulness training, and other allied health care professionals. A Callout for OB-GYN Education Reform  WHO IS ACOG AND HOW DO THEY INFLUENCE THE PROTOCOL FOR PELVIC PAIN?The American Congress of Obstetricians and Gynecologists (ACOG) is the companion organization to the American College of Obstetricians and Gynecologists. Both entities are non-profit professional membership organizations for physicians providing health care to women. With over 58,000 members both The College and ACOG are recognized as the nation’s leading authority on all things women’s health. Though based out of Washington D.C. ACOG is made of various districts and sections that operate throughout the US. The purpose of The College and ACOG is to advocate for quality health care for women, maintain the highest standards of clinical practice, maintain the highest standards of continuing education for their members, promote patient education, and increase public awareness and awareness among their members of the changing issues facing women’s health care. ACOG in particular is dedicated to the advancement of women’s health care as well as the interests of its members through medical education, research, practice, and advocacy. Operations of The College and ACOG are overseen by member elected Executive Committees, Executive Staff, and Board of Trustees. Because of the nationally and internationally recognized authority of these organizations, they play a significant role in the influence of academia and education for students in residency who are in training to become board certified Ob-Gyn physicians. The head of The College’s Education division oversees the Council on Resident Education in Obstetrics and Gynecology. Currently, Sandra A. Carson, MD holds this position. They also play a significant role in the influence of clinical guidelines for women’s health providers through professional materials that are made available to their members. The Vice President of Practice Activities oversees these clinical guidelines. Currently Dr. Chris Zahn is holding this executive staff position. Previously, Hal C. Lawrence III, MD held this Practice Activities position and in 2011 was appointed The College’s Executive Vice President, a position that puts him at the helm of The American College of Obstetricians and Gynecologists. ACOG STRENGTHS & WEAKNESSESAs one can imagine, “all things women’s health” encompasses a vast array of subjects and challenges. From cervical cancer to health care reform. From pregnancy, labor and delivery to hysterectomies. From infertility to birth control to member medical liability. From mammograms to breast feeding to sexually transmitted infections. Clearly ACOG and The College (we’ll collectively call them ACOG now) is tasked with an enormous undertaking. Focusing in on the category of “Gynecologic Problems” ACOG does have guidelines on chronic pelvic pain found in the Fourth Edition Resource Manual, copyright 2014. While the section is very short, coming in at under a page in length, there are several reasons to be hopeful that ACOG is beginning to steering things in the right direction. The guidelines say that chronic pelvic pain is common among women. And requires a multidisciplinary approach in its diagnosis and treatment. Bladder, colorectal, neurological, musculoskeletal, abuse, pelvic surgeries and traumas are all listed as potential sources of the pain. Though psychological causes are also listed, they directly instruct the reader not to ignore the significance of the pain despite normal or inconclusive physical exams, evaluations, or findings. Management of the pain is to involve addressing the underlying causes. Any cause found not to be gynecological in nature should be referred to an appropriate specialist. If the source of pain cannot be determined the manual refers readers to Part 4 on managing chronic pain, which is mostly information about opioids and anti-inflammatory medications. In addition to the general guidelines on chronic pelvic pain, ACOG has also released a 2006 reaffirmed Committee Opinion on Vulvodynia, a 2013 reaffirmed Practice Bulletin on Female Sexual Dysfunction, and guidelines on vulvar skin disorders. These four resources in combination available to women’s health practitioners cover good ground in at least defining terms like vaginismus and vulvodynia as well some starting places for diagnosis and treatment. Somewhat disconcerting is my personal experience with these disorders in 2007 and 2008, after information would have been made available on them; yet I experienced looks of confusion from multiple practitioners who didn’t seem to be aware these terms even existed. ACOG, according to a recent letter from Dr. Chris Zahn Vice President of Practice Activities, strives to create practice guidelines and recommendations that are “heavily based upon published medical literature, mostly from peer-reviewed journals”. Dr. Zahn goes on to say that while the research takes time, it is essential that their recommendations reflect high quality evidence and data. ACOG’s strict adherence to peer reviewed medical evidence and the vast subject areas within women’s health for which ACOG must advocate, promote, and educate could be counted among its strengths. Though, as is often the case, they could also very well be counted as two of its greatest weaknesses. Chronic pelvic pain triggers go far beyond the scope of the currently available guidelines, opinions, and bulletins released by ACOG, even for the more common disorders that have been known to affect up to 20% of women in the U.S. alone. And, completely absent from all of these resources are two disorders in the pelvic region: Pudendal Neuralgia and Persistent Genital Arousal Disorder (or PGAD). While these conditions are thought to be rare by some practitioners, it is unknown the actual incidents in the general population. Research on the estimation of these conditions needs to catch up with actual occurrences, and account for the many individuals who present with these conditions but are misdiagnosed or ignored. Whatever the unknown figure may be, the effect on women (and men) is life altering, significantly reducing quality of life on a day by day basis, not just as it relates to sexual pain and discomfort. Pudendal Neuralgia is characterized by sharp pain surrounding the pudendal nerve due to dysfunction or compression of this nerve. The pudendal nerve stems from the sacrum (the triangle shaped bone at the base of the spine that your tail bone is attached to) but it runs throughout the entire pelvic region. Other symptoms can include numbness, tingling, burning, and incontinence (loss of bladder or bowel control). If you feel like you need a visual tour of the pudendal nerve “google” search ‘pudendal nerve tour’ and then click on videos. (Also view this informative video by Dr. Valovska) You will gain immense respect for this nerve immediately and better understand how its injury or dysfunction could indeed cause exquisite pain and ongoing distress. Sufferers can experience PTSD due to mind-altering pain levels. Many lose the ability to work and function, being house-bound and bed-ridden. Suicide is, unfortunately, the only option many of these sufferers feel like they have, especially if no one can make sense of their pain. Persistent Genital Arousal Disorder (PGAD) has also been thought of as Restless Genital Syndrome, as it seems to mimic other neurological disorders such as Restless Leg Syndrome. PGAD is characterized by ongoing, spontaneous, uncontrollable genital arousal that is not related to sexual desire. This persistent arousal of the genitalia is sometimes completely debilitating for those who suffer from the symptoms. Interfering with everyday tasks of life, sufferers often experience depression, anxiety and anxiety attacks, and feelings of distress and hopelessness leading to suicidal ideation and action. THE CAMPAIGN TO REACH ACOGProject Angel, spearheaded by Pudendal Neuralgia sufferer & artist-advocate Atara Schimmel, has been tirelessly working to bring these disorders to the attention of ACOG, requesting that these and other Chronic Pelvic Pain disorders be not only recognized but also that clear guidelines, educational objectives, and curricula be put into place for the education of both currently practicing women’s health providers and the up-and-coming generation of providers who are in the classroom and residency programs. Many personal letters and testimonies from sufferers have already been received by ACOG. We want them to see that real women and men with real stories are being impacted. And we want them to know that many have already given up. Insufficient treatment options, lack of compassion and understanding on the part of providers, and the general disinterest on the part of the institution and the public leaves sufferers with very few choices. And some of them opt to take their own lives for the lack of a better option. Download the most recent response letter from Dr. Chris Zahn at ACOG to the Project Angel campaign. We are grateful that ACOG chooses to respond to us and that they relay their shared interest in addressing the urgent issue of debilitating pelvic pain. We respectfully disagree, however, that there is not enough scientific publications to make recommendations. At least under their “Level C” conclusions which are based on consensus and expert opinion, or under their “Level B” conclusions which are based on inconsistent scientific evidence. For the research of this blog, I spent about two hours at my local university searching for only peer-reviewed medical journal articles on both Pudendal Neuralgia and PGAD (notice the letter from Dr. Zahn makes no mention of PGAD though we specifically asked for it to also be addressed). In that time I was able to find over 15 published articles, most of them in the last 5 years, available through that university alone on Pudendal Neuralgia. And over 20 on PGAD. HOW TO GET INVOLVEDWe will continue to put respectful and appropriate pressure on ACOG to hear our pleas and create change. We do it for the millions of women and men who have already experienced chronic pelvic pain conditions and yet are unable to find OB-GYN practitioners who are able to make sense of their pain. And for the women and men who will experience CPP at some point in the future, that they might have access to the so desperately needed care that we should have received but couldn’t find.
We are petitioning ACOG to address two very specific requests: 1. Incorporate vulvovaginal and pelvic pain conditions into core curricula of gynecology and obstetrics and continuing ed. While ACOG may be on the right track given the resources they have released via their guidelines, resource manuals, and bulletins, we are not aware that they are incorporating this vital information into the core curricula of every gynecologist’s and obstetrician’s education. And while the current information is helpful, it is lacking considerably. It is crucial that practitioners and students in their residencies and fellowship programs receive training in the assessment and management of pudendal neuralgia, persistent genital arousal disorder, vulvodynia, interstitial cystitis, endometriosis, vestibulodynia, penile pain, ejaculatory pain, irritable bowel syndrome, pelvic floor dysfunction and a variety of peripheral neuropathies that occur commonly in the pelvic region. Lichen simplex, lichen sclerosis, and lichen planus are common skin disorders affecting the genitalia and also must be recognized. Many CPP patients experience multiple conditions that are interrelated. A multidisciplinary approach to diagnosing and treating vulvovaginal, penile and pelvic pain is imperative. 2. Create guidelines, educational objectives, and curricula for Pudendal Neuralgia (PN) and Persistent Genital Arousal Disorder (PGAD) While ACOG may currently recognize some CPP conditions in their guidelines such as vaginismus and vulvodynia, they don’t recognize PN or PGAD in their guidelines. We want to see these two disorders be specifically recognized by ACOG and guidelines and educational objectives be created for addressing them. Therefore also including them into the core curricula for students and practitioners as we are requesting in our first point above. We fully realize that these requests require time, energy, effort, and resources from ACOG and that this, along with their many other responsibilities, is a massive undertaking. We support them, we will send them our findings, we can recommend doctors to them that are having successes. But simply put, all OB-GYN practitioners need to know the basics of all CPP disorders and the basics of the multi-disciplinary approaches that are used to treat them. Perhaps there needs to be a re-structuring to allow for specialists in CPP related conditions that are either under the ACOG authority or under the authority of a different entity. But there is no excuse for any OB-GYN to tell a patient that pain "must be in their head". It must become the standard norm that all OB-GYN practitioners recognize CPP and its interrelated triggers and at least be aware of the treatment modalities available so they can make appropriate referrals and recommendations. Please join us in the campaign! More voices from many different directions will influence the changing of the tide, the paradigm shift that will ultimately turn something this massive in a whole new and better direction. Here’s how to help:
Loved one with a personal experience Public Advocate (no personal experience but want to contribute to the campaign)
 Chronic pelvic pain advocate, educator, and artist Soula Mantalvanos, brings us a new creation that is an incredible gift to anyone suffering from chronic pain. A chronic pain patient herself, Soula created this remarkable tool for patients by a patient. {Pain}Train is a web-based platform that allows us patients to store everything related to our pain in one place. So instead of trying to explain to multiple health care providers for the umpteenth time about you, your pain, your treatments, and your history - give that health care provider access to your {Pain}Train profile and it's all there for them. Your online profile allows you to save all your information on medications, treatments, health care providers, and dates. It also allows you to upload documents, images, and reports. Beyond the medical only, it also allows for a more holistic picture of who you are by telling your professional and personal story pre-injury. And of course there is space to describe your injury, your symptoms, your diagnosis (if you have one), any other medical history or conditions, and you can store all your information on any health care coverage. There is also a mood tracker and plenty of space to include additional information for your unique situation. Access to all of this information is secure using HTTPS protocol and your email address with chosen password. The "access" feature allows you to share your profile with anyone you want to give permission to view it. Simply input each health care provider into your account and they will be assigned a unique code (or QR code) for 'read only' access to all of your profile. You can either email this information to them or print it for them. Example Profile So Organized! FREE 3 Month "Test Ride"Since {Pain}Train is offering a free "test ride" for 3 months, I tried it out for myself. I must admit, it was pretty daunting to sit down and fill in everything (and I'm not even close to being done!) But I told myself to take it in chunks. Do a little now and I can always come back to it later, everything is saved and I won't lose what I've started. And once it's done it'll be a tool I can use and reuse and update, making life so much easier. I'm planning on taking it with me to my Ob/Gyn appointment this month. And since I'm not sure if she'll be interested in having email access to my profile, I'm planning on printing it. Thankfully, the print function creates a printer-friendly, well laid-out, physical page copy version of the profile. See below: Printable VersioN Print Version Looks Nice Too! SubScription to {PAIN}TrainIf after 3 months you are finding the platform helpful, it's just $29AUD yearly to continue your subscription. That's currently about $20/year US, based on the current exchange rate. If you choose not to subscribe after your 3 free months, your profile will be deleted. {Pain}Train doesn't ask you for payment information when you first register an account. After 3 months {Pain}Train will prompt you to pay the annual subscription fee. Pay at that time to keep your subscription. Your profile is deleted if you decide not to subscribe. I encourage you to give it a try! All Aboard! Need some help creating your profile? Download simple profile instructions from {Pain}Train.
Easing Vaginal Penetration PaiN 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. Entrance Pain: Vestibulitis (Vulvar Vestibulodynia) Vaginal penetration pain, or vaginal entrance pain. Pain in this region when "provoked" (trying to insert any object into the vagina) is most commonly due to a condition popularly known as vestibulitis. Vestibulitis is thought to be caused by highly sensitized nerve endings being contributed to by other pelvic pain triggers. This condition is frequently misdiagnosed as vaginal infections.
But let's back up. What do we call the vaginal opening anyway? If I had known more terms in my own research for answers, I may have gotten a bit farther a bit sooner. Vocab Lesson 1: What is the vaginal opening? The vaginal opening is known as the vestibule. The vestibule contains large amounts of pain receptors. Vocab Lesson 2: So then where is the vagina? The vagina is actually muscular tubing inside the female reproductive system that runs from the external genitalia to the cervix. Vocab Lesson 3: If that's the vagina then what do we call the external genitalia? The entirety of the female external genitalia (including the vestibule) is called the vulva. Vocab Lesson 4: So if I have pain at the vaginal opening... ahem.. I mean the vestibule... then what is that called? Pain in the vestibule is called Vulvar Vestibulodynia or Vulvar Vestibulitis (or you might hear it called just vestibulitis). Vocab Lesson 5: What if my pain occurs in other areas "down there" or seems to be spontaneous instead of provoked? Chronic pain anywhere in the region of the vulva (as far back as the rectal opening and as far forward as the clitoris) is known as vulvodynia. Vulvodynia has two categories. 1: Vulvar Vestibulodynia (see Lesson 4) and 2: Generalized Vulvodynia Generalized Vulvodynia is unprovoked pain. It is relatively constant and often described as burning or sore. It can occur in just one specific area or in multiple areas around the vulva. It is less common and more difficult to successfully treat. Pain emanating from the pudenal nerve may be a significant contributor to this condition in some cases (pudendal neuralgia). So that's the vocab lesson for now in vaginal penetration pain, or vaginal entrance pain. Want to understand more pelvic and genital pain related vocab? Go to the Glossary.  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. PAINFUL SEX PREVENTION  Prevention is a noun. An action. Something we have to do. While the triggers or reasons for persistent painful sex and chronic pelvic pain disorders can be complex, interconnected, and varied let's start with what we do know. Tight and clenched stomach, buttocks, legs and chest-breathing, carried over into everyday tasks and daily living, can be harmful to the pelvic floor. And a tight, tense, and too "turned-on" pelvic floor will eventually lose its proper function. Many sporting activities require these tight body positions in order to perform them well. Dance, running, gymnastics, track, soccer, martial arts, and others place heavy emphasis on core strength, tight body positions and breathing from the chest instead of the abdomen. Along with overly clenching techniques associated with training for many of these sports, there have been more injuries to young women over the past number of years with increasingly competitive young female athletes. Injuries to ankles, knees, hips, tailbones, and straddle type vulvar traumas all have contributed to chronic pelvic and sexual pain, as well. The book entitled: “Warrior Girls: Protecting Our Daughters Against the Injury Epidemic in Women’s Sports” by Michael Sokolove points out the consequences of cumulative injuries in young women, not necessarily solely from the lack of appropriate training over the course of their pre and post pubertal years, but also by the exuberance and passion and competitiveness that so many girls exhibit during the course of their athletic years. He points out that so much has been learned in the fields of sports medicine and training that could be preventative for injury, but that commonly, many factors prevent the implementation of good practices by the coaches, trainers, and even the parents of these young women. These cautions are certainly not meant to endorse quitting sports all together. Instead, we are asking you to be aware that you need to let clenched body positions go when you walk out of practice or performance. If you are a family member or friend of a young female athlete who may have the early symptoms of pelvic pain, try to talk to them about the consequences of holding clenched body positions even though this is quite counter-cultural right now, because it seems everyone is out there trying to actually “strengthen their core”. If you are injured or feel pain, don’t allow yourself or a family member or friend to “push through the pain” to keep performing. If you would like to learn about our prevention and education initiatives or would like to donate to the program please visit The Foundation for the Prevention of Chronic Pelvic Pain at thefpcpp.org (Now teamed up with Bridge for Pelvic Pain). Watch the CHapter on Prevention:Chapter 31: Ongoing TreatmentWatch Chapter 31 of the Video Resource Series Healing the Pain 'Down There': A Guide for Females with Persistent Genital & Sexual Pain. Managing your ongoing treatment to maintain healthy pelvic function. Now that you have the tools to treat the problem, decide what you need to continue in order to maintain healthy function and to manage your pelvic, genital, and sexual pain disorder. Many women experience painful sex for such a long period of time, they have no idea where the pain is coming from at first. But as you are able to map out your pain and understand where it is coming from (and why), you will begin to notice improvement. And you will begin to be confident that you have control over your pain. Should your pain return, you will begin to know why, and your confidence will build. Your learning curve about your own body will gradually increase and you will know how you can work to relieve it each time. With the techniques you have learned you can maintain proper function of the pelvic floor muscles and experience sexual intercourse with much less apprehension and discomfort. Prior to this educational experience you may not have even heard of such conditions as Painful Bladder Syndrome or Interstitial Cystitis, Generalized Vulvodynia, Vulvar Vestibulodynia, Pudendal Neuralgia, and Pelvic Floor Dysfunction. These conditions and others just as common, such as Endometriosis and Irritable Bowel Syndrome all can be causes of and triggers for a variety of pelvic and sexual pain disorders. The more you know and the more you advocate for yourself and others with these conditions, the sooner the health care system will trend towards recognizing how common they are and how important it is to diagnose and treat them as early as possible. The quality of life of so many young people will depend on these issues being included in the routine evaluation of their health care into the future. 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. View Chapter 1 of the Four-Disc DVD Set Healing the Pain 'Down There': A Guide for Females with Persistent Genital & Sexual Pain. Chronic pelvic, genital, and sexual pain patient, Stephanie Yeager, welcomes you to join her on the journey of healing. While you may feel alone in your suffering The International Pelvic Pain Society, The Interstitial Cystitis Association, The National Vulvodynia Association, The Endometriosis Association and The Institute for Women in Pain would all tell you that you are among tens of millions suffering from pelvic pain, genital pain, and sexual pain. Painful Sex and Intercourse Pain Causes
Painful sex can be an extremely worrying, frustrating, and baffling experience; especially if it persists after ruling out go-to medical explanations. Of course pleasurable intercourse requires adequate lubrication. Sufficient foreplay and using plenty of water-based lubricants like Slippery Stuff should cover that ground. But if painful sex continues, be evaluated by a women’s health doctor, OBGYN, or specialist.
Typical evaluations will check for vaginal infections, STDs, and any immediately noticeable problems or injuries to the vagina, uterus, or ovaries. If necessary, medical intervention will be prescribed by the doctor. However, if painful sex continues despite recurring treatment for these issues, insist on finding someone who can make sense of your pain. “Everything we’ve looked at is normal” and “We don’t see any reason for your pain” are not acceptable answers. 80% of the time, triggers for pain in the pelvic region come from bladder and/or bowel function and from gynecological factors alone only 20% of the time. So understand conditions like Interstitial Cystitis (IC or Painful Bladder Syndrome) and Irritable Bowel Syndrome (IBS). Consider pelvic endometriosis but remember that endometriosis is associated with monthly cyclical pain, not pain that is intermittent and all month long. Vestibulitis (more accurately Vulvar Vestibulodynia) is the number one cause of vaginal entrance pain in premenopausal women. Musculoskeletal, ligamental, and nerve related factors can also be heavy influencers in painful sex. Yet they are often overlooked as primary causes. Hypertonic Pelvic Floor Dysfunction (pelvic floor muscles that are clenched or in spasm) and Pudendal Neuralgia are other conditions to be familiar with. See a women’s health physical therapist as they are well equipped in structural matters of the pelvis and determining how this may be influencing your pain. There are many reasons or “triggers” in the pelvis for persistent pain. Often, these triggers are interrelated; meaning more than one is present. Seek the support of a counselor or sexual health therapist along the way. Painful sex isn’t just an individual problem, it is a relational problem that affects us at the core of our most intimate relationships due to painful sex and intercourse.  Women:If you're one of millions of women suffering from painful sexual intercourse, pain after sex, vaginal pain or a myriad of other persistent, unpleasant sensations in the pelvic region: we're offering a way for you to receive a free guide for healing the pain 'down there'. For a limited time [September 15, 2015 - December 15, 2015] refer any health care provider (PT, Doctor, NP, Nutritionist, etc.) to register for our Health Care Provider Bulk Discount Page and we'll send you the full digital download for free! No purchase is necessary from the health care provider you refer. So spread the word and help yourself, help your healthcare providers, and help your health care providers help others! Health Care Providers:If you're a health care provider working in any area of women's health and you come across patients looking for help for painful intercourse, consider offering them a tangible, on the spot resource. Make the DVD Healing the Pain Down There: A Guide for Females with Persistent Genital & Pelvic Pain available for purchase in your office or clinic. Just register for our Health Care Provider Bulk Discount Page then order 3 or more DVDs at the discounted price of $50 a piece and resell the DVDs at your practice for at least the retail list price of $64.95. You/Your Practice keeps the difference. Orders of 10 or more DVDs qualify for free shipping, even internationally.
If you have questions please contact us!  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. 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.  If you have specific questions about painful sex or pelvic pain and aren't sure where to turn, we want to introduce you to Maven: the first digital clinic for women. Through the Maven app you can schedule and connect with a women's practitioner directly via video appointment. And use the Maven app for other questions you might have about yourself or you kids (nurse, nutritionist, psychologist, etc.) Maven's goal is to make healthcare more accessible for women. Fees are stated upfront and start at $18. And the App is super user-friendly. 1. Pick a practitioner 2. Book the appointment and confirm the cost then meet via the app in real time 3. Have access to history and appointment notes from your provider. Easily schedule another appointment. Our own Physical Therapist, Karen Liberi, can meet with you over the Maven digital clinic app. Download the app to your Apple device and use promo code: KARENLFRIEND for 10 minutes free between now and August 31, 2015.   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.  Continuing to have sex that is painful will perpetuate or reinforce the pain. This is because the mind is already anticipating the pain, it is a known response within the same environment you keep putting yourself in - having sex with your partner. But if we can remove the "red flags" from the brain and place you in control through the use of dilators, we can re-train the brain. We can unwind that "fight or flight" response within the nervous system.
When you start with an extra small dilator and can insert it, move it, do self stretches with no to low pain - then the brain starts to realize that "ok, that wasn't so bad" and the secondary response of muscular tensions ease, allowing for less pain. Scanning and mapping the pelvic floor alongside your dilator use also helps the brain perceive these muscles in a more normalized way. This allows for much less "red flag signals" being sent to the brain. Your overall confidence level with repeated successful sessions with the dilator and vaginal canal mapping allows you return to intercourse with low to no pain. So essentially what you are doing is changing the perception in your brain about the health of your vagina and decreasing the sensitivity of the nervous system to keep muscle tension in check. Along with dilator work there are other exercises such as flexibility work to the hips and trunk and relaxation breathing to quiet the nervous system. It is important that during this process you abstain from sexual intercourse. But of course this is not to say that you abstain from intimacy. We strongly recommend the personalized training of a women's health physical therapist to guide you. You can also use these and other techniques taught in our DVD guide under the consultation of a health care provider. *Be advised that some conditions such as Vulvar Vestibulodynia (Vestibulitis) may need further medical management before beginning the use of dilators. |
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
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