This article appeared on Popsugar.com September 5, 2017:
"Can Your Vagina Actually Be Depressed? The Answer Is Yes"
Read the responses from two women's health professionals below:
Response From Two Women's Health Professionals:
Women's Health Physical Therapist, Stephanie Pendergast, MPT
The answer is actually no. I am not sure which news outlet started this incorrect and damaging trend of reporting that Vulvodynia is synonymous with a depressed vagina but it has to stop. Last week Rachel Gelman and I contacted Reader’s Digest because they suggested Vulvodynia came from a lack of sex. Rightfully they recognized their mistakes and they are printing a retraction. I am hoping those at Popsugar will consider doing the same, my reasons are listed below. We need to set the record straight on what Vulvodynia is and is not, this type of misinformation in the media is devastating to those suffering from this disorder and it needs to stop.
First, please use the correct anatomy. A recent article came out stating 50% of men cannot correctly identify a vagina (http://nypost.com/2017/08/31/50-of-men-cant-correctly-identify-a-vagina/). Perhaps this is because the terms ‘vulva’ and ‘vagina’ are incorrectly being used interchangeably in multiple places, including this article. Two structures most commonly affected in women with vulvodynia are the vulva and teh vestibule. These two structures are not synonymous with the ‘vagina’. It is incorrect to say the vagina is depressed and it is incorrect to say the vulvodynia is vaginal pain. However, it is important to note that vaginal pain can exist with vulvodynia.
Vulvodynia is NOT caused by a depressed vagina.
There are 7 known causes of vulvodynia and 8 associated causes and depression is NOT one of them. I know because I was part of the task force that reviewed the literature and published a consensus paper in 2015. Ref: Bornstein J, Goldstein AT, Stockdale CK et al. 2015 ISSVD, ISSWSH, and IPPS consensus terminology and classification of persistent vulvar pain vulvodynia. J Sex Med 2016; 13(4):6-7 -12. The first paragraph of the Popsugar article quotes a sexologist, Kristie Overstreet. She is using the ISSVD definition of Vulvodynia from 2003. This information has been updated but even so, I can assure your the 2003 terminology does NOT list depression as a cause of Vulvodynia.
The term ‘depressed vagina’ is not synonymous with vulvodynia.
In all fairness to the writers calling vulvodynia a depressed vagina, I can see how they arrived at this conclusion. This topic is can be complicated. Tricyclic antidepressants (TCAs) are FDA-approved and effective for reducing neuropathic pain. Certain subtypes of vulvodynia have a neuropathic pain component and therefore TCAs are used as treatment. This is not because the woman, or her vagina, are depressed. TCAs reduce pain because they regulate the central nervous system, the dosage used for pain is lower than the dosage used for anti-depressive effects. Sex in the City misconstrued the disorder before we could tweet about our outrage. It wasn’t ok then and it isn’t ok now.
3. Experts DO know what causes Vulvodynia.
4. “ There is no treatment specifically for vulvodynia, and anything that is used is still pretty experimental. But due to the highly intrinsic connection between the vagina and brain, vulvodynia is often treated with antidepressants and other forms of therapy to adjust the serotonin levels in the brain rather than to address the painful symptoms themselves. Any course of treatment is individualised based on the person's experience with the condition.”
This is completely false. There are a number of treatments for vulvodynia and each treatment plan will vary based on the cause of a person’s vulvodynia. Effective treatments include pelvic floor physical therapy, topical medications, oral medications, medical interventions such as botox injections and nerve blocks and in some cases, surgery. Tricyclic antidepressants are used to treat Vulvodynia because of their neuromodulating effects and are used at a dosage lower than that used for depression. It is incorrect to say its mechanism of action is to influence serotonin levels and therefore ‘undepress a vagina”. Furthermore, the vagina is not the problem, the vulva and the vestibule are the problematic anatomic structures. The anatomy in this article needs to be corrected.
Reference: Vulvodynia: Assessment and Treatment. Goldstein AT, Pukall CF, Brown C, Bergeron S, Stein A, Kellogg-Spadt S.
J Sex Med. 2016 Apr;13(4):572-90. doi: 10.1016/j.jsxm.2016.01.020. Epub 2016 Mar 25. Review.
Gigi and editor, I speak on behalf of a large group of medical professionals who have dedicated their careers to helping men and women recover from debilitating pelvic pain syndromes, including vulvodynia. While this disorder may seem sensational to you it is most certainly not for those fighting to get better. I am strongly urging you to speak with some of the leading experts on this condition and publish an article that accurately depicts this syndrome and helps women get the help they need. It is possible for Vulvodynia to be successfully treated and they need to know that. I am more than happy to help and I look forward to hearing from you.
Stephanie A. Prendergast
CEO and Co-founder
Pelvic Health and Rehabilitation Center
Los Angeles Branch
Chronic Pelvic & Sexual Pain Practitioner, Robert J. Echenberg, MD, FACOG
I have read Stephanie Prendergast's excellent and accurate responses to these distorted, exaggerated, sensationalized and blatantly false articles that have been part of the media's misunderstanding of the disorders that affect approximately 30 million American women. As she correctly states, there is already plenty of misinformation or lack of information about these complex debilitating physical illnesses that affect women and men alike with chronic pelvic, genital and sexual pain. Basic anatomy and physiology about the pelvic and genital area is sorely lacking even among many of my colleagues in gynecology, urology, gastroenterology.
I am a Board Certified Ob/Gyn MD who spent 30 years caring for women with their pregnancies and surgical repairs of their reproductive organs. I have now spent 16 further years specializing in all of the illnesses that together form the overall category of chronic pelvic pain (CPP). These disorders include vulvodynia, vestibular non-infectious inflammatory pain, bladder pain syndromes, pain of irritable bowel, multiple neuropathies of the pelvic region, muscular spasming disorders between the mid-abdomen and mid thigh regions, and a host of other assorted associated "triggers" of pain in the pelvic and genital region in women and also in men. These patients are socially stigmatized and often become more and more isolated in their lives because they are commonly told these complaints are "made up" and are "in their heads" or are "drug seekers".
In my experience of seeing over 1400 patients with these complex problems from all over the country and many from outside the US, it is obvious that these patients are desperate for help. Their relationships are in jeopardy, they often cannot work, continue school and have already had multiple surgeries, invasive diagnostic procedures, and every type of blood test, CT scan, MRI, Ultrasound and even young teens are getting many of these tests in the prime of their lives. There is no such thing as a "depressed vagina" or a "tiny bladder" or "sexual deviations" causing these highly disturbing illnesses. I have been interviewed countless times for various media and it is almost universal that what I say and try to get across as factual medical science about these issues is routinely edited down to a few "sound bites" of information out of context.
As Stephainie Prendergast said about being interviewed to do an accurate story about these disorders, I too would be more than happy to do so. A few years ago, I wrote to the NY Times and suggested that they do a series of investigative reports on these issues but only got a reply that indicated they would pass it on to their medical feature writers and I never heard anything further. If nothing more, it seems to be really important at this point in our debates over the skyrocketing costs of our health care system in this country, that some attention be paid to a very large patient population that is costing the system hundreds of billions of dollars utilizing many wasted procedures and other resources that don't seem to be working well for all chronic pain disorders, not just the ones in the pelvic and genital area. The study of pain itself is "exploding" but this neuro-science and many of its advancements are not yet "trickling down" to the average clinician, especially those working in the pelvic area of the body.
Proper acknowledgement and education about diagnosis and treatment that is now a reality in the relatively small medical community of pelvic pain could serve the whole medical care system well - since chronic pain costs our system more than diabetes, stroke, heart disease and cancer combined. I am attaching that letter I wrote in 2009 to the NY Times.
Robert J. Echenberg, MD, FACOG
Member: International Pelvic Pain Society and International Association for the Study of Pain
Co-Author: "Secret Suffering: How Women's Sexual and Pelvic Pain Affects Their Relationships"
Co-Producer: "Healing the Pain Down There: A Guide for Females with Persistent Genital & Sexual Pain"
WANT TO HELP?
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.
2. Interstitial Cystitis (IC)
Unlike the kind of cystitis that can be treated with antibiotics, IC is a chronic inflammatory condition of the bladder wall. Some of the symptoms are an urge to urinate frequently, stinging the area surrounding the urethra, increased nighttime voiding (urinating), and a variety of pelvic and sexual pain symptoms.
3. Irritable Bowel (IBS)
Constipation and/or diarrhea are symptoms of this syndrome. Some women find that IBS flare ups correlate to an increase in vaginal irritation. Therefore foods that aggravate the bowel may also cause vaginal symptoms.
4. Lichen Sclerosis
This is an inflammatory chronic skin condition most common in the external genital area. Symptoms may range from none (for years) to mild or severe itching and irritation. Lichen Sclerosis does appear to be relatively prevalent in women with vulvodynia and sexual pain disorders. It can cause splitting and "paper cut" type tears in the region around the vaginal opening.
5. Myofascial Pain Syndrome
Myofascia are the muscles and connective tissue in the body. When in spasm, knots and "trigger points" develop that need to be released to eliminate pain and restore function. These trigger points in the pelvic myofascia can cause sexual pain.
6. Pelvic Endometriosis
Endometriosis occurs when endometrial cells, normally found only in the uterus, become imbedded in locations outside the uterus. These locations are usually within the pelvic cavity on reproductive organs, supportive ligaments, or structural systems like the bladder or bowel.
This misplaced tissue forms growths that look like dark spots. These growths respond to the menstrual cycle and break down and bleed each month, the same way the lining of the uterus does. This causes cyclical pain and inflammation - called dysmenorrhea. Additionally, the body’s immune response to this internal bleeding and breakdown of blood and tissues begins to cause scar tissue and adhesions (affected pelvic organs or structures adhering to one another) which can also cause ongoing pain.
Endometriosis affects millions of women but is often over diagnosed as the primary cause of pelvic and sexual pain. If the pain or deep sexual discomfort is intermittent and all month long, even though it may become worse leading up to the menstrual period, endometriosis may not be the primary reason for the pain. If you have been diagnosed and treated for endometriosis and you don't begin to get signifiant improvement either after medication or surgical treatment, insist on further evaluation for bladder, bowel, musculoskeletal, or nerve related causes of your pain.
7. Pelvic Floor Dysfunction
The pelvic floor encompasses all the muscles that surround and support the pelvic organs (uterus, bladder, and lower bowel). To function appropriately, these muscles must be toned. However, elevated tone in the pelvic floor muscles, making them too tight, tense, and "turned on" can result in painful sex and difficulty with bladder and bowel function. On the other hand, too little tone can lead to bladder and bowel incontinence (leakage) or prolapse (falling down, out of normal position). Pelvic floor dysfunction can refer to either too much or too little tone.
8. Previous life-long Pelvic Trauma
Events such as physical, emotional, and sexual abuse, surgeries, accidental injuries, and cumulative aggravating structural factors can play a role in sexual pain. Additional possibilities include years of various sports activities such as gymnastics, cheerleading, track & field, soccer, ballet dancing, horseback riding, skating, etc. More and more women have engaged heavily and competitively in these sports over the past few decades, making them extremely vulnerable to these types of bodily stresses. The nervous system bio-chemically "imprints" and "remembers" these accumulated traumas, and any or all of these may predispose a young woman to sexual and pelvic pain disorders even years later.
9. Generalized Vulvodynia
Generalized vulvodynia is a subset of vulvodynia, it is less common than vulvar vestibulodynia (see below) and often very difficult to successfully treat. It is a deeper, more generalized pain. Pain can occur spontaneously (unprovoked) or in response to touch or pressure (provoked, such as by intercourse). Pain emanating from the pudendal nerve and its distribution may be a significant contributor to this condition in some cases (pudendal neuralgia).
10. Vulvar Vestibulodynia (Vestibulitis)
This condition causes pain and inflammation at the vaginal opening. Women describe the pain as burning, itching, raw, sandpaper, ground glass, and stinging. It is commonly mistaken for vaginal yeast infections and is often treated incorrectly. Vestibulitis is the most common reason for entrance pain (painful sex) in reproductive-aged women.
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.