(upbeat music)
- Vestibulodynia, a common cause for painful intercourse
presented by the Program in Vulvar Health
at Oregon Health and Science University.
Chapter one, defining vestibulodynia.
Vestibulodynia is a sexual pain disorder
that affects eight to 15% of women
sometime in their lifetime.
It is much more common than most people realize.
This condition is known by several different names
such as vulvodynia, vulvar vestibulitis syndrome,
vestibulodynia, and recently
as localized provoked vulvodynia.
Vestibulodynia is a condition that affects
a small area of the inner vulva.
The vulva is the external female genitalia
that includes the clitoris, the urethra,
which is the opening to the bladder and the vaginal opening.
The vulva also includes the vestibule,
which is a small area of skin surrounding
the vaginal opening, measuring less than two inches.
Most women experience no pain when this skin is touched.
However, women with vestibulodynia experience pain
when the vestibule is even lightly touched.
Pain is often described as burning, searing,
tearing, and raw.
Women with vestibulodynia often present
to their healthcare provider with the concern
of painful intercourse.
Usually women with vestibulodynia experience pain
only with sexual penetration,
like when the penis first enters the vagina.
Otherwise, most women with vestibulodynia
are not bothered with day-to-day pain.
Women with this condition
can usually wear jeans comfortably,
exercise without discomfort,
and enjoy all other aspects of life.
Some women with vestibulodynia may have difficulty
with tampon insertion or pain in speculum exams
during their annual pap smear,
since these activities also include insertion
into the vagina through the painful vestibule.
Vestibulodynia is a sexual disorder
that can be further divided into two types,
primary and secondary.
Primary vestibulodynia occurs
when a woman has experienced pain
since the first time she tried to use a tampon,
have a pap smear or attempt vaginal intercourse,
the pain has always been there.
Secondary vestibulodynia occurs
when a woman has had pain-free intercourse
for some period of time and then later develops pain.
Although the cause of vestibulodynia is unknown,
new research reveals that primary
and secondary vestibulodynia may be different
from each other even though women
with either type experience similar symptoms.
Chapter two, scientific investigation of vestibulodynia.
Although the cause of vestibulodynia is unknown,
we understand that the vestibule skin in women
with this condition is abnormal.
Research in the last 10-20 years has shown
that the tissue environment is different
in women with this condition.
Normally the vestibule skin is nourished
by blood vessels and nerves,
the sensation of touch is transmitted
to the brain via nerves.
In women with vestibulodynia the painful tissue
has bigger, thicker and more abundant nerves.
The painful vestibule also shows
more inflammation cells than normal.
We also suspect that pain interpretive center
in the brain changes so that women
with vestibulodynia experience light touch
as searing and burning instead of soft and feathery.
Researchers believe that both of these changes
increase inflammation cells and bigger thicker nerves
lead to the pain women experience in vestibulodynia.
Researchers in this field are trying to understand
what leads to these changes.
We believe that the trigger may be different for each woman.
For example, the trigger may be a genetic predisposition,
or it may be an exposure of the vestibule
to an environmental irritant.
It may also be a brief infection with a virus
or yeast or bacteria.
Finally the trigger may be a hormonal change
like menopause or postpartum.
We think there may be different triggers
and it may be different for each woman.
Regardless, all women with vestibulodynia experience pain
in the vestibule leading to difficulty having intercourse
or penetrative activities.
Even though the vestibule skin is abnormal,
we understand that the way the body deals
with this pain is complicated.
Coping with painful sex affects the emotional,
physical and psychological way
the body responds to sexual cues.
It also greatly affects the way couples manage intimacy.
Chapter three, understanding vestibulodynia.
We've come to understand that vestibulodynia
affects three different areas of physical and mental health.
Each part contributes significantly to the distress
and pain women feel with this condition.
These three areas of health include the vestibule skin,
the pelvic floor muscles and the psychological wellbeing
of the woman affected by pain.
First, we know that the vestibule skin is painful to touch.
This is often the symptom that drives
most women to seek help.
Next, the muscles deep in the pelvis
that surround the vagina are affected.
These muscles are often clenched, tight and sore.
Finally, the emotional sexual wellbeing
of the woman with vestibulodynia is greatly impacted.
Many women feel sad and angry about their inability
to have a normal sex life.
Each part is equally important and often requires treatment
in order for a woman and her partner to share intimacy
with less pain and less distress.
Each part of the vestibulodynia triad
is important to address.
In the beginning, most women only identify difficulty
with vaginal intercourse, not appreciating
the complexity of the problem.
In fact, most women present to their healthcare provider
with the complaint to pain
at the vaginal opening during penetration.
Since there is a cultural and social belief
that intercourse can sometimes be painful,
many women try to compensate for this pain
with lubricants and position changes.
However despite these techniques, women with vestibulodynia
find that the vestibule skin pain leads to challenges
with maintaining intimacy.
For some sexual intercourse becomes impossible.
Most women with vestibulodynia also have sore
and clenched pelvic floor muscles.
This is the second component of the vestibulodynia triad
that contributes to physical and emotional pain
during sexual intercourse.
Pelvic floor muscles surround the vagina
and can be voluntarily contracted and relaxed.
These are the same muscles that keeps a woman
from losing urine or passing gas.
The pelvic floor muscles normally relax and become soft
when the vagina is penetrated, easily allowing a tampon
or a finger or a penis to enter the vagina.
In vestibulodynia these muscles become tight
and clenched as a way for the body to protect against pain.
This muscle clenching is sometimes referred
to as vaginismus.
During attempts at vaginal intercourse,
the pelvic floor muscles involuntarily respond
by withdrawing and tightening.
The woman often has little awareness
that her pelvic floor is doing this.
This makes the vagina tight and hard to penetrate,
which then adds to the pain and difficulty
of having vaginal intercourse.
Finally, it's important to realize
the psychosexual effects of vestibulodynia,
this is the last part of the triad.
Women with this condition often remark
on how profoundly painful intercourse
has affected their ability to be intimate
with their partner.
Many women share that they begin to lose confidence
in their ability to be sexual.
Women describe feeling sad and angry
about their inability to have enjoyable sex.
Some women begin to feel worried
every time sex is attempted,
since it's usually results in terrible pain
and feelings of guilt and shame.
Women often described not only a loss in their interest
to have sex, but also in their ability to become aroused.
They worry about their ability to have children
since having intercourse has become infrequent
or impossible due to pain.
In summary, understanding vestibulodynia means appreciating
that each part of the triad contributes significantly
to the distress and pain women feel with this condition.
The painful vestibule skin, the contracted and sore
pelvic floor muscles and the suffering psychosexual health
all play a role in the sexual pain disorder.
Women describe many ways in which their lives
have been affected by this difficult condition.
Chapter four, treating vestibulodynia.
Treating this condition is often a journey
that incorporates an integrated team of practitioners
who are all invested in helping you
have pain-free and enjoyable sex.
Research supports that when each part of the triad
is addressed, women have the best outcomes.
Although there is no fast and easy cure for vestibulodynia.
Women who actively participate
in an integrated treatment program,
often show the greatest improvement in pain.
Most women with vestibulodynia have seen a number of doctors
or clinicians before they receive the diagnosis.
By then these women are feeling frustrated,
hopeless, and suffering.
Receiving a diagnosis often feels like relief
for many women, and yet they're also very interested
in learning about treatment.
Through important clinical research,
we have found that an integrated care model
leads to the best results in reducing pain
and returning women to healthy sexual function.
When women first receive the diagnosis of vestibulodynia,
they naturally inquire about treatment
since sex has become painful for many months or years.
Both topical and oral medicines are typically prescribed,
these medicines help reduce the pain in the vestibule.
In addition, lidocaine is a commonly prescribed medication
for women with this condition.
Lidocaine is a numbing gel or liquid
that can be applied directly to the vestibule
to decrease the sensation of pain.
In some women numbing the skin 10-15 minutes prior
to intercourse allows them to have comfortable sex.
Another treatment for the painful vestibule skin
is a localized minor surgery called vestibulectomy.
Some women choose this when lidocaine or other medicines
and treatments are not effective in reducing their pain.
Vestibulectomy is an outpatient procedure
that is performed in the day surgery unit
in about 60 minutes.
Each surgery is tailored to the patient
so that only the painful superficial areas are removed.
Vestibulectomy is a treatment most studied in research
and is associated with a 60-90% improvement in pain.
Research has also shown that outcomes are improved
when women also undergo treatment
for their sore pelvic floor muscles and counseling
in addition to this minor procedure.
Most women with vestibulodynia need rehabilitation
of the pelvic floor muscles since they've become sore.
Over time, these muscles no longer function normally
and retain a constant contracted state
contributing to the pain and vestibulodynia.
Pelvic floor physical rehabilitation
is the primary treatment for these muscles
and is performed by a physical therapist
who specializes in women's health problems.
When a woman with vestibulodynia sees
a pelvic floor physical therapist,
she will carefully assess the woman's muscles
of the abdomen and pelvis.
After the assessment, the pelvic floor physical therapist
will outline her treatment plan.
This evaluation and treatment is done in a gentle,
private and safe setting
where vaginal muscle rehabilitation can be done.
Treatment may include muscle awareness and training,
muscle stretching and massage, biofeedback,
and dilator therapy.
Dilator therapy is unique to pelvic floor physical therapy
and is a vital part of gaining control
over the pelvic floor muscles.
Dilators are cone shaped objects that are used in the vagina
to help the body accommodate and rehabilitate
the pelvic floor muscles.
Dilator work is also performed at home,
since regular interaction with these muscles
allows ongoing successful treatment of the pelvic floor.
Finally, many women share how vestibulodynia
has affected their sense of sexual wellbeing and intimacy.
Research supports that women who engage
in counseling around these challenges report feeling
more in control of their pain.
Special counseling allows a woman to learn tools and skills
to manage these emotions more effectively.
Although many women and couples feel initially reluctant
to participate in this part of treatment,
almost all state that it is beneficial and worthwhile
in relieving the stress and burden of this condition.
Referral to individual, group and or couples counseling
is frequently made so that a woman and her partner
can begin to deal with the profound effect
the sexual pain condition has had on their relationship.
Vestibulodynia is a common sexual pain condition
affecting eight to 15% of women.
Although the cause is unknown,
the skin of the vestibule shows a greater number
of nerves and inflammation cells that are likely triggered
from genetic, environmental, infectious or hormonal factors.
Successful treatment of vestibulodynia includes
an integrated model of direct treatment
to the painful vestibule skin,
the sore pelvic floor muscles,
and the psychosexual wellbeing
of the woman affected by this condition.
With devotion to this care model,
every woman with vestibulodynia should have
the expectation that her pain will improve,
and she and her partner will return to a more enriching
and pleasurable sexual relationship.