Trusting Estrogen Part 3

So let’s back up.  Way up.

Estrogen.

People are scared of estrogen.  People don’t understand estrogen.  People hate estrogen.  People love estrogen.

We have a lot of emotions towards estrogen.

Estrogen can help with vulvovaginal issues.  So how do you know what kind of estrogen to use?  That is a really big question.  Estrogens can be given orally, via a gel, with a patch or topically.

Oral, gel and patch estrogens are meant to be absorbed throughout your whole body.  That is considered “systemic” absorption.  That is body system wide.  Topical estrogens are to be applied to the vulvovaginal tissue.  They are typically only absorbed “locally”.  This means that the estrogen isn’t going to affect your body outside of the vulvovaginal tissue.  The tricky thing is that there are some women who have sensitive nervous systems.  These women do notice more systemic absorption of topical estrogens.  They might notice mood irritability, breast tenderness among other body changes.

One thing you must know:  Just because you are using systemic estrogen does NOT mean you are getting an adequate amount at your vulvovaginal tissue.  Many, many women need topical hormones on their vulvovaginal tissue IN ADDITION TO the systemic estrogen they are using.  Most doctors don’t understand this.

To review…

Orals, gels and patch estrogen = systemic estrogen = changes body wide

Topical creams applied to the vulvovaginal tissue = localized estrogen = changes in vulvovaginal tissue (but can be body wide for some)

So, there’s that.

Now if we look just at localized estrogen we can answer some more questions.  There are lots of different companies making localized estrogen.  You may have heard of names like:  Estrace, Premarin, Vagifem and now there is an oral pill called Osphena that is supposed to target only vulvovaginal tissue.   And there are more names that I’ve not listed.  There are three different types of estrogen found in the human body.  The type of estrogen used in these creams can differ.  Each estrogen, regardless of type, needs to be transmitted to vulvovaginal tissue through a base.  So, all estrogens are mixed with a base.  What we’ve got here now is different types of estrogens and different bases.  We’ve got a confusing situation.  We’ve almost got too many options.

Too many options.  It’s true.  But, when you go to your doctor, it might not seem that way.  It might seem as if there is only one or two options and those are called Estrace and Premarin.  Doctors get lots of free samples of Estrace and Premarin.  I’m going to talk about only three topical options because if I talked about any more I might type forever and have to rename this entire blog Blog About Pelvic Pain and Also A Lot About Topical Hormones – But, Men, I Have Stuff For You Too, I Promise and oddly enough – that url was taken….  Who knew?

Let’s talk about Estrace.

Estrace is estradiol + propylene glycol.

Estradiol is the estrogen and propylene glycol is the base.

Estradiol is is bio-synthetic.  It is very much like what our own body produces.  It is a very helpful estrogen.  It is a very powerful estrogen.  It is my favorite type of estrogen for women to apply topically to the vulvovaginal tissue.

Propylene glycol is an alcohol base.  So…if you already have issues at the vulvovaginal tissue – say you already have pain and are seeing your doctor to resolve this pain, then applying alcohol (albeit with a good estrogen) to your vulvovaginal tissue might actually burn.

When it burns…ah, let’s talk about when you’ve been prescribed Estrace and it burns.  Oy.  A lot of times a doctor will tell you to keep using the Estrace if it burns, but a lot of times patients just give up.  Because it burns.  Because they went to the doctor to get relief from the burning in their vulvovaginal tissue and were prescribed a topical hormone that created more burning in their vulvovaginal tissue.  Doctors will often say, well, if you’re really deprived of estrogen at the vulvovaginal tissue, then the estrogen alone will burn.  And, they are right – if your vulvovaginal tissue is super duper incredibly out of this world unbelievably deprived of estrogen.  Just touching it to apply anything at all can hurt.  But, for the most part, if your vulvovaginal tissue is super deprived of estrogen and you give it estrogen (without also introducing alcohol), then it will feel pretty decent to good to really nice a lot of the time.  I think that doctors think that the estrogen is burning because they are largely unaware that they are issuing estrogen with an alcohol base.  I think that, honestly, is the main problem.

The way you get around that is by compounding the estradiol in a very gentle base.  There are tons of bases out there with really exciting names.  But, I like to keep it simple.  I like plain old coconut oil as a base.  It’s good for your, it’s anti-microbial and I haven’t met anyone that it irritates.  (Actually, one person was irritated by it and they ended up using Slippery Stuff as their base.)  The point is, there is a base option out there for the very sensitive vulvovaginal tissue.  The downside of this option is that insurance doesn’t pay for compounded topical hormones.  Insurance doesn’t get it.  The other thing is – you have to advocate for yourself and ask your doctor for this.  They aren’t going to jump right to it most of the time, but they have probably heard of the idea of a compounded topical hormone.

Let’s talk about Premarin.

Premarin is made from pregnant horse’s urine.

Pre(gnant) + Mar(e) + (Ur)in(e) = Premarin

This is not bio-synthetic…because it’s from a horse.  It’s considered a conjugated equine estrogen (CEE).  This means that it is a horse estrogen that has been converted to a form that can be used by the human body.  The implications of this are that the estrogen sticks to your body’s estrogen receptors very aggressively and it’s affects last for a really long time.  The other part of this is that our body doesn’t metabolize these estrogens in the same way that it would metabolize something that is more bio-synthetic.  For some women, this has been really problematic.  You can google it and find lots of crazy stories.

Nevertheless, Premarin is heavily marketed to physicians and it is heavily used by physicians.  It’s not my first choice, by any means, but it’s one choice and for some people it’s better than nothing at all – if they can tolerate it.

That’s the basics.  The basics of the basics.

 

If you have questions or comments, please leave them anonymously in the comment section below or email me at Sara@Sullivanphysicaltherapy.com

Trusting Estrogen Part 2

Remember a week ago where I left off?  I was being compared to Adam.  If you can’t remember -you’ll have to read it again, because that right there…that name-calling.  Well, that brings me back to estrogen.

Estrogen is in the male and female body.  But, when a woman goes through menopause (or when she is young and on specific medication(s)), she has a sharp drop in estrogen.  One of those places in her body that loses a lot of estrogen (and testosterone) is the vagina and the vulva.  Remember – the vagina is the cave inside the body and the vulva is the genitals that you can see with your eyes (it’s on the outside of the body).  Both of these locations have a decrease in estrogen (and testosterone) during pre, peri- and good old menopause.  This affects the body in a lot of ways.  In a global sense, the body gets drier.  Skin loses it’s rebound and elasticity, the mouth dries, the eyes feel drier.  Memory can be affected.  Hair on the vulva might start shedding.  More plaque might start forming on blood vessels.  Specifically in the vulvovaginal tissue, you might see that you are getting more actual infections, more symptoms of fake infections, dry sex, dryness without sex, lower sex drive, painful sex and a slew of bladder issues.

Let’s break these apart.

Estrogen helps plump up all of your vulvovaginal tissue.  If you have a drop in estrogen (and testosterone), then your tissue is more fragile.  This means that if you have friction at the vulvovaginal tissue, its more likely to form microscopic tears.  It means it can form larger tears – tears that don’t require a microscope to see.  Let’s call these eyescopic tears.  And I mean tears like a rip in paper, not a tear from crying.  I’m getting less and less unequivocal.  (Did you get all that?  I walked myself deep into a word maze.  Puns and using a stupidly long word that means “to be clear”, yet ironically is the most unclear word of all.  Public education.  That’s all I have to say.)  So these tears of skin – they can hurt.  They can burn.  They can also allow bacteria that would normally just bounce around and off closed tissue to then incept that broken tissue and create an infection.

Estrogen helps bring blood and oxygen to vulvovaginal tissue.  When you’ve got blood and oxygen, everything works better.  Your tissues are more plump.  Your tissues will hurt less.  Your tissues will be more pliable to a penetrating item (penis, dilator, vibrator, speculum, finger, toy) and respond to physical therapy treatment better.  When you don’t have enough blood and oxygen in your body, then you can develop tightness in your tissue making stretching painful.  This can keep your muscles in the vagina and the rectum short.  So if the muscles are short because stretching is painful, then when your muscles need to stretch to let items in or out of the pelvic area, then it will hurt.  Also, short pelvic floor muscles can give bad information to your brain.  It can create false senses of urinary urgency and frequency and can make urinating burn.  This can feel like an infection.  The confusion comes in when you get tested for an infection and there is none.  Then what? Then your doctor puts you on an antibiotic anyways.  Maybe long-term.  Maybe every time you have sex.  But, still, you’re on an antibiotic that is fighting off something that isn’t there.   The antibiotic is like a dumb Jedi with a light saber fighting off…nothing…just air…just fighting in your body…just wreaking blind havoc to your gastrointestinal system.  Just because it’s got nothing else to contest with.

Then there’s the dry sex.  Estrogen helps your vulvovaginal tissue lubricate and it helps your vagina stay at a healthy pH.  So when you take the combination of lack of natural vulvovaginal lubrication, possible change in pH and possible miscroscopic tears, then it makes sense that sex might be dry and painful.  And then there’s the added thing of a drop (or plummet) in libido because of a potential drop in estrogen (and testosterone).  Or – perhaps the drop in libido is a result of recurrent dry, painful sex.  Chicken or egg, chicken or egg.

Ok, so now take sex out of the equation.  With a lack of natural vulvovaginal lubrication, possible change in pH and possible microscopic tears and lack of estrogen and oxygen to plump the vulvovaginal tissue – you’re just going to feel dry.  Even when you’re not having sex.

But then there’s the bladder stuff.  This is one of my favorites.  See, it makes sense that if the vulvovaginal muscles are tight and making the nervous system send false signals to the brain about urinary urgency and frequency and if these tight muscles are causing painful urination that you would think there is a problem with your bladder.  (And that a doctor would jump to thinking you have Interstitial Cystitis.)  But, it’s not always the bladder that’s the problem, right?  Because you just read this paragraph.  The vulvovaginal tissues are the culprit and they are too cowardly to tell you that they are the trouble makers, so they are mimicking bladder symptoms so that you will look to get bladder treatments.  The vulvovaginal tissues are very tricky, they are liars and they have no conscience, I swear!  They put all the blame on the bladder and never admit to what they have done.  Shame on them!

What you must know, is that there is a part of the vulva (the external genitalia) that is called the vestibule.  The vestibule is embryologically the same tissue as the urethra and parts of the bladder.  What that means to you is that if the vestibule has a problem, then it can feel like your urethra and bladder also have that same problem.  They can feel one and the same.  The vestibule is super dependent on estrogen (and testosterone), so if your vestibule has reduced estrogen (and testosterone) you can start to feel like your bladder is acting up (among many, many other things).

Part 3 of this trilogy – err, no, it’s going to be longer than that… and Blog About Pelvic Pain’s 100th post is next!

 

If you have any questions or comments, please leave them anonymously in the comment section below or email me at Sara@Sullivanphysicaltherapy.com

Release Your Inner Diva

I talked about diaphragmatic breathing before.  It’s so important.  It’s so, so, so important that I want to go back to it.

The thing is, I’m learning that breathing with your diaphragm is not enough.  You’ve got to breathe with your diaphragm when you are in pain.  You’ve got to breathe with your diaphragm when you are stressed.  You’ve got to breathe with your diaphragm when you are not in pain.  You’ve got to breathe with your diaphragm all the live long day.

Have you heard that Otis Redding song with that little part where he goes into a singing seizure? “You got to…You got to…You got to got to got to got to got to got to ARGH!”  At that moment he becomes possessed with the ghosts of stuttering singers past.  And that’s fine with me because it sounds really good and I wish I was so taken with my own singing that I could just one day sing and lose all of my own senses, possibly even pee on myself while delivering a moving and beautiful melody – a melody that essentially tells people what to do – controls the world – you know, let’s me be bossy.  But, that will never happen…not in that way.  I mean, yeah, I can make myself lose my senses and pee on myself, but no one will ever be moved by any melody that comes out of my mouth.  But, for a moment, can you pretend to hear the sound of my voice and be moved?  You’ll do that for me?  You’ll grant me that one kindness?  Okay, thank you.  Then, let’s try it again.

“You got to, you got to, you got to breathe with your diaphragm when you are in pain!  You got to, you got to got to got to got to got to got to breathe with your diaphragm when you got to got to got to be stressed! You got to breathe with your…you got to got to breathe with your…you got to got to…you got to breathe with your…ARGH!…you got to breathe with your…ARGH!…you got to breathe with your diaphragm when you are not in pain!”

But I’ve already said that.  I said that months and months ago.  What I haven’t said is that breathing with your diaphragm is no longer good enough in my books.  My book has been re-written.  Now I write that your diaphragm really needs to be released.  If you are a person who is alive and has eyes in the front of your head and hands in front of your body and tend to any task at all during the day that needs to be performed while sitting in a chair or if you wash dishes, do laundry, drive a car, type on a computer, write on your phone, watch TV, look at things ahead of you or even shave your own legs…then what I’m about to say is for you.  If you don’t fall into any of these categories, go ahead and skip this post.  It’s going to be a waste of your time.

So, if you are in any way remotely like the person I described above, then it’s not enough to breathe with your diaphragm all the time.  The person described above needs to have their diaphragm “released” because it will be “functionally” “short”.  I made up that phrase.  A lot of times we use the word “functional” in front of an undesired medical description to indicate that even though this part of the body is doing a bad, bad thing, it has to actually do that bad, bad thing in order for the body to keep working because there is something else in that body that is not doing it’s job because it’s too lazy to or because it really wants to do it’s job right but for one reason or another it is incapable of doing so.  But, I’m erasing that definition and making my own.  I’m saying that a “functionally” “short” diaphragm is one that is shorter than it should be because it has no other choice.  We sit.  We do things in front of us.  So, if the diaphragm attaches from the rib cage and slices through the body to attach to our back…then when we allow ourselves to slide into normalcy and and imperfection via sub par posture, then the front of the ribs and the back get closer together.  The diaphragm therefore hangs out in a shorter position.  When it is asked to allow for a good inhalation requiring it to expand, it will only give a percentage of the true length it was intended to give.  This is a problem for a lot of reasons.  One big reason is that your diaphragm work synergistically with your pelvic floor muscles.  Your pelvic floor does what your diaphragm does.

Putting it another way:  If your diaphragm is tight, then you won’t be able to breathe well.

If you can’t breathe well, you won’t be able to relax your pelvic floor muscles well.

If you can’t relax your pelvic floor muscles well, you will continue to be in pelvic pain.

 

Let’s talk about another point succinctly.

If your diaphragm is tight, then you won’t be able to breathe well.

If you can’t breathe well, you won’t be able to sleep well.

If you can’t sleep well, you won’t be able to produce hormones and cell repair in order to heal your body and calm your nervous system.

If you can’t sleep well, you will continue to be in pain.

If you can’t sleep well, you will be tired.

Are you tired of me? (Then release your diaphragm, breathe better and get good sleep.)   Okay, I’ll post the how’s next week.

 

If you have any questions or comments, please leave them anonymously in the comment section below or email me at Sara@Sullivanphysicaltherapy.com

Voodoo Doo Doo Work Part 2

The voodoo doo doo continues… one long, healthy, completely connected, fully formed piece of crap.  Actually – no, it doesn’t continue.  It stops here.  Because here is where I explain how I turned a hard corner. Like a precision driver.  Like Clark Gable’s grandson.  (That is a story for another post.)

Time to wipe….

Last month I ventured out into the cold air of Salt Lake City to follow Ramona Horton to her Level 1 visceral course. The greatest thing that I learned taking my first visceral course with Ramona Horton was that skin rolling is working a different layer of fascia than visceral work.  What that means to the person in pain is that there are still more options out there.  What that means to me as someone who treats people in pain is that there are still more options out there.  It’s just up to me to identify when I need to be using visceral work.  And it’s up to me to get good at the visceral work I have learned.

What Ramona did for me was take all the voodoo doo doo out of visceral work.  She made it a very “normal” way to treat patients.  She took the time to convince me that my hands don’t have to be stupid and that I can actually feel things with them.  I wasn’t told that I had to put my hands on a patient’s head, I didn’t have to connect with their third eye and I didn’t have to fake anything until I made anything.

Visceral work is working on the deepest layer of fascia.  If fascia has an incredibly supply of nerve endings, which it does, then I need to address all of it, not just some of it.  Just like I need to address the whole person, not just one part of the person.  What I learned about paying attention to the deepest layer of fascia is that there are parts of patients’ pain stories that now make sense when they didn’t before.  For example, the symptoms of feeling unexplained nausea after eating seemed so crazy and a bit psychological when I first heard it.  But now, a little more sense has been made of it.  I now understand that the vagus nerve could be part of this symptom and by working on the deepest layer of fascia over the diaphragm, I can most likely affect the vagus nerve and this once seemingly delusional symptom.

I now have ideas for patients that stumped me.  I find that incredible.  I have an immediate game plan for what seemed to be the trickiest patients.  It’s just so refreshing and exciting.  I have a dear patient that came to me after having plateau’d with physical therapy with another therapist.  We did move forward and saw excellent results.  But, I couldn’t sustain those improvements consistently.  She boggled my mind.  I thought of her often.  I emailed several amazing pelvic pain physicians across the country about her case.  I talked about her in all the classes and conferences I attended.  I kept this patient in my back pocket at all times.  She made sense to no one.  I brought her case to Ramona Horton and instantly Ramona tells me what to do.  I’m thinking: What?  Who ARE you?  WHAT are you?  Ramona is like a backwards voodoo worker gypsy good witch outfitted in white lace and a kind smile.  I get back to Austin and do what Ramona told me to do.  And…the patient feels better.  Not 100%, but significantly better.  The best she has felt in a long time.  Now, I attribute this to two things.  First – Ramona knew what was up.  Second – the patient might have better results if I was more skilled in visceral work, but unfortunately that will only come with time.

Now, I’m not saying that I’m going to use visceral work all the time.  I’m not saying I’m going to use skin rolling any less.  I’m saying that I’ve got another piece of this puzzle figured out.  Is that cocky?  No,I don’t think so.  I think as pelvic floor physical therapists we are detectives.  It is our job to figure out your pelvic pain puzzle…because the way our healthcare system and education is set up…it is a puzzle.

Yet again, my practice is changed.  That is such an amazing feeling.  To experience the view from a higher floor.  If this inspires me, it should certainly inspire anyone with pelvic pain.  You are not out of hope, you are not out of answers, you are not out of your mind.  You just need to find the right care.  And that is the battle, the expensive, tedious battle.  Just keep asking questions.  Keep writing emails.  Keep being your own advocate.

If you want to find someone who does visceral work, you need to ask.  In your vetting of your potential pelvic floor physical therapist you need to ask if your patient performs visceral work or if they know someone who does.  Just like anything else, we are not all good at the things we say we can do.  My skin rolling is a hell of a lot different than the next person’s skin rolling.  Same thing goes for anything else in medicine.  Vet, vet, vet and then vet again.

 

If you have any questions or comments, please leave them anonymously in the comment section below or email me at Sara@Sullivanphysicaltherapy.com

Voodoo Doo Doo Work

About a year ago a blog reader emailed me to notify me that I’d do well to improve my website and consider practicing some visceral mobilization.  He said that visceral mobilization provided by his physical therapist was the only type of treatment that created long-lasting maintenance of his improvement.  I worded that really oddly.  Let me say that a new way.  Visceral mobilizations helped him eliminate his symptoms and it kept things that way – eliminated.

I want to be clear that my goal in treating patients is to, when possible, correct the core issue driving their symptoms.  But, if a patient is dealing with something that I cannot change, then my next goal is to eliminate most all of their symptoms.  If I can’t eliminate symptoms, then my third goal, my lowest rung goal, my saddest goal, is to improve their symptoms, even if for just a few days.  Sometimes that is enough to get a person through the week.  Sometimes physical therapy does just enough to keep a person functioning – like Advil for a headache.  We can be like a short-acting medicine in times when a person is going through something that we cannot change.  (And, for the record, there are few times I’m treating someone for something that I cannot change.)

So, this blog reader connected me with his physical therapist.  She had a lot of great things to say about visceral mobilizations as part of a comprehensive treatment for pelvic floor dysfunction (among other issues).  After our conversation, I decided that this therapist had a level head on her shoulders and that maybe I ought to give this type of work a second chance.

A second chance.  I already gave the “visceral” world a first chance and it was a horrible experience.  There is a body of school that teaches visceral work to all types of “body workers” – physical therapists included.  I took a four day course in visceral mobilization.  It was a beginner course.  It involved lots of crazy stuff and at the time I was not in the mood for crazy.  I was in the mood for science-based effective treatment to help my pelvic pain patients.  I spent four days listening to an extremely young instructor tell me to put my hands on people’s heads to figure out where their bodily dysfunction was.  This novice instructor wanted me to put my finger on patients’ “third eye”.  I felt like this asshole was selling me snake oil.

For example, he had me stand behind a patient and gently push them forward.  I was then supposed to know where they had a problem in the body.  Guess what?  I knew.  I said “Oh, the right side of your low back hurts.”  The patient was completely amazed.  The instructor said “See? This works.”  I said “No.  This is a basic core stability test that I learned in orthopedic fellowship training.  You just give a little nudge and see where the back looks most unstable – it will move a little.”  It’s just common sense.

Then, he had a patient stand with their feet together and their eyes closed.  He wanted me to note how the patient’s body waivered.  He placed his index finger in the middle of their forehead and instantly the patient stopped wobbling.  The instructor explained that he had connected with their “third eye”.  Crazy, right?  Except…it’s not crazy.  When you give someone feedback from an outside source, they instantly are able to understand where their body is in space better, so they stop swaying.  It’s the opposite of crazy.  It’s actually kind of boring.

I thought I’d have a heart to heart with the instructor…the guy that repeatedly said “Don’t be mad at me!” when he couldn’t answer the students’ questions.  I told him I was really having trouble feeling all the things he expected us to feel with our hands.  He leaned in and looked me in the eyes and said “Fake it ’till you make it.”  That phrase is my “off” switch.  I fake nothing.  I don’t know how.  I can’t fake nice.  I can’t fake mean.  I can’t fake shit.  Can anyone fake shit?  If you could…what would you do with this skill?

After those four days tested all civility in me, I returned to my patients and practiced zero of what I witnessed in the class.  Yeah, I was too proud.  I basically wasted my time and money by not even attempting to use any of the concepts I was exposed to.  The worst part is, and I don’t know who to blame for this, but I feel that blame is necessary because I have a strong index finger and constantly want to point it at someone…the worst part is that the basic tenant of visceral work was completely lost on me.  And that is a shame because there is a lot of good in visceral work.  I don’t have to act voodoo, fortune-tellerish if I don’t want to.  I can actually make changes in the body using visceral work.

So what is this work I speak of?  Could it help your pelvic pain?  Who does this work?

Ah…stay tuned.

Those Who Can, Do. Those Who “Can’t Even”, Teach.

I’m teaching YA’LL!!!  But, it’s not because I can’t “do”, because I think I can “do”.  I’m teaching because I want to “do” and “teach”.  I want my cake and I want to eat it too.  It’s cuz I did make my bed and I think I will lie in it…thank you very much.

I hate the new young jargon where we destroy the English language by talking in half words and half sentences.  You know what I’m talking about…

“Oh my grd” for “Oh my God”.

“Because [insert any noun at all]” for describing the strength or power of that inserted noun as in “Because [cupcakes].

And my favorite phrase to hate…

“I can’t even” for “This bothers me a lot”.

The middle of the road treatment, the average treatment, the “classical?”, “conservative?”, “historical?” way of treating vestibulodynia “bothers me a lot”.

I can’t even.

So, I will teach.

I want to introduce my new vestibulodynia class titled Vestibulodynia:  A Pelvic Floor and Orthopedic Approach.  Vestibulodynia is defined as pain at the vestibule.  The vestibule is the opening of the vagina.   Typically, people with pain at the vestibule have pain with sitting, sex, pain with wearing tight clothes, sweating, wearing tampons and can also feel like they get urinary tract infections a lot or they feel like have a lot of issues with their bladder.

The goal of the course is to educate physical therapists in how to critically assess each patient so that the treatment of the patient addresses the true cause of the patient’s symptoms.  I’d like to see physical therapists grow more comfortable in identifying the cause of a person’s vestibulodynia symptoms so that they can better treat it.  And, if they can’t treat the symptoms themselves, I’d like to see physical therapists confidently discuss the patient’s case with the right physicians.  There are many times when the physical therapist will need to educate the physician…and there is nothing wrong with that.

I’m tired of patient’s having their symptoms managed, their symptoms masked, their symptoms tackled.  The goal is to take care of the root of the problem.  The root of the problem is the reason why the symptoms exist in the first place.

The other reason I wanted to teach was because I think the pelvic floor physical therapist should have really strong orthopedic skills.  Orthopedic skills are what you think of when you get physical therapy for your hip or your knee in a big open gym.  Pelvic floor physical therapists truly focus on the pelvic floor, but we also need to be really good at assessing and treating the back and hips as well.  My co-teacher in the course is Kelli Wilson.  She is a highly trained physical therapist with amazing orthopedic skills as a result of her years and years of tedious fellowship training.

Together, we want to teach physical therapists to be true detectives who look at the whole picture when treating patients with vestibulodynia.

Share this information with your physical therapist if you think they are open minded and hungry to learn.

More information can be found at our website:  www.alcoveeducation.com 

Your Tailbone Hurts? CHOP IT OFF!

The word is coccygectomy.

It means surgical removal of the coccyx (the tailbone).

This is a surgery that is commonly practiced today.

Let’s rephrase this:

Some doctors decide that if a part of your body hurts, then they should just surgically remove it.  Like, if your hand hurts…you could just cut it off.  Sound stupid?  Well, it is.

There is this concept that the tailbone is a “vestigial” body part, much like the appendix.  This means that it once served a purpose, but it no longer serves that purpose because our bodies have changed over years and years.  Our bodies have supposedly adapted to the differing demands of the world.  The tailbone was thought to be the bone for the “tail”.  We don’t have “tails” anymore, so why do we need a tailbone?  If the tailbone hurts, just remove it.  Coccygectomy, right?

Oddly enough, there’s several research articles that promote surgical removal of the coccyx.  They site that patients tried “conservative” treatment first, this includes physical therapy.  When questioned a year after surgery, according to these articles, most of the patients had improved.  These articles scare me.  Why?  Because doctors want to practice medicine in a way that has been proved to be efficient and therapeutic…proved by science…by research.  What what if the research sucks?  What if the research doesn’t look at the whole picture? (Maybe this is where we need to go back to what I think about research.  You can see that here.)

Okay, so here are some of my thoughts:

Conservative treatment failed for the people who underwent tailbone removal.  They included physical therapy in this category.  But I take issue with that.  What kind of physical therapy did these patients receive?  Were all of these patients going to orthopedic PT’s?  Were they going to pelvic floor PT’s who didn’t know how to treat tailbone pain?  I have many patients see other PT’s without success, but were able to find success ultimately with the right PT for them.  How many sessions did they go for?  I do take issue with PT being lumped into conservative treatment, but I need to get over it, because that’s not a huge deal.  The point is that some people got better after getting their tailbone removed, regardless of what happened before this.

Umm..the tailbone is the site of attachment for a lot of stuff.  What happened to all this “stuff” after their attachment site was removed?  Did they shift everything upwards and bolster it all onto the sacrum?  What does that then do to pelvic floor muscle, nerve and ligament function?  I can’t imagine what these patients are going to be saying in three, five, ten, twenty years.  I can’t imagine how the increased tension on the muscles is going to twist their pelvic and spinal alignment.  What is going to happen to their pooping and peeing and sexiness functions?  I want to see follow ups of these patients waaaay after one year post-operatively.

So most of these patients are improved a year after surgery, but…I want to know, are these patients still taking pain meds a year after surgery?  What is “improvement” anyways?  You always need to question what defines a positive outcome.  What is “feeling better”?  Sometimes it is measured as a small improvement in the pain experience, sometimes it’s measured as elimination of pain.  Sometimes it is measured as a change in the way the body can move.  It requires a definition, so you always need to ask this question when reading the outcomes of any treatment option for anything – not just pelvic pain.

One article noted that some of the patients who underwent coccygectomy had “mental instability”, “depression” or “hypochondria”.  Don’t you love that?  This actually really confuses me.  I can understand one picture:  You have tailbone pain, your doctor doesn’t see anything wrong with you, everything you have tried fails to improve your pain so your doctor determines you are mentally unstable, depressed or are a hypochondriac.  This makes sense to me because a lot of doctors think my patients are mentally unstable, depressed or a hypochondriac solely because the doctor themselves have no understanding of pelvic pain.  But then I get confused about this because the articles are discussing patients who are going to receive a surgical removal of their tailbones.  I have to believe that these surgeons do believe that the patient has true tailbone pain and is not creating psychosomatic symptoms because of psychiatric issues.  Because…if a surgeon thinks nothing is wrong with the tailbone, but decides to remove it anyways…to appease the patient…then perhaps it is the surgeon who is mentally unstable.

It might be just me, but I don’t think we should go around chopping off parts of our body…unless it’s our hair or our nails.

 

If you have any questions or comments, please leave them anonymously in the comment section below or email me at Sara@Sullivanphysicaltherapy.com

Treating Tailbone Pain (Getting the Stick Out Part 2)

In Part 1 I discussed getting the alignment of the lumbar spine, pelvis and sacrum corrected.  Once that is in order, I like to look at the actual tailbone itself.  Well…I guess I should say I like to feel the actual tailbone itself.  I can place my finger externally and run it along the curve of the tailbone to tell if it’s kind of sidebent or flexed too far forward.  But, what I can’t tell by just touching it externally is if it’s capable of moving well.  The tailbone should move about 15 degrees forward and another 15 degrees backwards – that’s 30 degrees of total movement.  If your tailbone can’t do that, it’s going to hurt when you transition into sitting and standing.  If your tailbone is doing too much movement, that can hurt too.

So – to recap:

  1. We look at the lumbar spine
  2. We look at the pelvic alignment
  3. We look at sacral alignment
  4. We look at tailbone alignment and movement

And I’m just getting started….

So, let’s talk about #4 some more.  In order for me to get my finger all the way up to the tailbone (which, remember is the tip of the spine), I really have to be gentle and conscientious of what the patient is experiencing.  It’s kind of a long way up to the tailbone.  Your therapist doesn’t have to be tall and lanky like me in order for their finger to reach way up, there can a little gentle pressure to ensure that the finger gets to where it needs to go.  But, if your therapist does this, they need to be sure to always ask how your anus feels.  If I’m not mindful, my knuckles could be a little rough on the anus and that’s not necessary…ever.  The other thing that is important is that I have to go really slow when I’m making my way up to the tailbone.  I’m not going to just go straight to my target.  The rectal pelvic floor muscles need a little time to adjust to the fact that there is a foreign intruder.  And then…my rings…I take them off.  No one wants a diamond shoved up their rectum…or do they…?

Speaking of diamonds…I lost my wedding band at work.  AT WORK!  It was on my finger one minute, it was not on my finger the next.  I never took it off.  So, what would you do in this situation?  Would you do what I did???  Want to know what I did?

Yes.

Oh yes.

That thing that you would think of doing, but might not actually do…

I did it.

I went through all my dirty gloves in the trash can.  All of them.  Every single goopy, gooey, gross, gunky glove.  To make matters worse, I didn’t find my ring!!!  When I tell my patients this, they chuckle and say one lucky patient is shitting out diamonds!  I’m not ready to laugh about it.

Back to the rectal exploration.  A lot of times patients will feel like they are going to have a bowel movement when my finger is in their rectum.  This doesn’t really happen.  I warn my patients before I start the internal work that they probably will feel like they need to go to the bathroom, but that’s only because my finger is in their rectum and most of the time it’s only stool in the rectum…so the sensation is familiar.  This eases their minds a lot.  But, you know, sometimes when a finger is in the rectum, it genuinely stimulates a bowel movement.  So, if my patients need to go, I tell them to get up and go to the bathroom.  I don’t want them holding their pelvic floor muscles tight and stressing about surprising me with an uninvited visitor.  I will say this though…sometimes my patient gets an unexpected visitor of the other kind: gas.  It is the scariest, coolest thing ever when someone passes gas while I’m doing rectal work.  The first time it happened I actually jumped and said “Oh my God!” and then the patient and I just had to laugh for a while.  It’s an amazing feeling to have air rush against your finger while it’s kind of in a weird vacuum.  There is nothing like it…not in an “exhilarating” way where I feel like you haven’t quite lived unless this has happened to you, but more in a “I really like my job and I’m a pelvic floor nerd” kind of way.

So…tailbone contact.  Once tailbone contact is made, I like to also have one of my fingers on the outside of the tailbone (external) so I feel the tailbone movement internally and externally at the same time.  I’m making the tailbone move so I can figure out if it’s kind of stuck or if it’s moving nicely or if it’s moving too much.  I’m also trying to figure out if the tailbone is pointing way too far forward, backward, to the side or even if it’s kind of rotated like it’s trying to point behind itself.  Like a weirdo.  Like a weirdo tailbone.

If the tailbone is sticking too far in one deviant direction, I can correct this by manually moving the tailbone or by using muscles that attach to the tailbone.  For example, if a tailbone is leaning to the left a bit, I can try to relax the muscles that attach to the left side of the tailbone and/or I can try to get the person to activate the muscles on the right of the tailbone.  It’s kind of common sense.  Basic…kinesiology…physics?  It’s the basics of a science.  It’s important for me to keep checking the tailbone placement in future appointments because I want to know if the tailbone keeps moving back into the same deviant location.  If this is happening, I really need to focus on the reason why…not just the symptom itself (which is the misalignment of the tailbone.)  Why is this happening?  Is it the lumbar spine?  Is it the pelvic alignment?  Is it the sacral alignment?  Is it the muscle pull?  Is it the repetitive micro-traumas of different positioning habits?  The “why” is so important.

I have only ever had one patient whose tailbone moved way too much.  It had excessive movement.  This patient was desperate for help.  I ended up actually putting her through a monitored stabilization program (involving strengthening specific weak muscles surrounding the pelvis and hips) and it improved her pelvic floor function and it eliminated her tailbone pain.  I want to note that I tested each of my patient’s muscles to determine which ones were weak and I had her work on those specific muscles.  Nothing is cookie cutter – not if you want to get better….

Then, sometimes this happens:  I assess someone’s tailbone and it is fine.  It’s not doing anything wrong.  It moves well.  It doesn’t hurt when I touch it.  So then I go exploring the muscles attaching to the tailbone and “BAM!” that’s the patient’s “tailbone pain”.  Sometimes it only feels like your tailbone is hurting, but it’s actually a muscle kind of close to or attached to the tailbone that hurts.  It’s really important to be aware of this possibility because if your therapist is only doing external work on you…and you’re not getting better…this could be one major reason why.  (Well, one major reason of many major reasons.)

If you have any questions or comments, please leave them anonymously in the comment section below or email me at Sara@Sullivanphysicaltherapy.com

Treating Tailbone Pain (Getting the Stick Out Part 1)

When you have tailbone pain, it’s really a pain in the ass.  Right?  It can hurt when you sit, stand, transition from sit to stand, lie down, walk, poop, all of it.  It has the potential to constantly nag at you.

I’ve got some suggestions on what you can ask your physical therapist to consider or what you can try to do at home on your own.

First, I’m all about good alignment.  I’ll never stop staying this.  (Never say never.) I think that it’s important for the lumbar spine to be screened and for the pelvis to be aligned.  This is because the bottom two segments of the lumbar spine (the lowest part of your back, that part that pregnant women will grab when their belly gets really big in that typical “Oh, my back hurts” gesture)…the bottom two segments of the lumbar spine are intimately related to the alignment of the pelvis because of a connection via ligaments.  So, if your pelvis is not aligned…if the foundation of your pelvic floor muscles and nerves are not aligned, then that will make the pull and performance of pelvic muscles and nerves asymmetrical.  This can cause tailbone pain.  This can cause weird body symptoms.  This needs to be addressed.  I have written a post about how to correct your pelvic alignment here.  You probably can’t address your lumbar spine yourself, but if you correct your pelvic alignment, this can affect the lumbar spine.  And, the reverse is true, correcting any rotations or opening or closing issues at the lumbar spine can affect the pelvic alignment.  The body is cool.  Understanding the body is cooler???  No.  It’s ice cold.

Part of correcting pelvic alignment involves correcting the sacral alignment.  The sacrum is the part of the spine below the lumbar spine and above the tailbone (the coccyx).  The sacrum is part of the spine, but it is also part of the pelvis.  It’s the “S” in “SI” joint.  The SI joint is the “sacroiliac joint.  You really need a professional therapist (not an unprofessional therapist) to be looking at your sacral spine.  Not all therapist are well-versed in this.  It’s not hard to assess and correct this, it’s just not common knowledge for all therapists.  That’s the tricky part.  That’s the rub.  (I love saying “That’s the rub.”  Hope it doesn’t rub you the wrong way.)  The sacrum is a huge attachment point for a lot of musculature and it is joined to the tailbone.  They have a joint that connects them.  So, if you leave out correction of the sacral alignment, in my book, it’s kind of like missing one of the most obvious pieces of the puzzle of tailbone pain.

So let’s back up a little bit.  Say, your lumbar spine, pelvic and especially sacral alignment is corrected and that in itself abolishes your tailbone pain.  Well, look at you!  Congratulations!  But, we don’t want to celebrate yet because we need to make sure that you understand the habits that created the lumbar, pelvic or sacral issue which resulted in tailbone pain in the first place.  Think about the things you do every day.

How do you sleep?  Do you sleep in fetal position?  Do you have assymmetry in your leg position?  Do you wrap your leg over your partner in a type of gymnastic contortion?  This could be a really prolonged posture that kind of sets your lumbar spine, pelvis and sacrum in a certain wonky position.

How do you sit?  Do you prefer to cross your left leg over your right?  (I do.) Do you read on the couch while sitting on your knees and cock-eyed over to one preferred side?

How do you stand?  Are you constantly judging people or trying to bring back the 80’s with your hand on your hip, body completely shifted to one side while the foot of the other leg points completely to the opposite side?  Well, I have news for you…the 80’s are over!  So pull that side ponytail out of your hair and shift your weight equally over both legs.  Not only will you look more “current”, you will be helping reduce constant excessive one-sided forces through your spine and pelvis.

Do you have a heavy bag or a baby that you like to carry on one side of your body?  This will totally overload just that one favored side and will affect your lumbar spine, pelvis and sacrum.

Just think about what you do every day, how do you like to move, what are your relaxation position preferences?  Whatever you discover, figure out a way to make the load through your body more symmetrical.  You don’t have to stop crossing your legs all together, but maybe you should give the other leg a chance to be on top from time to time.

So, that’s just ONE THING that could contribute to tailbone pain.  Let’s talk about more, so much more in the next post.

If you have any questions or comments, please leave them anonymously in the comment section below or email me at Sara@Sullivanphysicaltherapy.com

Pso Your Iliopsoas Is Psuper Psore.

Pso you’re wondering what a tight iliopsoas looks like?

You want to know if your iliopsoas is psore?

Pson, you want to know if your psomatic symptoms are from the iliopsoas?

Are you hoping that psome day you don’t have to deal with some of your psymptoms?

What?  It’s fun.

Pso what!

Okay, a tight iliopsoas.  What does this look like?

Here’s a reminder of where the iliopsoas runs.  Take an image of a human spine in your mind.  Think about the part that is the back of the spine, this is the part that you can trace your finger along if a finger is tracing up and down your spine.  You feel the bumps of each spinal level just under the skin of your back.

Now forget that image.

Think about the opposite side of that part and try to imagine the smooth, curved side of the spine that faces the inside of your body.  Starting from your neck you have the cervical spine, then around your rib cage you have the thoracic spine and then in the lower back you have the lumbar spine (then there is the sacrum and tailbone below that).  The lumbar spine is the typically the part of the spine that curves slightly forward – forward meaning the curve moves toward the front of your body where your belly is.  So, the anterior (front) part of the lumbar spine (and even the lower bit of the thoracic spine) is where the psoas muscle starts.  Then the psoas takes a three dimensional diagonal route to attach to the iliacus muscle which is the filling on the inside of one side of the pelvic bone.  The iliacus is like the meat of the avocado if you were to scoop it out of the skin.  Think of the skin of the avocado as the iliacus bone.  The ilacus bone is that fan-shaped bone that you can literally place your hands on.  It’s the bone you are putting your hands on when you think of putting your hands on your “hips”.  We don’t actually ever scowl with our hands on our true hips, we scowl with our hands on our iliacus.  Really.  Go ahead and scowl and place your hands where they naturally want to go – that’s the iliacus, not the hips.  Now scowl and place your hands on your real hips.  That’s just weird, right?  If you were to scowl at me and place your hands on your real hips I’d point and cock my head and walk away.  It would have no punishing effect on me.  I’m just saying….

Back to the course of the iliopsoas.  Pso…we were saying that the psoas comes from the low back and goes through the abdominal cavity (on each side) and attaches to the iliacus muscle.  Then the attachment goes down to the head of the femur which is the hip bone.

Remember that the action of the iliopsoas muscle is to bring the hip bone up – to “flex” it.  So, it takes the hip from being straight to being flexed.  The iliopsoas also flexes the trunk.  So, it takes the trunk from being straight up to bending over.

My iliopsoas are tight.  A lot of people have tight iliopsoas’ or iliopsoi (<— cute).  If you ever try to sleep on your belly at night and it feels like your low back is arching backwards or there is a lot of pressure or discomfort on your low back because of it, it’s probably because your iliopsoas is tight.  Try alleviating this by placing a pillow under your belly so your back doesn’t arch so much.  And yeah, it might be stretching your iliopsoas a bit to do this too.  Or if you are one of those people who just naturally have a huge curve in your low back when you are standing, it’s probably because your iliopsoas is tight.  Some people think that huge curve in the low back is sexy, but it’s not sexy to have back pain and pelvic pain.

If the iliopsoas is tight, it can create twelve angry Americans, as discussed in my first post about the iliopsoas.  A plethora of symptoms all from this tight muscle.  But, the question again, how do we know if this muscle is tight?  The first thing I would do is test the muscle length.  I do this by performing what is called a Modified Thomas Test.  The cool thing is that this “test” is also a stretch.  So, this is what it looks like (picture obtained from PThelper.com):

thomas stretch 3_800

There are a few things to take note of here:

  1.  You are at the edge of a bed, only half your butt is on the edge and you grab one leg with your hands and bring it to your chest.  This is done to flatten your low back.  If your low back still isn’t flat after doing this, then you need to bring your knee even closer to your chest via pulling on it with your arms.
  2. The leg that is hanging down is the leg that is being tested or stretches.  So, for a test, we are looking to see if the thigh is parallel with your body or parallel with the ground (same thing) or if it is raised upwards.  If it is raised upwards, then that means your iliopsoas is tight.  The reason this means that the iliopsoas is tight is because if one end of the iliopsoas is connected to the front of the low back and the low back is completely stabilized by flattening it against the surface you are lying on, then they back cannot arch and give any “give” or slack to the iliopsoas from that end point.  The other end point is at the head of the femur which is the hip.  So, if back is stapled down, then if the iliopsoas is tight, it is going to flex the hip so that the thigh is not parallel to your ground or to the body.  It will tug on it because it’s too short.
  3. The stretch that you do to lengthen the iliposoas is the same as the test.  You just lie in that position and let gravity push on your leg.  I like for people to do their stretches without any bouncing for a total of 30 seconds in real time.  Not 30 seconds of counting in your head, but 30 seconds of real time in real life with a real clock in the real world.
  4. The other thing you can do is have someone gently, gently put a little pressure on your thigh.  The pressure should push your thigh towards the ground.  The key is that your back is not allowed to arch, cuz then you aren’t fixing the end points of the muscle.  You might as well just arch your back all the way and watch your stretching leg lower and look magically parallel to the ground all of a sudden.  Don’t do it.  You are wasting time if you arch your back.  Be very mindful of the low back.
  5. Stretches shouldn’t hurt, they should feel like a nice stretch.  Don’t do too much, do just exactly what you need.
  6. The other thing to keep in mind is that you really need to do this stretch (and all stretches for that matter) with an aligned pelvis.  Check out the post where I teach how to correct your own pelvic alignment.  The thing is that if your iliopsoas is more tight on one side than on the other, it can pull you out of alignment.  If you correct your alignment and don’t stretch a tight muscle that is a culprit in moving you out of alignment, you will keep going out of alignment.  If you stretch your iliopsoas when you aren’t in alignment, you aren’t going to get a great stretch or you might get a stretch “test” that makes it look like you don’t have a short iliospoas when you actually do.
  7. I see a lot of other ways of stretching the iliopsoas and I just don’t like them.  I don’t like the “on bended knee” stretch because it’s really easy to arch your back that way, in fact it’s a considerable amount of effort to keep your back from arching.  Also, a lot of the pictures that I see that depict how to do an iliopsoas stretch show the person actually arching their back.  I can’t explain why there is bad information out there, I can only judge it and tell you it’s bad information.  I love to judge.  I love to judge so much.  Nothing is good enough!
  8. For now, ignore the red arrow in the picture.  I am so bad at computers, all I know how to do is type.  Don’t expect any proper photoshop or editing from me.

 

If you have any questions or concerns, please leave them anonymously in the comment section below or email me at Sara@Sullivanphysicaltherapy.com.

 

 

Relax Your Pelvic Floor Some More

Okay – now we can get into the “classic” stuff.  How to relax your pelvic floor muscles via stretching.  So the first thing is that you need to understand what the pelvic floor muscles are.  These muscles go from front to back and side to side from the clitoris/penis to the tailbone and sacrum and then side to side from one hip to the other hip.  Stretching this is achieved through a lot of ridiculous positions, many which may seem like actual sexual intercourse positions for a woman.  But, think about it – that makes sense.  With vaginal penetration, the woman is essentially getting in positions that open the vaginal entrance to allow for penetration.  These positions lengthen the pelvic floor muscles.  This lengthening is a stretch of the pelvic floor muscles.

So, there are a few basic stretches I give people when I think they need stretching.  The key to stretching is that it should be 100% pain-free when performed and there should be no pain afterwards as a result of doing the  stretches.  I have my patients hold their stretches for 45 seconds.  The reason is because there is research to show that a stretch held for 30 seconds will make lasting changes in tissue, but a stretch less than 30 seconds will make no lasting change and a stretch over 30 seconds provides no added benefit.  So why do I ask for 45 seconds?  Because I don’t trust that my patients will give me 30 if I ask for 30.  I ask for more and then they”ll probably truly hold for 30 seconds.  It’s manipulative, but it’s not mean.  The other thing is that repeating a stretch isn’t going to change your tissue any further, so I only have people do a stretch more than once if it just “feels” good or if it instantly reduces pain.  I think this is helpful because I’m not a fan of overwhelming patients with exercises just for the sake of giving them a ton of stuff to do.

1.  Pelvic Drop – this I learned from the ladies at Pelvic Health and Rehabilitation Center.  They discuss this exercise in a blog post that you can find here.  Sometimes I just have patient’s hold this position by placing their hand grip on the ankles while their hands are going between the legs.  I’ll even have patients use their dilators in this position.

2.  Happy Baby Stretch – Yup, this is the yoga move.  It’s fantastic for the pelvic floor.  It’s fun to do too!

3.  Child’s Pose – Another yoga stretch, but for this one I like the knees to be apart and the feet to stay together.  I tell people that they want to feel the stretch in the anus itself.

So then, you can stretch the other muscles that effect the pelvic floor.  It’s like indirectly treating the pelvic floor if you can’t do some of the suggested stretches.  So, if you know that the abdomen, inner thigh, outer thigh, and buttocks and diaphragm can tighten the pelvic floor, then when they are stretched, they can relax the pelvic floor too.  Do stretches that focus on these body parts.  Simple enough.

Performing trigger point releases to the pelvic floor internally and externally is very helpful, but you can go one step further and do trigger point releases in these muscles that effect the pelvic floor.  It’s all connected and so many of the same principles apply.  Pay attention to the trigger points in the abdomen, inner thigh, outer thigh and buttocks and diaphragm.

The last suggestion I have is progressive relaxation.  I really like this one because it involves the whole body.  Progressive relaxation is when you ask the whole body to relax, one body part at a time.  I like patients to lie down, close their eyes and be quiet.  Then they relax their scalp, their forehead, the eyes, the cheeks, the ears, the lips, the tongue, the jaw, the neck, the shoulders, the arms, the hands, the fingers, etc….  Some people just fall asleep after doing this, so it’s nice to make this part of your bedtime routine.  If you can’t feel your pelvic floor relax, then doing this will without a doubt get your pelvic floor to relax without your awareness of it.

 

If you have any questions or comments, please leave them anonymously in the comment section below or email me at Sara@Sullivanphysicaltherapy.com

How to Correct Your Pelvic Alignment

Your pelvis is made up of several bones that are “fused” together.  There is a group on the left side and a group on the right side.  They come together in the middle and there is cartilage in the very front called joining them together.  This is your pubic symphysis and it is located just above your penis or clitoris.  Feel it, this bone is hard and easy to find.  Each side, each collection of grouping of bones, is called an innominate.  Though I’ve known several physicians to dispute this in the past, your innominates can move.  When this happens, you are considered “out of alignment”.  A lot of people are familiar with chiropractors correcting their alignment, but guess what, physical therapists do it too.  My goal for this post is to teach you how to do this at home.

If your pelvic alignment is off, then the entire foundation that your pelvic floor muscles, nerves and ligaments are lying on is off.  For those with pelvic pain, I think this is a problem and I think it needs to be corrected.  I remember hearing in a course once that “Sometimes people are just out of alignment and that’s how they are.  If it’s not broke, don’t fix it.”  I agree to an extent.  If you’re my grandma and for fun I decide to check your alignment and you’re misaligned, but you’ve got not pelvic issues, I’m not going to fix you for kicks.  But, if you’re my patient with pelvic floor problems then I’m considering it “broke” and I’m going to fix it.  How irresponsible for someone to tell pelvic floor therapists not to correct pelvic alignment on their patients.  Why would we throw orthopedic care out the window?  This is a personal pet-peeve of mine, as you can clearly see.

I like to correct my patient’s pelvic alignment in treatment, but I also need to teach my patient’s how to do this independently at home.  You really do need someone to help you with this, so often times I even have my patient’s friend or partner come in for a pelvic alignment crash course.

Here is your crash course, but please note, this only works if your legs are the same length.  If they are different lengths, you might need a heel lift.

  1. Lie on your back and bend both knees.  Lift your hips up like you’re doing a bridge and immediately put them back down.  Have someone pull both your legs straight.  This “resets” the pelvis so you can get an accurate picture of what is going on.
  2. Place your hands high on your waist like you are an angry mother scolding a child.  Get a good firm grip of your sides and slide your hands down until you feel a bone on both sides.  This is called the iliac crest.  I call this the “top of the sides of the pelvis”.  So, go ahead and check the top of the sides of the pelvis to see if one side is higher than the other.  “Higher” means close to your head.  “Lower” means closer your feet.  The relationship is to each other – the left and the right side.  Check the front of the boney parts of the pelvis to see if one side is higher than the other.
    1. If one side is higher, have someone gently pull the leg on that side at the ankle for a few slow, gentle tugs.
    2. Recheck to see if the pelvis has been aligned by bending your knees and doing a bridge while someone pulls your legs straight. Recheck the top of the sides of the pelvis to see if they are level. If they are not, try the leg pull technique again.
    3. Steps 1 and 2 can be repeated as many times as necessary until your iliac crests are aligned.  But, I’d say after 3-5 attempts to correct this, if it’s not corrected, it could be that you need some muscle or connective tissue work done first and then your alignment will more easily be corrected.
  3. Next step is to find the anterior superior iliac spine.  Also called the ASIS.  Also called “the front of the boney parts of the pelvis”.  So, have you ever seen a picture of a really skinny girl (or boy) in really low cut jeans?  These bones are the ones that jut out like spikes on skinny people.  Heavy people, you have these too, but they are not quite “spikes”, more like a rock under a pillow.  That’s okay too.  Just want to let you know what to look for.  So…check the front of the boney parts of the pelvis to see if one side is higher than the other.  Again, “higher” means closer to your head and “lower” means closer to your feet.
    1. If one side is higher, bend the knee on that side and flex the hip to 90 degrees. Take your hand and try to push your knee away from you while your knee pushes into your hand. Do this for 8 seconds and repeat 3x. Recheck to see if your pelvis is aligned by doing step 1.
    2. If one side is lower, bend the knee on that side and flex the hip to 90 degrees. Try to bring your leg down straight while someone else resists you at your hamstrings. Do this for 8 seconds and repeat 3x. Recheck to see if your pelvis is aligned by doing the first step 1.

You’re always going to try to correct the side that hurts.  None of this should increase your pain.  It should all feel pretty good.  But, if you do these corrections and you end up with more pain, just do the opposite of what you just did and you will reverse your correction.

Why do you keep going out of alignment? Some people go out of alignment every few hours, some go out of alignment every few days, some never go out of alignment again.  If you are someone that goes out of alignment a lot, it’s important to look at what you are doing.  Do you sit with your legs crossed the same way all the time?  Do you sleep with one hip flexed and one straight all the time?  Do you stand with your weight shifted on the same leg?  Do you hang out on the couch leaning more onto one hip?  Look at the way you move your body and the positions you lounge in.  The key is to make things symmetrical.  Shift how you cross your legs.  Sleep with the other hip flexed and the other leg straight (if you can).  Shift your weight onto the other leg when standing or don’t stand with your weight shifted at all.  Get the point?  Don’t let one side do all the work, either make your movements centered or make sure your other half gets in on the action.

What can correcting alignment help with?  Theoretically, it should help with any SI joint pain (this is pain more around the center of the butt cheek on either side), some low back pain and really most pelvic floor dysfunctions.  This doesn’t mean correcting alignment resolves these problems 100%, it just helps improve them.  It’s a big claim to say it helps with most pelvic floor dysfunctions, but it’s true.  Like I said above, we are correcting the foundation that everything in the pelvic floor lies on.

Who shouldn’t correct their own alignment?  I think that you should really see a professional if you have had surgery, spinal cord issues, or any other larger condition more than just run of the mill back pain or “just” chronic pelvic pain.  What I’m saying is, if you’ve been diagnosed as just having back or pelvic pain, then it’s probably okay to correct your own alignment, but if something larger is going on, then consult your doctor or physical therapist first.

What if you go out of alignment all the time?  If you go out of alignment easily, I suggest that you make sure your pelvis is in alignment before working out and stretching.  If you go out of alignment really, really easily, like with just the transition from sitting to standing, then you might want to get a belt to apply pressure to your pelvis.  These belts are called SI belts.  SI stands for sacroiliac.  Some pregnant women wear these to keep their pelvis stable and to take the belly weight off the pelvis just a bit.  Others who are not pregnant can use it as needed.  Some need it 24 hours a day, even while sleeping.  Others need it just when they are being active or running.

How can you tell if an SI belt is right for you?  I will correct someone’s alignment and have them walk thinking about their pelvic pain levels.  Then, I’ll put them in an SI belt and have them walk thinking about their pelvic pain levels.  If there is an obvious and instant reduction in their pelvic pain, then the belt is a good option.  If they put the belt on and walk for a bit and cock their head to the side and say “Umm, it’s a little better…I think.”  – Then I don’t suggest the belt.  I personally feel that the belt is best when there is a marked and obvious improvement in pain and movement.  Think about this too – if there isn’t an obvious improvement when you put the belt on, then you probably aren’t going to wear it very much anyways.  One note about the belt – it can be a little uncomfortable if you sit a lot because the edge of the belt might dig into your hips and thighs.

What if you put the SI belt on and it makes your pain worse?  Then you probably put it on when you were out of alignment.  Re-check and correct your pelvic alignment and put the SI belt back on.  It should typically feel better.

Does this really help in the long run? I get asked about the efficacy of the SI belt a lot.  People want to know if the belt just helps to reduce pain at that moment, or if it helps their pelvis in the long run.  I’ve heard different therapists say different things about this.  Some therapists say that the SI belt is a band-aid, it just helps reduce pain in the moment that you’re having pain.  They say that the SI belt keeps you from using your own muscles to stabilize your pelvis and therefore is probably hurting you in the long run.

The other camp says that the SI belt is not only helpful in reducing pain, but it helps improve the health of the pelvis.  The ligaments that keep your pelvis aligned can become injured or too lax and that is why someone who goes out of alignment easily goes out of alignment so easily.  It takes almost a full year for these ligaments to regrow more appropriate tissue and you want this tissue to grow at the right angle to keep you from going out of alignment all over again.  Because of this, some therapists want you to wear your SI belt all the time for a year.  I sit in this camp.  The only thing is, I don’t know any patient that has actually done this.  Wearing an SI belt is kind of awkward and when you want to look good in a nice outfit, it might show a bit.  While I don’t think anyone will wear their SI belt constantly for a year, I do tell people to wear it all the time for as long as they can.  If they can align their pelvis as often as it goes out, even if they aren’t wearing their SI belt, then their ligaments will heal and regrow at an appropriate angle.

Correcting your own alignment is huge in helping to reduce your pelvic pain.  However, this in itself doesn’t replace the professional help of a physical therapist.  Your alignment may be stuck. You may try and try to use the suggestions I’ve given, but your alignment doesn’t improve.  You might need some work done by a therapist before your pelvis is ready to work with you.  In addition, like I said before, if your legs are different lengths, it’s very possible that you need a therapist to help you determine if you need a heel lift.  Lastly, something I’m not teaching in this post is how to correct an issue with the sacrum – which is the little cupped part of the pelvis on your backside.  This is half of what we call the sacroiliac joint – better known as the SI joint.  Only a skilled clinician can really address this, I do not think this is something that a post can or should teach because it’s not that cut and dry.

If you have any questions, please email me at Sara@sullivanphysicaltherapy.com or leave them in the comment section below.

Interview with Dr. Deborah Coady – Part 2

Part 2 of Dr. Deborah Coady’s interview….

 

6.  What is your advice on finding the best way to approach physicians who are not familiar with pelvic pain or are not interested in pelvic pain symptoms?

debcoadypicDr. Coady: This is exactly what I’m working by mentoring and lecturing. I totally understand OB/GYN’s not being interested in focusing their profession on pelvic pain. OB/GYN’s and me too, a lot of us want to do surgery, take care of pregnancy and delivery, infertility and cancer – all the wonderful things that OB/GYN’s do, there’s not anybody that I know that goes into OB/GYN thinking they want to take care of people in pain. So, it’s fine not to be interested in it, but it’s totally negligent to not have somebody to refer to who is interested. I don’t care where they are practicing, what part of the country – if somebody comes in with vulvar pain and you feel it’s not something that you are geared for to take care of, then make a referral to somebody. It may not be an OB/GYN, it may be a physiatrist. A lot of physiatry doctors are seeing this now because these are people who actually go to medical school knowing they will be helping people in pain – that’s what their field does. I can foresee, because I have beating my head against the wall with my GYN colleagues, I could foresee that that could be a place where pelvic and vulvar pain would see a physiatrist. So, that’s my advice.

Now, if somebody does have an interest, the other thing is – there’s a time issue. It’s very time consuming to take care of pain – any kind of pain. If you take insurance and you go to see an OB patient every 10 minutes in order to pay your overhead, it’s not going to work in your practice. There are practical considerations when it comes to taking care of people in pain. So, some people have to be practical and say, “Well, in this time in my career I can’t do this.” A lot of OB/GYN’s are giving up obstetrics, so as they get older they have time. If they do have an interest, because there are 16 million women suffering from vulvar and pelvic pain in this country – then they have to get educated. They should go to IPPS, they should join the National Vulvodynia Association and also the ISSVD. At this point now, not when I was just starting, there are lots of professional societies who give great training courses. We need one big textbook that will cover it all – there are some out there, the science is changing day by day. We have good research in chronic pain going on. They need to take one of the courses and get started. If they don’t know, then the first patient comes in and they’ve been suffering for 15 years with pudendal nerve pain, vulvodynia and IC and all the co-morbidities, then they just have to have somebody they can ask, you know, to mentor them. They could do that through these societies now.

 

7.  In the book, you talk about clitoral pain and PGAD (Persistent Genital Arousal Disorder). Both diagnoses you feel are treatable. Can you touch on some of the causes of clitoral pain and PGAD and what options you think are beneficial?

Dr. Coady: Well, speaking of clitoral pain – clitoraldynia, we have to keep researching it, but most clitoral pain is related to compression, inflammation or neuronal formation in the dorsal branch of the pudendal nerve that goes to the clitoris. So, that said, there are cases that could be treated or could be partly dermatologic. Sometimes there is Lichen Sclerosus that is hiding on the clitoris or even Lichen Planus or a fungal infection or chronic, other skin things. I’ve seen a patient that has on and off herpes ulcers that hides on the clitoris. So you have to do a great magnification of the clitoris to really know, to rule out the surface explanation. Once that’s done, that kind of pain is a neuropathic pain related to branches of the pudendal nerve. It’s a burning, terrible pain that is nerve pain. That then takes some of the mystery out of this disorder and treatment should be directed towards why the nerve is inflamed. It could even be something like an autoimmune cause for nerve inflammation. Most of the time it’s biomechanical or an injury, maybe something very not recognized.

For PGAD, similar types of infections and etiologies exist, but there is also some other kinds of things like vascular problems that affect the clitoris. Also, central – pain that is causing a stimulatory effect. For instance, there are functional MRI studies that are starting to look at some of these things. But, the most important thing is too look at what is going on in the local environment. It’s very interesting that some of the “arousal” symptoms that are similar to what women feel with persistent or recurrent arousal. Some of those same symptoms can be felt with urethral inflammation like with Painful Bladder Syndrome/IC. We are seeing an overlap that some cases of PGAD may be related to both the vestibular mucosa and urethral mucosa and Painful Bladder Syndrome. The same branches, the perineal branch, the labial [also known as dorsal] branch of the pudendal nerve are all involved in innervating all of those structures. It’s a situation where a real individualized approach for PGAD needs to take place – looking at everything that can be affecting the function of the structures that are by the clitoris if not the clitoris itself. By calming down a urethraldynia, we can make an impact women suffering from PGAD.

There is still more to learn especially about the central issues. Some medications can cause it – you know, what you were saying before about watching some of these people develop these things – I mean, a couple patients that I treated for vulvodynia, first of all, that could be another topic of conversation – just the term vulvodynia – a term I don’t agree with at all. But, treating vulvar pain syndromes – I’ve treated patients with Cymbalta and the next thing I know, the patient says “I’m feeling a little bit better with my general vulvar pain, but now I’m feeling aroused.” There are medications that can do the same thing, so we know that it is probably working centrally in the brain. You’ve got to take out your detective tool kit a lot and keep an open mind on what’s going on here. But, it’s a very distressing, disturbing situation. I think of all the different types of pain that I’ve treated – you know, clitoral pain – PGAD can be really the most distressing to women. It’s not a sexual dysfunction. We have to keep saying that. It’s not a sexual dysfunction issue. It is a physical pain disorder.

Sara: It’s one of the worst ones because no one wants to go around telling their family and friends about their pelvic pain, but no one really wants to go around telling them about their clitoral pain or how they have persistent genital arousal.

Dr. Coady: It’s a really tough one.

Sara: I knew I would learn from your interview, but I was really shocked by some of your answers because you gave me more than what’s in your book, so I was really pleased.

Dr. Coady: I have to do a new edition on my book, I really do. Since I wrote that, I really woke up to the benefit of mind-body therapy and complimentary medicine with chronic pain. I would love to just go back and redo the book and add in what I’ve learned about treating pain in general with meditation, yoga, tapping, mindfulness – all of the therapies that we know now affect pain processing in the pain. Most of folks with vulvar pain don’t have centralized pain, the have pain and they get better. But, the patient’s I really specialized in when I was in practice were really those that tried everything and even went through spinal cord stimulation and nerve decompression surgery – it’s not just a vulvar pain for them, it’s a whole body pain for them.

I’m getting more involved in integrative approaches to pain. That’s because I see that that works better than all these drugs we’re giving to people. And then the opiod epidemic has been horrific with overdoses. So many patients that I see really depend on opiods and it wasn’t even doing anything for them, but that was the nature of response from their previous doctor. It’s very dangerous. There is research out there with functional MRI’s that say you can change the brain with centralized pain with mind-body therapies including breathing therapies so I have a commitment to getting that word out there now too. I understand that there is a limit to everything else Western medicine has to offer with chronic pain.

Generalized vulvodynia and clitoraldynia are very much pudendal or other pelvic nerve pain. They just are. You can’t see that nerve. You guys as physical therapists can help release that nerve. That nerve can get compressed, but with all the myofascial changes that occur in the pelvic floor and the pelvic girdle.

I hope that the word vulvodynia is going to go out of favor because we are going to be more focused on what the etiology of vulvar pain is – myofascial, neurologic and often autoimmune. Lee Dellon and I just got a paper accepted in the Journal of Microsurgery that suggests a total reclassification of the terminology so the word vulvodynia can be thrown out. You know why it needs to be thrown out?

Sara: Why?

Dr. Coady: Because people just use it as saying “okay, it’s pain from unknown origin, therefore there is nothing that we can do about it.”

Sara: Yeah. It stops right there.

Dr. Coady: If I don’t see anything wrong with you, then you have vulvodynia and you have that and that’s it. It really impedes care. It’s like telling somebody “Oh, well you have a headache and there’s nothing we can do about that.” Meanwhile, there’s many different types of headaches. If somebody said that to a patient – “headaches of unknown etiology” – they’d be laughed at. The last classification system was in 2003 and it’s 2014. There has been a lot of research since that time.

 

Dr. Deborah Coady is an active member in the pelvic pain community.  She lectures on pelvic pain topics for numerous organizations and she is one of the founders of the Alliance for Pelvic Pain – an annual, educational weekend retreat for people with chronic pelvic pain.  She is author of the book Healing Painful Sex and with Dr. Lee Dellon has most recently published the article Vulvar and pelvic pain terminology: Implications for microsurgeons in the journal Microsurgery.

 

healingpainfulsex

 

If you have any questions, please email me at Sara@Sullivanphysicaltherapy.com or leave them anonymously in the comment section below.

Interview with Dr. Deborah Coady – Part 1

Author of Healing Painful Sex, Dr. Deborah Coady is on a mission to educate healthcare providers in effectively treating vulvar pain.  I wasn’t expecting her to share information beyond what’s in her book, but not only did she do that, she inspired me to keep being that little thorn in a doctor’s ass – for my patient’s of course.  Have you ever wondered how someone would get a thorn in their ass?  The more I interview, the more I see that pelvic pain specialists like Dr. Coady are bold and plucky – how lucky for their patients.

 

1.  How did you first become introduced to sexual and pelvic pain for women?

debcoadypicDr. Coady: Honestly, I was just doing pretty much general OB/GYN in our practice back in the early 90’s – the mid 90’s. We had added a mid-wife, so they kind of freed me up to do more gynecology and I started to see a lot of people with chronic pelvic pain. I had no place then [to refer patients to], basically, it was NYC and you’d think there would be somebody.   There was one older dermatologist who would take care of some of the skin disorders and that was it. I had one or two or three or four patients and I had to start taking care of them because I wasn’t going to just abandon them. They were in so much pain. I had to start self-teaching, reading anything I could – there wasn’t much out there. [I was] trying to actually start reading about chronic pain and even then there wasn’t much out there. I was doing a lot of trial and error treatment and I started getting known for it. So it was really not that I chose to do it, but I suddenly realized the need and I liked it and people were getting better. Now they were those really tough patients with centralized pain, but a lot of them got better.  I’m 60 years old now so I’m going back a ways – The V Book came out which was an unbelievably wonderful addition to the kind of things that affected me – Dr. Stewart wrote that. And then the International Pelvic Pain Society started spending more time on vulvar pain. Gradually most of my practice ended up becoming pretty focused on vulvar pain and vulvar dermatology and different skin disorders. It was gradual, but in some ways it was kind of quick. Basically by about 2002, a little more than 10 years ago, I was dealing with a lot of this. What’s interesting is – I had patients who were developing vulvar symptoms right before my eyes. I was around long enough to see the development of vestibulodynia on patients who I had treated with the birth control pill. I was aware that this existed. It was a very cool experience that I had. To have been around to kind of just see things happening in front of your eyes.

Then, the final step a few years ago, a patient of mine with vulvar pain kept saying “You gotta write a book, you gotta write a book.” So I said “Well, write it with me.” She was a psychologist. We worked on that for three or four years on and off because we didn’t have an agent, but then we finally got an agent. That kind of helped put a lot together. It helped me because during that time I got diagnosed with breast cancer – a fairly aggressive form, so during the time I was writing the book – I was doing chemo and it was really helpful and therapeutic for me to have something to focus on instead of being depressed about having cancer. My cancer came back two years ago. I’m very stable and fine, but my energy level really took a dive. It will be two years in September since I retired from clinical practice, but I’m still really involved with my ex-partner with consulting. It’s kind of great in a lot of ways. For example, I’m writing up this paper – I could never do that while I was in practice 12 hours a day, it just would not be possible to do this. I’m working more globally now trying to educate. I really want to get the word out to gynecologists. I’ve been lecturing physical therapists all around on this. But, trying to get into residency programs and lecture – even in medical school there is such a vacuum on training of MD’s on chronic pain in general, especially vulvar pain. Now I have time to do it.

 

2.  That’s really great. You know, on a much smaller scale, I can relate to some of the things that you’re saying. Number one with seeing patients change before your eyes – I’ve been doing this no where near as long as you have, but it’s been fascinating for me to see a patient before a hysterectomy and after a hysterectomy and see them push into surgical menopause and say “You have vestibulodynia now. You did not have this before your surgery.” It’s been a huge learning experience and I love it.

When you prescribe estrogen for vestibulodynia, are you doing any sort of hormone testing first?

Dr. Coady: No. It’s not necessary. Once you start doing all of that, there is such a wide range of what the normal estrogen level is in the blood stream, there is no evidence that it correlates. It’s the tissue, the end organ that you are getting the blood supply to, the vestibule mucosa that needs the estrogen. No matter what estrogen level is going on in the blood stream, it might not be getting where you need it. It doesn’t help. I mean with testosterone you can do blood levels to check for sex hormone binding globulin and see if the free testosterone level is low and that makes sense. It’s not like this is going to drive you one way or another to do the treatment because the treatment is very effective and very safe topically so I don’t think anybody needs to do that. With the cost and everything else too.

 

3.  Do you do the same dosage for everyone or do you do different dosages? If you do different dosages, what determines that?

Dr. Coady: There is a basic dose that a few years ago that I kind of empirically started using. 0.5 mg/g of estradiol, but over the years I’ve switched a lot to estriol because it’s not as potent systemically as estradiol.   So there’s all sorts of different little, you know – fine tuning over the years that I’ve done – only because I’ve done it so long, but it doesn’t mean that everyone has to do that kind of thing.

But, the biggest issue with topicals on the vestibule is that it’s such a sensitive area and people react. So, the bases often have to be varied and there is a lot of trial and error. Starting with the typical dose and figuring out – depending on the person, some people are very chemically sensitive – and then if the vestibule is really raw adding testosterone immediately might be too much. The bases are so important. Using estrace is very difficult for a lot of patients because it’s got alcohol, it’s got paraffin’s. I think the most important thing is finding a very gentle base that you can tolerate because it’s important to put it on like three times a day to really get the activity there. I like the oils, safflower oil, olive oil – the compounding pharmacy that we work with has been around for a while now, you can change bases if somebody’s reacting. You can start with a touch, a dab to see if they react. It takes work, close communication and education of the patients and saying “This can help you, but you’re really raw.” And you know, some of them actually tolerate Estrace. It’s just individual and it’s important to let them know not to get frustrated.

Sara: I think that’s a really excellent point because I get a lot of patients that say “I can’t tolerate estrogen. I don’t respond well to topical estrogen.”

Dr. Coady: With a lot of pain treatments, people come to you and say that they tried this and that. Well, it’s important to ask “What was it that you put on? How did you put it on?” Even oral medications – people will say “I tried amitryptyline and it didn’t work.” Meanwhile, they took it for three days and it wasn’t a therapeutic dose that would make anybody feel horrible and it takes time to work. Yeah, it takes a lot of education and a lot of communication. I email with my patients a lot. I say “Put a dab on, drop me an email, let me know if it’s okay. We’ll take it from there, step by step.”

 

4.  What options exist for women who you think would benefit from estrogen supplementation, but have a history of estrogen-positive cancer?

Dr. Coady: Are you talking about women who have been treated for breast cancer and are menopausal and now they have vestibulodynia triggered by low estrogen? Well, the first thing is to really try to use moisturizers as protection there. Even something as simple as Aquaphor can be a very good thing to kind of protect the vestibule from any drying or any contact from chemicals. Once it gets raw, it’s really going to get worse and worse and worse. I myself feel, even as a breast cancer sufferer – I have breast cancer – that a tiny bit of low dose estriol really goes a long way. Things like Vagifem have had studies to see what’s in the blood level – and that’s in the vagina, but to put a really tiny bit of estrogen on the vestibule – I know it’s really hard for women to get over the fear of that – there is no evidence that that’s going to do anything for them. Same thing with testosterone and DHEA – another hormone that could be beneficial topically to the vestibule. But, if they don’t want to do that, then it’s maybe worth trying some of the non-hormonal things that are out there – combination Baclofen and topical amitryptyline, but unfortunately from my experience, nothing works as well as estrogen on the vestibule. So, PT can be very helpful to try to bring in blood supply and increased elasticity of the tissues and to reverse some of the atrophic changes that some of the muscles and the fascia get. I mean, there’s estrogen receptors in fascia. So, due to natural menopause or especially to chemotherapy or radiation induced menopause, all the tissue suffers, it’s not just the mucosa. Bringing in blood supply, keeping the tissue strong, not allowing it to come into contact with any toxins, keeping it moist – all of that helps.

 

5.  What is some of the best advice that you have received in treating sexual, vulvar and pelvic pain?

Dr. Coady: Hmm. I don’t know! I need to think about that for a while! I’m always the one giving the advice.

Sara: I’m curious about who helped you. But, here’s the opposite: What’s some of the worst advice you’ve gotten in regards to treating sexual, vulvar and pelvic pain?

Dr. Coady: From my colleagues? Oh, I constantly get terrible advice. I mean, even people I respect and think are good doctors will come up to me and – it’s unbelievable, I was at a meeting recently and there was a fertility expert who said to me “Oh, I wonder whatever happened to so and so that I sent to you. You know, I really think she’s crazy.” Well, this woman is really sane and normal, but she was driven crazy by all the doctors she saw who made her think it was in her head! It is very depressing to be in pain. There are enough studies now that show depression comes from being in pain – it doesn’t cause pain. Depression is a very common thing, you know 20% of people that walk into the offices of primary care doctors, they fill out the forms that look for signs of depression and they test positive – that’s what the studies are showing – you’re going to get 20% of people that are fulfilling the criteria of being depressed. 20% of women with vulvar pain may have been depressed before getting the vulvar pain, but that doesn’t mean that it’s mental illness caused kind of thing. Who’s not going to get depressed when they’re going from doctor to doctor getting abused by the medical system for pain? It’s such a huge quality of life impact for them, sexually, bowel and bladder function, you can’t sit – people are disabled by this if it’s bad enough. So, if you’re not depressed, there’s something wrong with you!  That’s a really common thing and it really bothers me so much.

 

Dr. Deborah Coady is an active member in the pelvic pain community.  She lectures on pelvic pain topics for numerous organizations and she is one of the founders of the Alliance for Pelvic Pain – an annual, educational weekend retreat for people with chronic pelvic pain.  She is author of the book Healing Painful Sex and with Dr. Lee Dellon has most recently published the article Vulvar and pelvic pain terminology: Implications for microsurgeons in the journal Microsurgery.

 

healingpainfulsex

 

If you have any questions, please contact me at Sara@Sullivanphysicaltherapy.com or leave them anonymously in the comment section below.

Interview with Dr. Andrew Goldstein Part 2

A week’s worth of time probably did your mind some good.  Here’s the second half of my interview with Dr. Andrew Goldstein.

 

6.  I’m curious. Are you treating any pregnant women with vulvar pain?

dr.goldsteinpicDr. Goldstein: Yeah, I mean, unfortunately with pregnancy there’s not much that I can do during pregnancy, not because I’m scared about it, but because, well, you can’t give them too many medicines. But, again, it depends on the cause of the pain. Women with pelvic floor dysfunction get better because of progesterone and smooth muscle relaxation during pregnancy plus the weight of the fetus and the uterus pushing down on the pelvic floor tends to improve hypertonicity. It worsens, of course, pudendal neuralgia. Of course, it’s one of the few times vaginal delivery is contra-indicated – for true pudendal neuralgia.

7.  That makes sense. Are there any medical management or surgical procedure options that are going to soon become available for vulvar pain that you are excited about or looking forward to?

Dr. Goldstein: Well, I mean, the ones that we use are a lot different than some others. We use topical hormonal treatments that a lot of people don’t. And again, we use topical estrogen and testosterone as opposed to just estrogen because the glands of the vestibule are testosterone-dependent glands. Again, it’s using the right thing at the right time. We are going to do a study on using something called platelet rich plasma on vestibulodynia. PRP. I guess you may know about this for joints and things like that, so we are going to do this for vestibulodynia. And this will be for for the people who really do have inflammation– the true “vestibulitis.’”

 

8.  Do you ever see people that have nickel allergies that create pain at the vestibule?

Dr. Goldstein: Not that I know of.

 

9.  What are your thoughts on Osphena to help with localizing estrogen in the vagina for women who are not menopausal?

Dr. Goldstein: So, we have absolutely zero, zero data – actually not “we” – no one has any data on what Osphena does for the vulva. There is not one study, there is not one bit of data – I’ve begged the company again and again to do this – and given that the vulva is essentially the center of where the majority of pain is, until that study is done, I can’t recommend the drug. It’s just, we have no idea what it does at the area where most people have pain.  So, it’s impossible to recommend something without any information whatsoever. And I say the same thing for menopausal women. I just can’t recommend the drug right now because there is no data.

 

10.  Let’s get serious.  What was it like to tell Barbara Walters where her G-spot was?

Dr. Goldstein: Oh God. She actually had zero desire to actually know.  Three seconds before I got on the air, live, she was like “Why are we talking about this? Who wants to talk about this?” This is just clearly not her – it wasn’t her desire to have me on.  She obviously didn’t know about me. But, people like Whoopi were very interested as well as Joy Behar. It was fun being on The View.

Sara: I watched you on it, I mean, not at the time, I’ve seen the clip.  My husband actually says “That’s interesting, because Barbara Walters has made a career out of not knowing where her G-spot is.”

Dr. Goldstein: Exactly, she had no desire.  “Why are we talking about this? Who wants to talk about this?”

Sara: Who wants to talk about this??? I don’t know, maybe people under 80!!!   People over 80 as well…

Dr. Goldstein: So funny.

 

11.  What song best describes your work ethic and why?

Dr. Goldstein: That’s a good one, I have no idea. It’s funny, I’ve been to so many concerts in the past ten years. It’s funny, I can’t answer that question.

Sara: Okay, let me put it another way then. When you’re in surgery, what do you want to hear?

Dr. Goldstein: Every single time, before I operate, every single time, I listen to Werewolves of London. I have no idea why. It started way back when. I love the song. I’m not even a huge Warren Zevon fan. For some reason, it just gets me “up” and really focused to do the surgery and not to be superstitious, I think I have really good success with the surgery. I really care about my patients. When I operate, they are a part of the family and I have to do the best possible thing – every single time, I listen to that song.

 

12.  Who is your professional mentor?

Dr. Goldstein: I can name a lot of people. Stan Marinoff who is definitely a mentor. I have learned a lot from Gordon Davis. He is really the first guy to put me on to the importance of birth control pills as the cause of pain. I’ve learned a lot from Irwin Goldstein – he really taught me the importance of the role of androgens, testosterone, in sexual health. I also have learned a lot working with Susan Kellogg. We’ve given many, many, many lectures together. I think that every time we give lectures together we each teach each other. We do very similar stuff. And so, she teaches me a ton. I hope that I teach her too.

Carolyn Pukall, who is a Canadian psychologist. We wrote the textbook of Female Sexual Pain Disorders as well as When Sex Hurts. She really has taught me a ton about two things: One – the importance of really adhering to the biopsychosocial model. Even if it’s a purely physiological and I can take care of the pain, that doesn’t absolve the other responsibility of taking care of the psychological ramifications of their pain. So, that’s very important. As well as good study design. She designs beautifully designed studies. So, I think these people have really helped me a lot and hopefully in return I have helped them too. I think it’s a very collaborative effort.

Oh, I also have to [mention] how much physical therapists Amy Stein and Pam Morrison have taught me. They both have spent a fair amount of time in my office teaching me and hopefully I am teaching them. It’s really important. No less than probably 35 physical therapists have spent at least a day with me. Each one teaches me something about the exam, what I may be missing, so I think it’s helped me with my pelvic floor exam. So, I don’t have the amazing evaluation like a good PT.  I know when someone has pelvic floor dysfunction, but I also can make the distinction between pelvic floor dysfunction causing pudendal neuralgia or some pudendal neuralgia causing pelvic floor dysfunction. I’m getting decent at figuring out the role of the hip and SI joint. Now, again, I rely on my physical therapists to – you guys spend much more time doing this, right? I have to say, working with Pam Morrison, well I consider her one of the world’s best diagnosticians of these things.  She really starts at the top of the spine and works her way down and she really just can put her finger on the important things. As well as Amy Stein. Both her book and her new video – it’s just so important because we know there are not enough good pelvic floor physical therapists around the country. We are lucky in certain major metropolitan areas, but a lot of people don’t live there, so without those tools, it would be very, very difficult. So, those are the people I would say who have meant a lot. You know, they continue to teach me and my goal is to continue to teach as many people as possible.

 

13.  If you were not a gynecologist, what would you be doing?

Dr. Goldstein: In medicine?

Sara: If you were not a gynecologist, what would you be doing if the world was your oyster?

Dr. Goldstein: I’d probably be a psychiatrist. Umm – if I could do anything I’d have a rock club and a brewery.

 

And there you have it:  Dr. Andrew Goldstein.

It was a lot of fun to talk to him – I think that he challenges me in a great way and I am grateful for the opportunity to have interviewed him.

 

Dr. Andrew Goldstein is located at the Centers for Vulvovaginal Disorders in New York City, Washington DC and Annapolis, Maryland.  He was the president of the International Society for the Study of Women’s Sexual Health (ISSWSH) 2013-2014 and is still a vital leader in the group lecturing to the sexual health medical community.  Dr. Goldstein is the author of Reclaiming Desire and When Sex Hurts, the editor of the the textbook Female Sexual Pain Disorders:  Evaluation and Management and associate-editor of Journal of Sexual Medicine and the Female Patient.

 

If you have any questions, please email me at Sara@Sullivanphysicaltherapy.com or leave them anonymously in the comment section below.

 

ReclaimDesire300b when_sex_hurts_cover

Painful Sex (Vulvodynia and Vestibulodynia and/or the diagnosis formerly known as Vulvar Vestibulitis Syndrome or Provoked Vestibulodynia or Pain in My Ass in My Crotch) Part 2

In Part 1 we went over the definition, symptoms and causes of vulvodynia – specifically vestibulodynia.  The aim now is to understand what you can do at home and in therapy to tackle this issue.  And…this issue is pressing.  It’s pressing your privates.  So, let’s get on with it.

 

What can be done :

  • Allergies
    • Get tested for environmental allergens by an allergist – ideally one who is familiar with how allergens can effect pelvic pain or the bladder.  This might be hard to do, but do some research.  Also, make sure that you are being tested for nickel sensitivity.  Nickel is in food and in parts of our wardrobe and maybe even in our toilet paper.
    • Change your laundry detergent to one that is “free and clear” of chemicals.  If you tolerate wearing underwear, wear white, cotton underwear (not thongs) to avoid synthetic materials in the fabric and the dyes.
    • Wear your underwear inside out to avoid seams causing irritation at the vulva or vestibule.
    • Avoid tight clothing temporarily.
    • When cleansing your bordy, use a gentle soap like unscented Dove and do not put soap at the vulva.  Just let warm water rinse over this area because you have good bacteria that will help you self-cleanse.  You can even spread the labias to let the warm water rinse over it, but make sure you have already rinsed your body of soap.  Removing good bacteria with soap will continue to provoke dryness and irritation.  If odor is what you are concerned with, please know that you will have more of an odor if your remove this important bacteria.
  • Diet
    • Pay attention to what you are eating and see if there is a relationship between food and your pain levels.  It is a good idea to start a food log.  If you can’t seem to find a correlation, it might be useful to start a few different diets, one at a time to see which one, if any are really helpful.  Some diet suggestions are a low oxalate diet, anti-histamine diet, anti-inflammatory diet, Interstitial Cystitis diet and trying an increase in anti-oxidant foods.
    • Consider buying pH strips to test your urine with.  If your diet is creating really acidic urine, this will really bother your vestibule every time you urinate.  Now, urine that is high in oxalates will irritate the vulvar vestibule as well, but I’m not sure if it will necessarily test acidic on a pH strip.  Regardless, if you have more pain at the vestibule (not inside at the urethra) when you urinate, then take a squeeze type water bottle with you to the bathroom and gently rinse the vestibule after you urinate (or even sweat – this can be bothersome too).  No one has to know you’re doing this.  It’s just a water bottle.
  • Damage to the pudendal nerve (Note – I will do a post on the pudendal nerve)
    • Sit on a cushion if this decreases pain.
    • Pelvic floor physical therapy can be hugely helpful in decreasing pain from damage to the pudendal nerve.
    • See a physician that is familiar with treating the pudendal nerve and/or vulvar vestibulitis.  These physicians are rare, so do your homework first.
    • Talk to your physician about medical management options.
    • Avoid things that flare up your pain like irritating exercises, irritating stretches, don’t do kegels, don’t do squats, don’t do abdominal exercises that require you “crunch” at the abdomen.  Relax as much as possible and try to decrease your stress levels.
  • Overactive Muscles
    • Again, pelvic floor physical therapy can really guide you here as treatments will aim at relaxing the overactive muscles and you will learn stretches that will beneficial, not harmful for you.
    • Relax as much as possible so that your stress doesn’t create tension in the pelvic floor muscles further increasing your pain levels.
    • Learn to perform diaphragmatic breathing to promote more pelvic floor muscle relaxation.
    • Talking to your doctor about a vaginal suppository to relax the pelvic floor muscles can be really effective as well.
    • The dilator program is very helpful in relaxing the overactive muscles, but it also helps to retrain the vestibule that not everything that touches it is a “pain” experience.  The “friction” (for lack of a better word) of the dilator against the vestibule surrounding the vaginal opening (the introitus) is part of the problem with sex and with wearing clothing.  The dilator program helps reduce this discomfort because you are in control of the discomfort during this technique.
    • If therapy isn’t enough and your medical management isn’t enough, consider seeing a specialist for trigger point injections and/or Botox injections to the pelvic floor muscles at the vulva and inside your vagina.  In addition to Botox injections, you could have a nerve block to the pudendal nerve.  Ideally, you will undergo these procedures under general anesthesia because they hurt!  And remember, any time you hurt, your muscles are going to tense up further perpetuating the problem.  So, please get your specialists to do what they can to ensure that you are experiencing only what is medically necessary during these procedures.  I will post more about these procedures in the future.
  • Infections – Get tested every single time you think you have an infection.  This will reduce the number of times you are misdiagnosed and overtreated incorrectly.  I can’t stress this enough.
  • Inflammation
    • Consider the suggestions under the allergy and diet section.
    • Talk to your doctor about getting on a Magnesium supplement, Alpha-Lipoic Acid and/or topical medications.
    • Ask your doctor to check your sex and stress hormone levels.
    • Discuss the option of topical lidocaine.  Please note that there are some people who experience burning with use of lidocaine.  This seems weird because lidocaine is supposed to reduce a painful sensation.  Either the dosage of the lidocaine needs to be changed (increased or decreased) or lidocaine just isn’t a good option for you.  Once my patient called their doctor to tell them that the lidocaine burned.  The doctor said “Lidocaine isn’t supposed to burn.”  Then the patient said “Well, it does burn.”  The doctor said “Lidocaine isn’t supposed to burn.”  Then the patient said “Well, it does burn.”  And this continued for several minutes.  Don’t be like this patient.  Ask to have the dosage changed or stopping using it.
    • One thing that I have patients work on is decreasing the extreme irritation at the vestibule by using a q-tip to re-train the nerves that are sending pain impulses to the brain.  I call it vestibule “de-sensitization”, but it doesn’t mean we’re removing all sensation, it means we’re removing the exaggerated pain sensation.  This is how you do it:  1. Take a q-tip and gently press on your vestibule.  Press so that there is no more than 2/10 discomfort.  Hold the q-tip at that pressure and breathe deeply and wait for the pain to subside to 0/10, stop if it takes more than 90 seconds.  Do this all the way around the vestibule.  Do this daily for 5 minutes.  2. Start on the outer portions of the vestibule and work your way closer to the vaginal opening in a clock-wise fashion.  3. If you feel more irritated after you’ve done this, then your pressure was too much.  Do far less pressure next time.  You can use ice wrapped in a hand towel and place it on your genital area for a few minutes to relieve irritation.  Just do this for a few minutes because you don’t want the ice to make your genital area burn.  You can do this repeatedly throughout the day.  4. If you find that it is difficult for you to crouch down and access your vestibule, consider using a mirror and a really long handled q-tip.  You can find these on Amazon.  What can’t you find on Amazon?  I’ll tell you what you can’t find.  A new vestibule.  You can’t find that there.

 

A word about a controversial word:  Vestibulectomy  

This can be an ugly word.  This is exactly what it sounds like.  It is surgical removal of parts or all of the vestibule.  I think that the physicians who perform this believe that the pain is coming from an overgrowth of nerve endings at the vestibule.  So, they’re thinking that if you cut the overgrowth out, then the pain should slowly go down.  The problem is, too many physicians who shouldn’t be doing this are doing them.  Too many physicians who don’t fully understand vestibulodynia are doing imperfect vestibulectomies that will ultimately not resolve the core issue.  If the issue is solely nerve overgrowth, then a vestibulectomy makes sense, but if the issue is not nerve overgrowth at all, then you’ve got a real problem undergoing a vestibulectomy.  In this specific case, having a surgery like this doesn’t correct that issue and it might further encourage pelvic floor muscle overactivity.  If you are considering a vestibulectomy, please, please do your research first.  Make sure you are seeing a physician that is extremely well-versed in this surgery.  I think that it is worth getting on a plane and flying to a specialist for this surgery.  Ask about the outcomes and make the doctor define what they are considering “success”.  Is their definition of “success” good enough for you?  Some doctors say “success” after surgery is a 2 point pain difference or the fact that the patient can now wear underwear, but still can’t have sex.  “Success” can be anything.

Vestibulodynia is a beast ya’ll – but you can get better!  I hope that you can find some good help from this post and from your pelvic floor physical therapist and doctor.  If your doctor isn’t familiar with this diagnosis and you can’t find a doctor that is, please encourage dialogue between your therapist and your doctor.  This is good for you and others in the long run.

 

If you have any questions, please email me at Sara@Sullivanphysicaltherapy.com or leave your questions anonymously in the comment section below.

Painful Sex (Vulvodynia and Vestibulodynia and/or the diagnosis formerly known as Vulvar Vestibulitis Syndrome or Pain in My Ass in My Crotch) Part 1

It’s very likely you’ve heard the term vulvodynia, but you may not have heard the term vestibulodynia.  Let me explain what these are – in my own…terms.

What is vulvodynia : Vulvodynia is pain at the vulva (the external genital area on a woman).  This doesn’t mean that there is no pain in the vagina, this can happen as well.  But, vulvodynia literally means just pain at the vulva.  There are two main types of vulvodynia:  generalized vulvodynia and localized vulvodynia.   Generalized vulvodynia is pain at any part of the vulva.  Localized vulvodynia is in one specific spot.  Under this umbrella of vulvodynia is a diagnosis that is much more specific:  vestibulodynia.  Vestibulodynia is pain at the vulvar vestibule.  This is explained in much more detail in this post.

Let’s be unequivocal.  A note on “unequivocal”.  This means “to be clear”, however, I think that “unequivocal” sounds very confusing and is not clear at all.  Just like the word “unequivocal”, the terms surrounding vulvodynia and vestibulitis are very confusing.  Why do we have five different names for kind of the same thing?  Well, to ensure that we are never speaking the same language, I’m sure!  Look here:

Vulvodynia = generalized vulvodynia, localized vulvodynia, unprovoked vulvodynia

Vulvodynia = vestibulodynia, provoked vestibulodynia, vulvar vestibulitis syndrome

Vulvodynia is a general term.

Generalized vulvodynia and unprovoked vulvodynia ARE NOT EXACTLY THE SAME AS vulvar vestibulitis, vestibulodynia, provoked vestibulodynia or vestibulitis.  Localized vulvodynia can be pain at just the left labia, or it could be pain just at the vulvar vestibule.  If the localized vulvodynia is just at the vulvar vestibule, then, technically, that can also be called vestibulodynia.  See?  There are too many names!

Another note on vestibulodynia – When you read about this and speak about this, yes,vulvar vestibulitis syndrome, vestibulodynia, provoked vestibulodynia, vestibulitis are all synonymous in super casual, cut-off short and barefoot conversation.  However, the correct term is vestibulodynia.  Vestibulitis is no longer used because the ending -itis assumes an inflammation at the vestibule.  Not all people with pain at the vestibule have inflammation.  Therefore, the truly correct term is vestibulodynia because the -dynia ending means pain.  So, vestibulodynia means “pain at the vestibule”. To explain one more term, there is another concept regarding the timing of the onset of your symptoms – specifically in regards to sex.  If sex was pain-free when you started having sex (in your life), then you have secondary vulvodynia.  It came on later.  If sex has always hurt, from the very beginning of your active sex life, then you have primary vulvodynia.

The National Vulvodynia Association is excellent.  There’s a lot of good free information on their website.  If you become a member, you can actually connect with other women who have experienced vulvodynia.  They have a really great patient tutorial about vulvodynia.  It’s really honest and walks you through a lot of hurdles you might experience in your medical care.

Definitely take a look:  http://learnpatient.nva.org/

I also really like The V Book by Dr. Elizabeth Stewart.  Excellent, excellent information about vulvovaginal issues.

 

Now on to vestibulodynia (vest-ib-you-low-din-EE-ah).

“Oh, vestibulodynia, you mask yourself as nothing so the naked eye cannot see your true evil.” 

– Sara K. Sauder

Yes, I made that up.

It’s just that vestibulodynia is so dramatic.  It brings out the actress in me.  When I evaluate a patient with vestibulodynia and am the first to educate them about it (which is way too often), I take a deep breath and think “Why doesn’t their doctor KNOW ABOUT THIS!  Good Lord above!”  Then I calm down and readjust my face and think “Okay, where to start…”.

And this is where I start:

What is vestibulodynia :  It’s when the vulvar vestibule is irritated.  The vulva is basically the front, external part of the genital area of a woman.  The vulvar vestibule (or just the “vestibule”) is the smooth space between the small, hairless labias – the labia minora.  It’s the tissue that extends from left to right and up and down.  Yes, the hole that is the vagina is in the middle.  (Anatomy lesson – the vagina is internal.  The hole that you see (the one below the urethral opening) is the vaginal opening.  The vaginal opening is technically called the introitus.  The vagina is inside the body of a woman.)  Yes, I did parentheses within parentheses.  Oh, that doesn’t make sense to you?

Okay, let me give you a mediocre analogy:  Think of your face.  Now, focus in on your lips on your face.  The skin around your lips is sensitive, yes, but the lips on your face are more sensitive.  Think of the lips on your face as the vulvar vestibule.  Now, open your mouth.  That void – that black hole that is your mouth – well, that’s like the vagina.  The vagina is inside –  it’s a space.  It’s surrounded by the lips on your face (and on your vulva).  Getting kind of poetic here…but I hate poetry, so I’ll stop soon.  Now, imagine your face, and zoom in on the lips on your face again with your mouth open.  Now, imagine that you are dehydrated and you have dry and cracked lips.  You don’t want to open your mouth and spread your lips because the cracks will crack a little more and bleed a little and the lips on your face are hurting, red and they are tender.  That’s like having an irritated vulvar vestibule.  Is this too much?  I hope that was mediocre.  I promised you mediocre.

What does it look like :  Irritation of the vestibule can look like the vestibule is red and mad.  Or it can look like nothing – like completely normal, healthy tissue.  This is when your doctor might say that everything looks good and nothing is wrong.  But you know something is wrong.  You literally feel something is wrong.  Your doctor is wrong and you are right.

What does it feel like :  Irritation of the vestibule can feel like burning, stabbing, cutting, fire, sandpaper, ripping [insert any dramatic word you’d like], etc.  These sensations can be experienced with clothing touching the area, sitting, stressing out, eating certain foods, urinating, having sex, getting infections, sweating, walking, experiencing allergies or any combination of these things.

What are the physical limitations :  Irritation of the vestibule may keep you from having sex, wearing a tampon, wearing clothes that fit you, wearing underwear, walking, exercising, sitting, being active.  You are limited by the amount of pain you experience.

What are the causes :  I think that in order to really grab ahold of this, you have to understand why you have this.  There are a variety of causes for vestibulodynia, it’s not a one-cause-fits-all situation.  I think there are three main thoughts behind this, though there should be more.  One line of thought is that there are an excessive number of nerve endings in the vestibule creating an exaggerated response to any stimulus.  There is the idea that nerve growth factor makes the nerve endings grow too much through chronic inflammation.  Some say there can be up to 10x the amount of nerve endings in the vestibule of someone with vestibulodynia compared to someone without vestibulodynia.  Another line of thought is that overactive muscles are creating the problem, essentially pinching off the nerve that is responsible for the sensation of the vestibule.  That nerve would be the pudendal nerve – the one I like to reference as:  The Queen of England.  My husband likes to point out that the the Queen of England isn’t really responsible for much anymore, but for the sake of my analogy, don’t be a know-it-all like my husband.  The Queen of England is still a big deal, so I’m still going to compare the pudendal nerve to it.  Just like the Queen, this nerve doesn’t like to be touched by anyone, not even Michelle Obama in an “affordable” and “sold out” J. Crew dress.  The third line of thought is that hormones can be creating the problem.

Okay, let’s talk some more about why someone would have either excessive nerve endings or tight pelvic floor muscles or a hormonal issue or an annoying combination of all three.  The theories behind this are as follows:

  • Environmental Allergies or Sensitivities – I’m talking about developing an allergy to things that touch your body like antifungals or even allergies to pollen, mold, cedar, nickel, etc.  This is the biggest reason why I think you could develop a proliferation of nerve endings at the vestibule.  It’s almost like an allergic response and your body does not like the increased histamine release from your mast cells, nor does it like the cascade of other inflammatory agents that begin to float around as a response to allergens.
  • Dietary Allergies or Sensitivities – Something in your diet could be changing your urine in a way that is very insulting to the vestibule.  When you urinate, the urine touches the vestibule and this might be provoking a pain response on a daily basis.  This could create inflammation and provoke an increase in nerve endings in the vestibule.
  • Damage to the pudendal nerve – Re-read this as “Damage to the Queen of England”.  Okay, now does it put things into perspective?  We never want to piss off the Queen.  She will get you back – no matter what.  If you have damage to the pudendal nerve because of an injury, multiple infections, anatomical predisposition, or whatever, it is very common to also have vestibulodynia.  The pudendal nerve is responsible for the sensation at the vestibule.  The pelvic floor muscles may respond by tensing to protect your vital parts.  This tension will further enhance pain at the vestibule.
  • Overactive Muscles – This could stem from stress or from living your life with a constant holding pattern of tight pelvic floor muscles.  These muscles will tighten around the pudendal nerve which is responsible for the sensation at the vestibule, as I said above.
  • Infections – Numerous actual infections requiring repeated medication use, symptoms of infections that don’t really exist and are inappropriately treated with repeated medications or mistreatment of incorrectly diagnosed infections can cause your nerves at the vestibule to become angry and/or the pelvic floor muscles to become angry and tight.  This will result in pain.  This is again why I say that you need to be tested every single time you think you have a yeast infection, a UTI or any other type of infection.
  • Hormones – Many physicians believe that long-term use of birth control will reduce vulvovaginal estrogen and testosterone levels.  Healthy amounts of estrogen and tesosterone at the vulvar vestiuble are necessary for a healthy vulvar vestibule.  As a result of the drop in vestibule and vaginal estrogen and testosterone from long-term birth control use, the vestibule becomes irritated.  According to Dr. Deborah Coady and Nancy Fish, authors of Healing Painful Sex, the vestibule is “especially rich in hormone receptors, it may be especially “needy””.  I think this is a really interesting idea and I have to say that in my practice, those patients with vestibulodynia that get a localized hormone boost do much better.  I think that this consideration needs to be made for all women with vestibulitis, not just those who have been on birth control.  Ask your doctor if they think you are appropriate for more hormones at the vestibule and vagina.  It’s not just for menopausal women.  Want to hear more about hormones?  Get this – according to Healing Pain Sex (again), during embryological development, the female fetus’ vestibule is made up cells that are similar to the urethral tissue in the male penis.  They hypothesize that it possibly becomes easily irritated because it “works better as an inner lining to a tube, not a surface that is out in the open.”  They suggest that this could be another reason why the vulvar vestibule is so very sensitive to hormones.
  • Genetic predisposition – In Healing Painful Sex, it’s suggested that there could be a genetic predisposition to vestibulodynia – they’ve seen identical twins with vestibulitis.  Guess what!?!  I have too!!!  Identical twins!  This is incredible!  I love my job because what I learn and what I do is always shocking me!

 

Vestibulodynia is a fascinating issue and I love to treat it.  Please make sure that you see an experienced pelvic floor physical therapist well-versed in vestibulodynia if you are suspicious of this diagnosis.  If your doctor won’t refer you to a therapist, find a doctor that will.  This can be a tricky thing to treat and it’s important to have a good work up done to screen out other issues, but there is help and with the right help you can see some really great improvement.

Stay tuned for the next post which will discuss what you can do about vulvodynia and vestibulodynia.

 

If you have any questions, please email me at Sara@sullivanphysicaltherapy.com or leave  your question anonymously in the comment section below.