Christmas hurts! Why pelvic pain flares during the holidays.

Holiday Heart attacks

Ok, this blog is supposed to be about pelvic pain...why are we talking heart attacks? Work with me here, and we'll get to the pelvic pain in a minute.

There's a really disturbing thing that happens, specifically on Christmas day and New Years. It's not the weird red-clad man climbing into strangers homes, dropping off gifts, and stealing cookies. It's the rate of sudden cardiac death. More people die of heart attacks on Christmas day and New Years than any other day in the year. Seriously? Yes. And it's not just old people who have no one to celebrate with. It's across the board.

For many of us, Christmas is fun, and exciting. But it's also a little stressful, right? Having to plan gifts, parties, buy the right ugly sweater to impress what's-his-name from the office. We have to deal with crazy uncle Ed who always makes the most inappropriate remarks during dinner. There's also the many out there that don't like Christmas because of lack of social support, or the memory of the loss of a loved one. The stress of the holidays is problem #1. The food of the holidays is problem #2.

Problem #1: STRESS

There's these chemicals called catecholamines that are the way your body responds to stress. Ones you might have heard of are norephinephrine and epinephrine. These chemicals activate the sympathetic nervous system. They're made in your body naturally, and can also be created from some of the foods we eat. They're what make your heart race and give you the feeling of shortness of breath when something startles you. It's an activation of the fight-or-flight response. During the stress of the holidays, these chemicals tend to run amok. They're at high levels in your blood. Whether that's from uncle Ed embarrassing you in front of the new boyfriend, or the stress of getting the right gift for mom.

Those stress hormones aren't good for your blood pressure and heart rate. They give you the necessary jolt to run away from a bear, if you live in Alaska. But if you're in Cedar Rapids, Iowa, it's unlikely you're being chased by a bear. And raising your blood pressure and heart rate isn't good for long periods of time.

Problem #2: The FOOD

Taking in excess amounts of alcohol and certain foods puts you at increased risk of a heart attack due to an enzyme in the foods that prevents the breakdown of catecholamines. The levels of stress hormones rise when they're not broken down properly, leading to sustained rises in blood pressure and heart rate.

What the heck does all this have to do with Pelvic Pain??

When you're in acute pain, like from slicing your finger while cutting potatoes, your sympathetic nervous system gets activated. The fight or flight response gets you to quickly move the knife away and grab the bleeding finger to slow the blood loss. This is a good deal, because sympathetic activation lets your brain know that the pain signals are important. They make you move the knife instead of continuing to cut.

When you're in chronic pain, elevated sympathetic nervous system chemicals make it hard for your brain to decide if pain signals are important or not. On the side of caution, the elevated catecholamines lead the brain to think that pain signals are important, so they're processed more rapidly.

When your sympathetic nervous system is all amped up for long periods of time, you get increased processing of pain signals. In patients with fibromylagia, the higher the activation of the sympathetic nervous system, the higher the magnitude of pain.

Holidays = stress + foods that prevent catecholamine breakdown

Stress + high catecholamine levels = high sympathetic nervous system activation

High sympathetic nervous system = increased pain processing

You're not crazy if you feel like your pain is worse around the holidays. It really is!

Do I just suffer through the holiday season, then?

ADD PIC

No, ma'am, you need not suffer. There's some good techniques to lower the sympathetic nervous system. The sympathetic nervous system has an arch enemy called the parasympathetic nervous system. Its whole deal is to lower blood pressure, lower heart rate, and calm you down. It's at its best when you're chilling, like taking in rays on the beach. Now, most of us don't have a beach nearby. If you do, I'm jealous. For the rest of us land-lubbers, we can activate the parasympathetic nervous system a few other ways. Doing something super relaxing, like getting your nails done, or having a massage can work wonders.

Other options include deep breathing and meditation. Deep belly breathing will trigger your parasympathetic system. Deep breathing involves taking slow deep breaths through your nose, pretending they're going into your stomach instead of your chest. Hold the breath for a few seconds, and then release it slowly. Meditation is also very good at triggering the parasympathetic system. Meditation is getting your mind to clear. That sounds super hard, but it really isn't. There's a few apps that you can get on your phone that will help you learn how to meditate. "Headspace" is a good one for newbies. 

As Always

If you're having worsening pelvic pain during the holidays, I may be able to help with some of my techniques too. I'd love to see you for an exam and treatment at Nurture Womens Health. You can make an appointment to see me and we'll figure out how to lower your pain, and your risk of heart attack!

Rescources

https://www.ncbi.nlm.nih.gov/pubmed/22678655

https://www.ncbi.nlm.nih.gov/pubmed/26816852

https://www.ncbi.nlm.nih.gov/pubmed/25963185

https://www.ncbi.nlm.nih.gov/pubmed/25786044

Why having sex is good for your vagina

Listen up, Ladies!

First, I'd like to commend my colleague, Dr. Jen Gunter, for gracefully addressing all of the media coverage of her vagina recently. Reading her rebuttal to all the men who had the gall to critique her vaginal aroma was the highlight of my month! One phrase she used in discussing vaginal health was "the vagina is a self cleaning oven." I've used this phrase with my patients too. There's a lot of confusion out there about vaginal odors due to the entire section of Walgreens dedicated to it. I agree that this whole section of the store should be removed. Another catch phrase I use a lot with my more mature patients is "The vagina is a use it or lose it kind of organ" You'd be surprised at the reactions I get. Most women either raise an eyebrow, or full out laugh. Beautiful ladies, I'm serious. The vagina needs to be used regularly when you're heading into menopause or you'll lose the ability to use it, potentially forever.


I've uttered "the vagina is a use it or lose it kind of organ" to an average of two women per week lately. As a pelvic and intimate pain specialist, one of the more frequent sexual issues I see is vaginal atrophy (dry vagina). I deal with this all the time. Women entering the end of their fertile years are at risk for "dry vagina." This is a frustrating and potentially disfiguring disorder of the vagina near to and in menopause. Up to 80% of women aged 65+ have problems with sex mostly due to dryness!

Sex and Midlife Estrogen

When you enter into the menopausal change, your ovaries start to poop out. They slow and eventually nearly stop the production of estrogen. Estrogen is the hormone that is responsible for keeping your lady parts moisturized. It also helps keep the vagina stretchy enough to allow your partner to enter. About 50% of women that are post-menopausal have vaginal atrophy with dryness. This typically starts within a few years of finishing your periods, but it can start when your periods get irregular and start spacing out, even years before they completely stop.


With reduced estrogen, there's less cells at the surface of your vagina. This causes problems with a host of things including lubrication, vaginal elasticity, thinning walls, and increased risk of tearing with sex. Ugh! There's also a change to the good bacteria in your vagina which leaves you at risk for discharge and bad bacterial overgrowth.

Why sex hurts in menopause

With a dry vagina, having sex begins to get uncomfortable. When your vaginal elastic qualities start to diminish, as you can imagine, putting an erect penis in there starts to hurt. If you don't have sex regularly, it hurts all the more because eventually the reduced elasticity turns in to a narrowing vagina. This isn't easy to fix once it's happened. It can get so bad that the vaginal entrance becomes tight and stiff, and the lips can even get stuck together!

Low estrogen = dry vagina and smaller opening = painful sex.

How, exactly, do I need to use my vagina?

This is a topic of some debate. The first thing to consider is that once the vagina starts to narrow, it's hard to stretch it back out. If you're in a relationship where his penis can be used to keep things stretched, then by all means that's an option. But only about 25% of women are able to orgasm with penetration, and orgasm helps with all this dryness stuff too. If you're not in a relationship, then consider obtaining a "sexual enhancement device." This is my politically correct term for a BOB (battery operated boyfriend), also known as a vibrator. The vibrator is much more likely to encourage orgasm with clitoral stimulation. Having orgasms regularly seems to help with the dryness, as it pulls in extra blood flow to the area. You may find it's a little more difficult to obtain orgasm after menopause, and that's ok. Keep working at it.

How do I get this treated?

Using your vagina regularly won't prevent it from being dry in menopause. That's an estrogen issue. What can be done to treat this? The best way to improve your vaginal dryness is with prescription estrogen. You'll need your doctor to discuss this with you, because there's a handful of medical conditions that make it dangerous to use estrogen. A history of breast cancer is one of the biggies. Other than estrogen, there are a few things that can help with dryness. DHEA vaginally is one thing that's being studied. There's also a few over-the-counter meds and prescription ones that help with dryness.


If you have vaginal dryness and aren't using your vagina, you're in a bad spot. Please get in to talk to your doctor about estrogen replacement. If you don't have a doc to do this for you, I can see you in my office! Please go to Nurture Womens Health and make an appointment to talk about vaginal dryness and painful sex. And buy yourself a fun Christmas present this year! A BOB will fit nicely in your stocking.

References:
https://www.ncbi.nlm.nih.gov/pubmed/28885410
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4389697/
https://www.ncbi.nlm.nih.gov/pubmed/28885410

Sex Hurts!!! Part 5- Vaginismus

"Sex is impossible- my vagina just won't cooperate!"

It's not an uncommon problem, sadly, to have an uncooperative vagina. Remember my "dreaded speculum exam" post? This is it...the most common cause of a painful speculum exam. Now, as you've seen in other posts, it's not the only reason. But it can cause some serious issues in your relationship, and obviously may make sex painful or impossible.

What is Vaginismus?

Vaginismus is when your vaginal muscles tighten up spontaneously, without your intentional help. This makes penetration with sex, or even placing a tampon, painful or almost impossible. It can also push things out of the vagina after they've been placed there.

For some people this happens with the very first time of trying to have sex. It can lead to what we call unconsummated marriages and is pretty common in some cultures. It can also start after having had no issues in the past. 

Primary Vaginismus

This is when you've never successfully had sex. Nothing, or at least a penis, has ever been in there. The partner may say it feels like there's some type of barrier when he tries to penetrate, or that "the hole is too small." Sometimes other muscles get in on the action and tighten up. Women often hold their breath. Primary vaginismus is often caused by societal ideas, family expectations, personal thoughts about sex, or cultural practices. But it can also be related to unusual anatomy or sometimes a history of abuse. 

Secondary Vaginismus

This is when you've been able to perform before without problems, but now you're getting painful vaginal tightening. Something almost always triggers this. It could be something as awful as rape, or as simple as a urinary tract infection. It's really common with marital issues, especially cheating. Once the trigger problem is treated and fixed, like antibiotics for the infection, the vagina may continue to tighten. This is a "knee jerk" type reaction that has been programmed. It's like Pavlov's dogs that salivated when a bell was rang because they associated the bell with food. If your brain associates pain with sex, it may tighten the vagina up without your conscious permission.

What does it feel like?

For you ladies, it can feel anywhere from mild discomfort, burning with tightening, to severe tightness, or a complete inability to allow anything in there. If something is forced inside it will cause severe pain. For your partner, it feels like a barrier, a wall, or a really tight vaginal opening. I've seen cases so bad that I couldn't get a single finger in for an exam.

What can be done for this?

If this seems like an awful diagnosis, I can assure you it's treatable. But, it requires some work on your part. There's some psychology that's in play with this diagnosis, so counseling is usually involved. It can be on the fun side, like a sex therapist, or more intellectual like counseling. The most important first step is education. Other therapies include dilators, medications, and injections.

Techniques for treatment include:

1. Education about your body, the vagina, and the muscles in the pelvic floor.
2. Physical therapy to teach you how to relax the muscles
3. Vaginal dilators. These you can purchase online and use at home. You start with a really small dilator and place it inside for 10-15 minutes every day. Once you can insert it without pain, you go up a size. It can take months to get up to the size you'll need to be able to have pain-free sex, but the work is worth it! You'll need to continue dilating for a while, usually 6-12 months to get full effect.
4. Injections of botox. This is obviously done by a trained expert.
5. Therapy- either sex therapy, or counseling, or both.

As Always

As always, if you have questions, or think you might have vaginismus, please make an appointment to see me at Nurture Womens Health.

Resources:

https://www.ncbi.nlm.nih.gov/pubmed/24894201
https://www.ncbi.nlm.nih.gov/pubmed/28363809

Sex Hurts!!! Part 4- Vulvar Pain Syndromes

"It hurts to place a tampon, like REALLY hurts"

If this is you, there's a good chance you might have a vulvar pain issue going on. If it hurts to try placing a tampon, or trying to have sex, or worst of all having a speculum exam, listen up!! There's hope, ladies!

Um, ok, but what's Vulvodynia?

So, this just means pain in the vulva that lasts for a long time without an identifiable cause (like an infection or yeast). The vulva includes the vestibule, the clitoris, the urethra, inner and outer labia (lips), the perineum, and the area above the clitoris called the mons pubis. For diagnosis purposes, vulvodynia can be pain all over the vulva, or just in certain parts of the vulva. It can come and go, or be constant. If it's all over the vulva, it's called generalized. If it's just in a certain place, it's localized. The localized is then further split in to the particular areas that hurt. Even more, it's classified by whether it hurts all the time, or just with touch, which is called provoked. So, to clarify:

Vulvodynia
     Generalized
     Localized (can be provoked or not)
Vestibulodynia (just the vestibule hurts)
Clitorodynia (just the clitoris hurts)


This kind of pain usually feels like burning, or like a knife stabbing. But not everyone is the same, so it can feel like throbbing or uncomfortable pressure too. When it's generalized, the pain is all over the vulva. Usually it gets worse with activities like sitting on a hard surface, riding a bike, or having sex.

Take me to Church!

I think it's fitting that the entrance to your vagina has the same name as the entrance to a church, don't you? Yep, the vestibule of a church is the outer courtyard or the entrance room. The vestibule of your vagina is the skin just around the vaginal opening.

So, vestibulodynia is...?

Yes!! It's pain just in the vestibule. Remember, that's the skin just around the outside of the vagina, including the outer hymenal ring and the opening to your urethra (where you pee from). If you take a mirror and look at your bottom...yes I'm serious...it appears just a little more pink that the skin around it.

If the pain is localized to just this area, it's often provoked, meaning it only hurts when TOUCHED. This kind of pain tends to be tearing or sharp. This area gets touched with a handful of activities, like trying to put in a tampon, attempting to have sex, or having a speculum or pelvic exam at the gyno's office. If I know on the front end that you have pain with these activities, I'll do something called the q-tip test. I'll touch a q-tip gently to areas around the vestibule, and if it hurts, that's not normal! Touching a q-tip anywhere on your skin shouldn't hurt.

What causes these issues?

To make it short and sweet, we don't know. Like, science doesn't actually know. There are some theories though. Most of us in the field think that there's at least an inflammatory and immune system up-regulaton. This may be triggered by yeast infections, or by muscles that are too tight. But to be honest, it's really still a mystery. That doesn't mean we are empty handed for treatments, but it DOES mean that not every treatment works for everyone, because we're not really sure what we're treating. Sounds lovely, right? So, to treat this, you and I are going to have to be partners, and be willing to try a few things to figure out what works.

What treatment options are we talking about?

1. Stop putting stuff on your vulva. Please see Sex Hurts!! Part 2 under the contact dermatitis part
2. Creams/ointments for the skin:
anesthetics like lidocaine
hormone ointments or creams (sometimes I get these mixed with the lidocaine)
prescription topical steroids
alternative creams- compounding pharmacies make these for you
3. Female pelvic physical therapy- this is a biggie!!
4. Nerve blocks
5. Nerve Stimulation
6. Surgery
7. Complimentary medicine- chiropractic, acupuncture, herbals
8. Counseling and mindfulness techniques

As Always

If you think you have vulvodynia or vestibulodynia, please make and appointment with me at Nurture Womens Health and I'll be happy to figure out what's going on with your "church".


Resources:
https://www.ncbi.nlm.nih.gov/pubmed/22951941
https://www.ncbi.nlm.nih.gov/pubmed/26132928
https://www.nva.org/
http://www.turner-white.com/pdf/jcom_may10_vulvodynia.pdf

Sex Hurts!!! Part 3- Fibroids and Endometriosis

Cramps suck!

Having cramps at the time of your period is expected. Most women just pop a couple of ibuprofen and go on with things. But deep cramping pain during sex is different and awful. It can completely disrupt a marriage and cause you to avoid sex altogether. Why are you having deep pain with sex? It can be several things. Endometriosis is a well know cause of pain with and after sex. A few recent literature articles are also pointing towards fibroids being associated with deep sexual pain. So let's dive in and see what info is out there.

Deep dyspareunia

This is the medical term for pain way down inside while having penetrative sex. It's usually a sense of cramping or intense pressure and sometimes my patients will say it feels like "he hits something" that causes the cramps which can last for hours.

Sometimes this is just a uterus that's tipped backwards (retroverted) and he's hitting the top of the uterus with deep thrusting. Usually this just causes cramping during, but not after, sex. This is easy to fix with changing positions; like going doggy-style or side-lying instead of missionary position.

If changing positions doesn't help, it may be fibroids or endometriosis causing the cramping. 

What is a fibroid and how does it cause pain with sex?

Fibroids are benign (non cancer) growths of the muscle tissue of the uterus. They can be in a lot of different places including inside the cavity of the uterus, growing inside the uterus wall, or growing off the edge of the uterus. They most often cause pain and heavy bleeding with your periods, and are a common reason for hysterectomy in the US. Deep pain with sex has recently been associated with an increased likelihood of finding fibroids on ultrasound, and especially with fibroids that are at or near the top of the uterus.

So what do we do about it? If you have deep pain with sex and we can't find a reason other than fibroids, I'd consider either removing the fibroids or doing a hysterectomy. As far as I'm aware, there isn't any literature proof that removing the fibroids or doing a hysterectomy resolves deep pain with sex, but it would stand to reason that it should. Most of my patients that have hysterectomies for fibroids wish they'd done them sooner as their lives in general improve, and especially their sex lives. Here at Nurture Womens Health, I do out-patient hysterectomies using the DaVinci robotic system. You'll go home the day of surgery, and have about a 2 week recovery.

After I finish my "sex hurts" series, I'll do more general blogging on fibroids and pelvic pain, so keep tuned for more info.

What is endometriosis and how does it cause pain with sex?

Endometriosis is when the tissue you shed every month with your period gets up in to your abdomen, attaches to a surface and starts growing there. Science isn't really sure exactly how this happens, but there are a few theories including the most popular one, retrograde menstruation (bleeding during your period out into your abdomen). Endometriosis is a BIG subject that I'll give a lot more love to in blogs to come. But for now, how does it relate to pain with sex?

Pain with sex related to endometriosis is most often caused by a sub-set called deep infiltrating endometriosis. Deep infiltrating endometriosis is when the cells growing in your abdomen invade deep in to the tissues of the pelvis. There are some studies that show any type of endometriosis can cause pain with sex, though.
How is it treated?

This is a really big topic...so I'll keep it simple for now and go in to more detail in later blogs. There's a lot of discussion among the specialists about how to treat endometriosis. My biggest addition to the conversation is that endometriosis is rarely the ONLY cause of someone's pelvic pain. Usually it's accompanied by pelvic floor dysfunction and can be associated with several other things, too. Endometriosis also often involves the bladder and bowel, so it's not as easy as "cut it out" when it comes to treatment. Things that can be done to treat endometriosis include, but are not limited to:


- Hormonal manipulation with birth control
- Leuprolide- an injectable med that makes your body think you're menopausal (imagine the side effects...)
- Orilissa- a new oral medication for endometriosis and fibroids
- Laparoscopic removal of visible implants and scarring
- Hysterectomy, with or without removal of ovaries (this is controversial)

More to come

As I said earlier, fibroids and endometriosis are HUGE topics and have a lot of bearing on pelvic pain in general. This very short synopsis was just about their relation to pain with sex. Please stay tuned to this blog for more information on both of these medical conditions. And as always, if you have been told or think you might have fibroids or endometriosis, please call or go online and make an appointment to see me at Nurture Womens Health.


Resources:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5503180/
https://www.ncbi.nlm.nih.gov/pubmed/22910685
https://www.ncbi.nlm.nih.gov/pubmed/24165172
https://www.ncbi.nlm.nih.gov/pubmed/18660692/
https://www.ncbi.nlm.nih.gov/pubmed/26246414
https://www.ncbi.nlm.nih.gov/pubmed/24366116
https://www.ncbi.nlm.nih.gov/pubmed/26363387
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-42302015000600507&lng=en&nrm=iso&tlng=en

Sex Hurts!!! Part 2- Vulvar skin issues

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Your vulva is sacred

The vulva is a sacred area, am I right? It's sensitive, and only seen by a few chosen folks in your adult life. Being a gynecologist, the fact that I'm one of those people is special, and I take it seriously. But showing me that sensitive area is one thing. Showing it to a sexual partner is another. If you're not sure what's going on down there, you may find yourself embarrassed or uncomfortable with sex, especially oral sex, because he/she is looking there too.

Vulvar skin disorders are one of the most common things that cause issues in your nether-regions, and are often a source of awkwardness with sex. They can cause itching, discharge, pain, and just generalized discomfort. And often times, those symptoms cause sexual dysfunction; either you're avoiding it altogether, or it hurts.

Where is my vulva, exactly?

Let's do a very quick anatomy lesson. The vulva is the area of skin around the outside of your vagina, encompassing all of your external genital organs. Here's a nice pictorial. You'll notice the internal structures in relation to the outside structures in this picture.

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The different types

There's several types of vulvar and vaginal skin disorders. Here's a short list of the most common ones I see and treat. We'll go into more detail in a minute:

- Contact dermatitis
- Lichen simplex chronicus
- Lichen sclerosus and lichen planus

Contact dermatitis

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Ok, ladies, this one's important!! This is one of the most common causes of itching and pain on the vulva. It's also the easiest to treat! The skin on your bottom is very sensitive. Many women are "allergic" to stuff that touches their vulva. A common list of allergens:

Pads (especially scented ones), soaps, laundry detergent, feminine wipes/sprays, condoms, latex, vulvar and vaginal creams.

First things first...stop putting this stuff on your bottom. Removing the irritant is the most important part of the treatment. It's not always easy to figure out what exactly is the cause, so I recommend not putting ANYTHING on your vulvar skin if you're having itching or discomfort there. Water is sufficient for washing your vulvar skin; you don't even need soap! And like I tell my patients, the vagina is like a self-cleaning oven. If you interrupt the vagina's normal flora, the self cleaning part doesn't work. So, no douches, wipes, sprays etc...up inside the vagina or on the vulva.

What you'll get from the gynecologist is a moderate to high dose steroid cream. This will clear up the skin reaction, and voila! Back to normal.

Lichen Simplex Chronicus (LSC)

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This is the fancy medical term for eczema (atopic dermatitis) of the vulva. Yep, you can get eczema down there. For some of women, it's the only place they get it. In fact, it's pretty common. So, LSC is an chronic inflammatory disorder of the skin which usually starts with some type of allergic trigger (see above). It can be isolated, or you can have other hypersensitivity reactions- like allergic asthma, bad seasonal allergies, and random skin rashes.

This type of skin disorder is an itch/scratch/itch cycle. It itches SOOOOO much that people wake up at night scratching. They avoid social situations due to it, and find really creative ways to scratch their bottoms in public. These people will say it feels really good to scratch, but then it hurts afterwards. With repetitive scratching, the skin eventually reacts by coming thicker and can get oozy. This skin thickening just perpetuates the cycle of itching. Diagnosis is usually just with a physical exam, but if I'm not sure, I might do a small biopsy to confirm it.

Treatment: BREAK THE CYCLE.

Unfortunately, this issue tends to be chronic and recurrences are common. So, breaking the cycle of itch/scratch/itch tends to be ongoing. It's important to identify and remove the trigger if it's still there. And then I use a constellation of meds to stop the itching and reduce the desire to scratch. Anxiety and depression are common with this, so I treat these too. 

Lichen Sclerosus (LS) and Lichen Planus (LP)

These are two separate chronic inflammatory disorders of the vulva. I'm lumping them together because they're kinda similar in their symptoms and how they are treated. We're not really sure exactly what causes them, but popular scientific opinion is that they're autoimmune related. Most likely there's a genetic susceptibility that's activated by a trigger, like a trauma (childbirth or genital piercing...). The reason we think they're autoimmune related is that a lot of people with LS and LP have another autoimmune disease too, like Hashimoto's thyroiditis or vitiligo, and show blood testing consistent with autoimmune skin issues.

The most common symptom of LS is itching, which is at it's worst at night. Chronic scratching then causes pain and breaks in the skin. These cause pain with sex. 

The most common symptoms of LP are pain and soreness.

Unfortunately these are unquestionably life-long diagnoses with their ups and downs. They can't be cured, but can be treated. In fact, treatment is really important because if untreated you can get scarring of your vulvar organs (like the clitoris) and eventually they can lead to cancer. A biopsy might be needed if I'm not sure, and to rule out cancer at the time of diagnosis. Treatment is medical with close monitoring for life to watch for cancer.


As always, if you think you might have one of these skin issues going on, please make an appointment with me at Nurture Womens Health in Frisco!

Resources:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3691475/
The vulvar dermatoses. Krapf MD et al.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5419035/

Sex hurts!!! Part 1

A Little TMI

"It hurts to have sex, so much that I just don't want to do it anymore".
"My husband wants to have sex more often, but I just don't enjoy it".
"He can't even get inside me, it hurts so bad".
"My vagina literally pushes him out, like it's got a mind of it's own".
"I have such intense cramps after sex, that it's not even worth it."
"Orgasm hurts, so what's the point?"

What makes sex hurt?

Painful sex, also known as dyspareunia, is persistent or recurrent pelvic or genital pain that occurs just before, during or after sex. Pain can be external with just touch, upon entry (penetration), with deep pushing (deep penetration), or afterwards. The more common causes are:

- Pelvic, vulvar or vaginal infection
- Urinary tract infection
- Vulvar skin disorders
- Trauma to the vagina
- Fibroids or endometriosis
- Vulvodynia/Vestibulodynia- a chronic pain disorder of the vulva/vestibule
- Vaginismus- a reflex contraction (tightening) of the muscles at the opening of your vagina
- Pelvic floor dysfunction (PFD) with trigger points (see my previous blog "When Ovary Pain Isn't Coming from your Ovary")
- Interstitial cystitis/Bladder Pain Syndrome (see my previous blog "Gotta Pee!! Recurrent UTI, or Bladder Pain Syndrome?")
- Irritable bowel syndrome (IBS)
- Menopause or peri-menopausal vaginal atrophy

That big list above...

That big list up above is a lot of doctor speak. So what are all those things? Some of them you've probably never heard of and that's ok. Let's do a quick overview of the more interesting ones I treat, and I'll go in to more detail about them in upcoming blog posts.

Vulvar skin disorders

The vulva is the area of skin around the outside of your vagina, encompassing all of your external genital organs. Most of the skin disorders of this area start out as itchy/scratchy problems. The itching is usually really intense and cannot be ignored, sometime waking people from sleep! This can then turn in to pain when you've scratched so much that the skin breaks down or gets thickened from repeated scratching. Some of these skin problems can also cause bleeding with sex, and discharge from the vagina.

Trauma to the vagina

The easiest was to traumatize the vagina is to push a baby through it. Episiotomies and vaginal tears from delivery are pretty common and can continue to cause pain if they don't heal well or involve the nerves to the overlying skin. Sometimes you can get trauma to the vulva or vagina from a quirky fall, like on the edge of a pool.

Fibroids and Endometriosis

Fibroids are non-cancerous growths of the muscle that makes up the uterus. They can get pretty big and usually cause too much bleeding or bad pain with your periods. Sometimes, depending on their position, they can also cause pain with sex.


Endometriosis is it's own thing...and deserves a few blogs by itself. I'll get to that eventually. But for now, we'll make it simple. Endometriosis is when the tissue that you're supposed to shed every month with your period gets out into the abdomen, attaches to something (like your ovaries or bladder) and starts growing there. It responds to your hormone cycles and causes bleeding into the abdomen every month. It's associated with heavy and painful periods, as well as intermittent pain throughout the month, but can be associated with painful sex if the endometriosis is growing around or inside the vagina or bladder. It's the most common cause of cramping after sex.

Vulvodynia/Vestibulodynia

Now we're getting interesting. This is "vulvar discomfort in the absence of relevant physical findings or a specific clinically identifiable neurologic disorder". It's really a symptom, but we use it like a diagnosis too. There's different kinds, like pain that you have all the time, or only with touch or attempted sex. It can be all over the vulva, or just the area right at the edge of the vaginal opening, called the vestibule. When it's at the vestibule, this causes burning pain with attempted penetration of the penis or a tampon. 

Vaginismus

Vaginismus is when your vaginal muscles tighen up spontaneously, without your intentional help. This makes penetration with sex, or even placing a tampon, painful or almost impossible. It can also push things out of the vagina after they've been placed there.

Pelvic Floor Dysfunction

My first blog was really about this. It's when your pelvic muscles are all tight, often in response to pain from elsewhere. When something "down there" hurts, your body alters the posture and muscle tension to minimize pain. This can fatigue the muscles and cause knots. For more info on this one, see my blog "When Ovary Pain Isn't Coming from your Ovary".

Irritable Bowel Syndrome

IBS is a group of symptoms including abdominal pain accompanied by changes in stool consistency (constipation or diarrhea), changes in color, as well as feelings of bloating or gas. There's different kinds which are treated differently. It's often associated with other chronic conditions like fibromyalgia and interstitial cystitis as well as generalized pelvic pain.

More to come.

I'll go in to all of these in detail in upcoming blog posts, so again, stay tuned. As always, if you think you may have one of these problems and want to get in to see me about it, please make an appointment with me at Nurture Womens Health. We'll tease out what's making you hurt and figure out a plan to make you feel better!



Resources:
https://www.vaginismus.com/
https://www.ncbi.nlm.nih.gov/pubmed/26745618
https://www.ncbi.nlm.nih.gov/pubmed/22672388
https://www.ncbi.nlm.nih.gov/pubmed/23551753

The Dreaded Speculum Exam

The Speculum Exam SHOULDN'T HURT!

If you're the kind of gal who avoids going to the gyno because you're afraid of the torture device known as a speculum, you're not alone. But did you know that it SHOULDN'T HURT to have a speculum placed??

It's a common misconception that the speculum exam is supposed to hurt. Gynecologists are expertly trained to place a speculum, with as little discomfort as possible. Now I'm not saying you should ENJOY this part of the exam, but it really shouldn't HURT.

These things shouldn't hurt either:

If you're afraid of the speculum exam, it's possible that you're also avoiding other things going inside your vagina. I'm not suggesting to try placing all of these in the vagina, and certainly not all at the same time...that might lead to an ER visit. None-the-less, it really shouldn't hurt to place any of the following in to your vagina:

1. A penis
2. Your fingers
3. A tampon
4. Any type of normally sized sexual toy (now work with me here, if it's marked XL...just don't go there)
5. The speculum

Stay tuned..

I'm about to start a blog series on everything that causes pain in the vagina, including pain with insertion of a speculum, and pain with sex... We'll do an overview first about types of pain, and what may be causing it and then dive into the nitty-gritty of each of them in subsequent posts.

If you've got pain with insertion of any of the above items and are just dying to know what the problem is before I blog about your particular situation, please make an appointment to see me here: Nurture Womens Health. Otherwise, keep reading. It's going to be an entertaining series!

Gotta Pee!! Recurrent UTI, or Bladder Pain Syndrome?

"I have UTI's all the time!"

Have you ever been to the doctor for a urinary tract infection and been told your urine wasn't infected? Or have you been on antibiotics for a urinary tract infection and it just didn't seem to get better, or came back really quickly?


It happens more often than you'd think, and it might NOT be an infection!!

UTI diagnosis

UTI is the most common cause of pain related to your bladder. With a normal urinary tract infection, these symptoms are most common:


- Burning, stinging, or pain when you pee


- Needing to go RIGHT NOW, also known as urgency


- No relief with urinating


- Funny smell to the urine, or possibly cloudy urine


If these are the symptoms you're having, it's probably a urinary tract infection, and your GYN can see you for diagnosis. Your urine dip will almost always be abnormal and you'll get a prescription for antibiotics.

Concerning symptoms

So, what kind of symptoms would lean toward something other than a simple UTI? In addition to some of the above mentioned symptoms, if you have any of these below, it would be worth the time to dig deeper...


- Recurrent UTIs diagnosed without a positive urine dip in the office (using teledoc)

- Discharge from the vagina or urethra (the tube that connects the bladder to the outside)

- Pain or overwhelming pressure as the bladder gets full, but relief with voiding

- Pain worsened by eating certain types of food/drink like citrus and caffeine

- Going pee more than 10 times during awake hours

- Going pee more than once at night

- Pain during intercourse (sex)

- Feeling like you still need to pee AFTER you've already gone

- A sensitive lump or bump inside or just outside the vagina

- Chronic pelvic pain

- Pain with having a bowel movement

So if it isn't a UTI, what IS it?

There are a lot of possibilities for the diagnosis. It could be an infection in the vagina, or one of the glands in or around the vagina. It could be a little out-pouching of the urethra. There are a lot of other things that a pelvic pain specialist can diagnose, but what I see most commonly is something called Interstitial Cystitis, also known as Bladder Pain Syndrome (IC/BPS). 

What is Interstitial Cystitis/Bladder Pain Syndrome?

The official definition is: "An unpleasant sensation (pain/pressure/discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks duration in the absence of infection or other identifiable cause".


What that really means is you've had pain type symptoms for more than 6 weeks and the doctor can't find a definitive infection or other reason for it. There's a questionnaire called PUF that helps us get an idea of what your symptoms are like at baseline.


IC/BPS often occurs in the setting of other pain problems like chronic pelvic pain, vulvar pain, irritable bowel syndrome, chronic fatigue, and fibromyalgia. We aren't really sure what causes IC/BPS, but we know it can cause other issues like depression, anxiety, and trigger points in the pelvis.

So, how is IC/BPS treated?

Initially, I'll rule out a UTI, check how much urine you retain in your bladder after voiding, and review your PUF. If you've got a history of smoking, I also rule out any type of bladder cancer, as you're at higher risk. If all of the signs still point to IC/BPS, then we start with the least invasive treatments first:

- Physical therapy with a specially trained pelvic PT

- Education on food/drink to avoid

- Oral medications

- Bladder instillations

Bladder instillations usually include several medications that seem to calm the inflammation in the bladder. They're done one to three times a week, either in the office, or at home if you're willing to do them yourself. Initially you may not see any benefit from the treatments. It can take a few weeks to up to 3 months for the full benefit to be felt. If you're not getting any better on these treatments, then I'll move to more invasive treatments not discussed here. 

I think I have IC/BPS...

If this blog sounds like I'm talking to you, please give me a call at 972-406-9911 or make an appointment with me online at Nurture Womens Health.


Resources:
1. Diagnosis and Treatment Interstitial Cystitis/Bladder Pain Syndrome. American Urological Association
2. Interstitial Cystits/Bladder Pain Syndrome. NIH
3. Treatment of Interstitial Cystitis/Bladder Pain Syndrome. UpToDate
4. Role of Inflammation in bladder function and interstitial cystitis. Sonal Grover, MD et al.
5. From interstitial cystitis to chronic pelvic pain. C Persu et al.
6. The Interstitial Cystitis Association of America: lessons learned over the past 30 years. Vicki Ratner

When Ovary Pain isn't Coming from your Ovary

"It hurts when I ovulate"

This is a common complaint in the Gyn's office. Up to 50% of women get pelvic pain mid-cycle, some every month. But is ovary pain really coming from your ovary? Sometimes it's not!

What is normal mid-cycle pain?

The most common cause of ovary pain is just plain ovulation and hormones (Mittelscherz). When the egg releases from the ovary, a small amount of fluid and blood comes with it. This fluid is irritating to the inside of your pelvis and can cause a quick sharp pain, then a mild ache.

The pain can also be considered normal if it is caused by uterine or tubal irritation just before or just after ovulating. This is more like mild period cramps and only lasts for a few minutes to a few hours, but can last up to 2 days. It won't interfere with your ability to function.

When is mid-cycle pain NOT normal?

When the pain is severe, or accompanied by any of the following, then regular ovary pain may not be the cause: 

Nausea and/or vomiting
Diarrhea
Pain that radiates to your back or groin
Burning sensation or numbness
Located under or around an old incision (like from a C-section)
Happens during intercourse (sex)
Happens with urinating or having a bowel movement
Affects your ability to go to work or school
You are on fertility medications

What else can cause mid-cycle pain?

There are many causes of consistent mid-cycle pain other than just ovulating. These include ovarian cysts, endometriosis, tubal infections, interstitial cystitis, irritable bowel syndrome, muscle or fascial pain, and nerve injuries.


After regular ovulatory pain, the most common cause I see in my practice is muscle/fascial pain. This is also known as pelvic floor dysfunction or levator ani syndrome. There's a lot of muscle and fascia in your pelvis; it's a really busy place! The muscles and fascia in your pelvis serve to hold up your insides when you sit and stand, as well as helping you go to the bathroom. Think of it like a hammock.





These muscles can get overworked for any number of reasons, from endometriosis, bladder problems, after having a bad urinary tract infection or surgery. Sometimes it's just stress related too! When the muscles work too hard for too long of a time, they can get tight and form something called trigger points. These are like muscle knots, the same kind you may get in your back or neck. Once they've formed, the trigger points themselves are causing the pain. They're tricky little guys too, and can cause your body to grow more nerves around them to transmit the pain back to the brain. They can also cause urinary and bowel symptoms, back pain, and buttocks pain.

Why do trigger points cause ovary pain?

That's a great question! The pelvis is a tight area, with lots of stuff in it, including your bladder, uterus, tubes, ovaries, bowel, muscles, nerves, and fascial tissue. The body has to transmit information from all these things to the brain for processing. Because it's such a tight area, there's only a few spots in the spinal cord that are available to transmit ALL of this information. Once the information gets to the spine, the pain signals all get thrown in together. What your brain reads is "there's pain somewhere in my pelvis". Every body feels that different. Some people feel it as bladder pain or bowel pain, some feel it as ovary pain.
What happens if I don't treat the pain?


Over time your body will get sensitized to the pain. The areas that are transmitting the pain actually grow more nerves by releasing a hormone called nerve growth factor. The brain can also up-regulate the pain by developing bigger centers to process it.

Think of it like a fire alarm. Normally the alarm only goes off if there's a lot of smoke. When the body and brain get sensitized to the pain, now lighting a match, or turning on your oven will set off the alarm. Things that didn't used to cause pain, like having a bowel movement, coughing, or having sex, will now cause pain too. It can get so bad that people quit work and go on disability. 

How are trigger points treated?

One of the most important factors that determine the treatment for trigger points is figuring out what is causing them in the first place. Trigger points don't usually form without a reason. They're a reaction to the pelvis tightening over time due to pain or stress. Once the source gets treated, the pain may stick around due to trigger points or sensitization. If trigger points are found, we treat them with a lot of different methods. It's best to use multiple methods to get relief, as most people won't get relief with just one thing. The treatments with the best evidence for relief are:
Physical therapy done by a trained female pelvic PT
Photobiomodulation therapy (near infrared lasers specially designed for the female pelvis)
Trigger point injections using anesthetics and steroids
Trigger point injections using Botox
Dry needling, acupuncture
Behavioral therapy
Medications to reduce nerve pain and sensitization 

Where can I go to get treated?

My name is Dr. Stoehr and I specialize in seeing the whole picture of pelvic pain. If you think you may have trigger points that need to be treated, or mid-cycle pain that may be related to this, please make an appointment to see me at Nurture Womens Health.


Resources:
ACOG bulletin #51
Relating Chronic Pelvic pain and Endometriosis to Signs of Sensitization and Myofascial Pain and Dysfunction. Aredo JV, et al.
A Randomized Clinical Trial for Women with Vulvodynia: Cognitive-behavioral Therapy vs. Supportive psychotherapy. Masheb RM, et al.
Improvement in pelvic pain with botulinum toxin type A- Single vs repeat injections. Nesbitt-Hawes EM, et al.
Chronic Pelvic Pain Syndrome: reduction of medication use after pelvic floor physical therapy with an internal myofascial trigger point wand. Anderson RU, et al.
Myofasical trigger points of the pelvic floor: associations with urological pain syndromes and treatment strategies including injection therapy. Moldwin RM, et al.
Role of nerve growth factor in pain. Mizumura K, et al.