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Will it actually get better with time? Talking about dyspareunia, vaginismus and vulvodynia

October 15, 2018
dyspareunia, vulvodynia, vaginismus, toronto naturopathi, naturopathic doctor toronto

“The pain will go away once you’ve had sex a few times. You’ll get used to it. “ Have you heard this before? Sex shouldn’t hurt. Putting a tampon in shouldn’t hurt. Yet, for some women they experience painful sex. 

Because there are a few reasons why sex can be painful, I’m breaking down the difference between dyspareunia, vaginismus and vulvodynia. 

Dyspareunia

Dyspareunia, the fancy word for painful sex, is essentially not a condition, per se, it’s a symptom. It can happen with vaginismus or vulvodynia, but is not a condition like they are. 


Painful sex can happen before, during, or after. It might be there when sex happens for the first time and every time after (primary dyspareunia) or it can happen after a period of painless sex (secondary dyspareunia). 

When compared to vaginismus, women who experience dyspareunia have less sexual desire, lubrication, and penetration-related painful thoughts. 

In terms of treatment, it’s best to figure out the underlying reason of why the pain is happening.

Vaginismus

Do you ever feel like you’re hitting a wall, or there’s a sensation of no hole being down there? That might be because of vaginismus.

It’s an involuntary muscle spasm of the pelvic floor (the set of muscles holding up your lower organs), incredibly tense pelvic floor muscles (it’s like doing a bicep curl but never relaxing), impossibility of penetration, or fear of pain. The spasm can be felt at the opening of the vaginal canal. 

Because it’s a penetration disorder, you may experience pain with fingers, tampons, vaginal dilators, pap exams and sex. Although it happens with penetration, it’s a physical AND an emotional disorder. 

There are two types of vaginismus:

  • Situational vaginismus: sex might be a no-go, but inserting a tampon or finger doesn’t hurt. 

  • Spasmodic vaginismus: When the vagina spasms with penetration. 

It’s considered primary vaginismus when there has always been pain with sex, and secondary vaginismus when there has previously been painless sex. 

Vaginismus may happen because of past sexual trauma, strict sexual or religious upbringing, fear of first-time sex (pain, bleeding, tearing, ripping, penis too large, vagina too small, sexually transmitted diseases, fear of pregnancy) or fear of pap exams.   

Treatment usually involves a pelvic floor physiotherapy – dilators, biofeedback, and counseling with a sex therapist (which includes mindfulness, cognitive behavioural therapy and pyschotherapy).

vulvodynia, vaginismus, dyspareunia, vulva, toronto naturopath, naturopathic doctor, painful sex

Vulvodynia

Vulvodynia (aka. vulvovestribular syndrome or vestibulodynia) is a chronic pain condition where there is vulvar inflammation and pain in the vulvar area. 

There’s no know cause of vulvodynia, so a bunch of conditions need to be ruled out before it’s diagnosed. The pain also needs to be there for at least 3 months for it to be vulvodynia. 

There are a couple types of vulvodynia:

  • Localized vulvodynia: pain in a distinct part of the vulva (ie. the vestibule)

  • Generalized vulvodynia: pain affecting the entire vulva

Pain can happen because:

  • Provoked vulvodynia: pain happens with touch (sexual or not sexual)

  • Unprovoked vulvodynia: pain happens without touch

Treatment usually involves a pelvic floor physiotherapist for muscle work, a sex therapist for counselling (like CBT), acupuncture with an acupuncturist or naturopathic doctor, or helping restore the vaginal microbiome, promoting healthy hormones and rebalancing the stress response with a naturopathic doctor. 

Final Thoughts

Sex shouldn’t be painful. And if it’s something that you’re experiencing, it’s important to figure out why it’s happening. Don’t listen to people when they say “Can you just relax” or “Just tell yourself that sex won’t hurt.”

What you’re feeling is real. Your experience is real. There are health professionals that can help you have pain-free sex. If you need any recommendations in the Toronto area, please let me know. 

If you found this information helpful, please sign up for my monthly newsletter called The Flow for great and informative content like this!

References

Simonelli, C., Eleuteri, S., Petruccelli, F. and Rossi, R. (2014). Female sexual pain disorders. Current Opinion in Psychiatry, 27(6), pp.406-412.

Pacik, P. (2014). Understanding and treating vaginismus: a multimodal approach. International Urogynecology Journal, 25(12), pp.1613-1620.

Why does it hurt to insert a tampon? It might be vulvodynia.

vulvodynia, painful sex, toronto naturopath, naturopathic doctor toronto

Inserting a tampon shouldn’t make you cry, right? What about pleasuring yourself? (If you are crying, it shouldn’t be because of pain). Then why does this happen? 

Vulvodynia (aka. vulvovestribular syndrome or vestibulodynia) is a chronic pain condition where there is vulvar inflammation in the vulvar vestibule area. Symptoms include: burning pain, redness and/or edema. About 20-30% of women will experience this condition in their lifetime.  

This is a pretty complex condition, and I go into detail in the article below to give you all the background information you may possibly need. Before your eyes glaze over, I talk about who can help you with vulvodynia and what natural treatments look like towards the end of the article. 

How is vulvodynia diagnosed?

Because we don’t know why vulvodynia happens, it’s considered a diagnosis of exclusion. This basically means that other conditions need to be ruled out before vulvodynia can be diagnosed. Also, you need to experience this pain for at least 3 months in order for it to be vulvodynia. 

How is vulvodynia classified?

This is another condition that uses the primary/secondary classification. 

Primary vulvodynia

Pain that is felt at first vaginal intercourse or tampon use.  

Secondary vulvodynia

Pain that occurs after a period of pain-free sex. 

What are the types of vulvodynia?

Provoked Vulvodynia (PVD)

This happens with sexual or non-sexual (ex. tampon insertion or contact with clothing) touch. 

Localized

Burning pain is felt at the vestibule, by touch or penetration. You may also experience a sensation of tearing during sex.  

Unprovoked Vulvodynia

Generalized

Aching or burning pain is felt around the entire vulva. Pain may radiate to perineum, thighs, bum, or the lower abdomen. Sitting, walking or tight clothing may make the pain worse. 

Mixed 

A combination of provoked and unprovoked pain. 

Why does vulvodynia happen?

Bad news: we don’t know why vulvodynia happens. But, we’ve got our theories!

Pain Theories

Believe it or not, there are 3 types of pain. Before you feel like you’ve been transported back to science class, let’s briefly explain them: 

  • Nociceptive pain: When pain is sensed at the vulvar vestibule (like when you’re inserting a tampon), pain sensing nerve cells basically turn on, a signal is sent to the spinal cord which is then transmitted to the brain. 

  • Inflammatory pain: This type begins with a nociceptive pain (ex. tampon touching the vestibule), but if it’s prolonged then inflammation will occur. Inflammation is a release of inflammatory cells (cytokines, histamine, other cells you may have learned about in grade 10 bio). These cells will cause an increase in the blood vessels, leading to inflammatory cells seeping outside of the vessels (near muscles and fat) and causing swelling. The inflammatory cells can also turn on the pain cells around the site of the vestibule causing aching pain.   

  • Pathological pain: Structural damage to the nervous system or abnormal function of the nervous system. 

Anatomy

Tight muscles of the pelvic floor, may contribute to vulvodynia. Women with vulvodynia usually have tense pelvic floor muscles, they’re unable to relax them and the muscles may not be all that flexible. 

Any damages to the pudendal nerve (which innervates the vulva) may contribute to the pain, and might have happened during any surgeries (ex. C-sections) or prolonged child birth. 

vulvodynia, vaginismus, dyspareunia, vulva, toronto naturopath, naturopathic doctor, painful sex

Common triggers

Last up, any vaginal (yeast or BV) or urinary tract infections, herpes simplex, trauma (using tools during delivery, including an episiotomy), back or hip injuries, hormonal changes (using birth control or simply perimenopause), past medications (like fungal cream) may cause vulvodynia. 

Stress, anxiety, depression, pain-related fear, may also play a hand in this too. 

Who can help treat vulvodynia?

Aside from your medical doctor, ob/gyn, or urogynecologist – there are other health professionals to consider adding to your team!

Pelvic Floor Physiotherapists

Remember how we talked about a tight pelvic floor? Before you attempt kegels (note: please don’t do that), go see a pelvic floor physiotherapist first. They will be able to assess your muscle tone and provide you with the right exercises to do, to get the muscles functioning properly. Be forewarned that this often requires an internal exam using 1-2 fingers to get an idea of how your muscles are working. 

Sex Therapists

It comes as no surprise that vulvodynia may put a damper on your sex life! Seeing a sex therapist may help with any negative thoughts or emotional distress associated with this condition. Because trauma like sexual abuse or divorce are likely to contribute to vulvodynia, these would likely be addressed as well. 

Naturopathic Doctors

NDs, like me, take a look at the whole body to figure out what exactly is going on. Remember all those common triggers we mentioned? My goal is to figure out if any of those are in play, and if they are, I treat them. I might change up your diet, prescribe a few supplements, or do some acupuncture – but it’s only because I want to feel better (because inserting a tampon shouldn’t make you cry). 

Acupuncturists

In the next section I’ll talk about how acupuncture can be helpful when treating vulvodynia. But basically, an acupuncturist is able to look at your specific symptoms through a different lens to determine how it can be treated by Traditional Chinese Medicine. Prescribing herbs and doing acupuncture are their go-tos for treatment. 

How is vulvodynia treated naturally?

This is a tough one. None of my texts, especially the ones about women’s health mention vulvodynia. And, if you search Pubmed (the mecca of all scientific articles), very few appear. But that doesn’t mean all hope is lost!

Vaginal Infections

If infections are the culprit, then I’ll start my infections protocol. Basically, I’ll make sure your immune system is keeping the bad bugs at bay, and you’re vagina is full of good bacteria (don’t worry, this doesn’t involve yogurt tampons). 

In on study looking at the vaginal microbiome, they found that the concentration of fungi was higher than the beneficial Lactobacillus! Therefore, making sure you have a healthy bacterial balance is key. 

Stress

Although I might not be able to get rid of every single source of stress, I can help your body manage it better. Studies show that women with vulvodynia have a blunted cortisol response, meaning that your body may not be handing as stress as good as it can. Using particular vitamins and minerals, as well as herbs, we can work together to re-establish a healthy stress response. 

Hormonal Changes

I’ve talked about the pill at length on the blog, but let’s quickly talk about what it specifically does to vaginal tissue. When you take hormonal birth control, your estrogen levels (not the one provided by the pill) and total testosterone decreases. The pill can make the vulva more sensitive to muscle strain, increased pain, decreased lubrication, and increased dyspareunia. No bueno. 

What does this mean for you? Well, we want to support hormone production, re-establish healthy hormone patterns, and help you to effectively detox the pill (we don’t need fake estrogens hanging around in your body). 

Acupuncture

Few studies have been done looking at the effectiveness of acupuncture and vulvodynia. If you’ve never had acupuncture done before (run, don’t walk!), it has been shown to be an effective treatment for pain. It helps to balance the yin and yang within the body, as well as ensure that the vital energy, your Qi, is flowing without obstruction. Qi flows through the meridians of the body, where acupuncture needles are placed. 

In a study from 2015, acupuncture was done in women with vulvodynia. Results showed that vulvar pain and dyspareunia were significantly reduced, although there was no significant change sexual desire, sexual arousal, lubrication, ability to orgasm or sexual satisfaction. 

Final Notes

If you’ve made it to the end, thanks for sticking with me! As you can see, this is a pretty complex condition, and your healthcare team may need to be quite diverse. At the end of the day, our goal is to help you feel better. 

If you found this information helpful, please sign up for my monthly newsletter called The Flow for great and informative content like this!

References

Thornton, A. and Drummond, C. (2015). Current concepts in vulvodynia with a focus on pathogenesis and pain mechanisms. Australasian Journal of Dermatology, 57(4), pp.253-263.

Pukall, C., Goldstein, A., Bergeron, S., Foster, D., Stein, A., Kellogg-Spadt, S. and Bachmann, G. (2016). Vulvodynia: Definition, Prevalence, Impact, and Pathophysiological Factors. The Journal of Sexual Medicine, 13(3), pp.291-304.

Vadala, M., Testa, C., Coda, L., Angioletti, S., Giuberti, R., Laurino, C. and Palmieri, B. (2018). Vulvovestibular Syndrome and Vaginal Microbiome: A Simple Evaluation. Journal of Clinical Medicine Research, 10(9), pp.688-692.

Schlaeger, J., Xu, N., Mejta, C., Park, C. and Wilkie, D. (2015). Acupuncture for the Treatment of Vulvodynia: A Randomized Wait-List Controlled Pilot Study. The Journal of Sexual Medicine, 12(4), pp.1019-1027.

Vulvodynia and Diet

June 25, 2018
vulvodynia and diet, toronto naturopath

Can there be a connection between what we eat and how we feel? Absolutely! Today, I’m talking about vulvodynia and its complex relationship with food. 

What is Vulvodynia

Vulvodynia refers to pain (burning, stinging, irritation, and rawness) at the vulva. The vulva is known as the external female genital area (and is often thought as the vagina). Vulvodynia is pain that lasts longer than 3 months, and is not caused by an infection, skin disorder, or other medical condition.

Vulvodynia is often seen in combination with two conditions: interstitial cystitis and irritable bowel syndrome. Because of this, I wanted to discuss which diets are often used in these conditions, how they may apply to vulvodynia, and why food sensitivity testing may be the best way to proceed. 

Interstitial Cystitis and Diet 

I’ll be writing a post on IC in the future, but generally it’s pain, discomfort, burning of some kind (in urethra, pelvis, or low back). It’s thought that a leaky gut may be a contributing factor to this condition. 

Leaky gut happens when there is damage to the gut lining, making it more permeable. It can be due to stress, certain medications, environmental toxins, nutritional deficiencies, microbiome dysbiosis, and food sensitivities. Permeability of the lining can lead to unwanted digestive system symptoms like gas, bloating, constipation, loose stools. Other symptoms like fatigue, mood changes, or rapid heart beat can also occur.

If you’ve followed my work for a while, then you know that I like focusing on food as medicine. We may not always be able to take supplements and get acupuncture, but we’re usually always able to eat. With IC, there have been specific foods known as potential triggers for this condition. Women often find relief by avoiding these foods. 

While this specific diet has not been studied in women with vulvodynia, it would be interesting to see if any relief is felt by avoiding these foods.  

Irritable Bowel Syndrome and the FODMAPs Diet

I’ve mentioned this particular diet on the blog before, especially as it’s being considered for the relief of digestive symptoms associated with endometriosis

A quick recap on IBS:

You may have IBS if you have recurrent abdominal pain on average at least one day/week in the last three months, associated with two or more of the following criteria:

  • related to defecation

  • associated with a change in frequency of stool

  • associated with a change in form (appearance) of stool

Studies have shown that a FODMAPs diet may be helpful in relieving symptoms associated with IBS. Similar to the IC diet, it would be interesting if women with vulvodynia experience similar relief. 

Vulvodynia and the Diet

Low Oxalate Diet

If you’re familiar with vulvodynia, you’ve probably heard about the low oxalate diet. Oxalates are organic acid found in plants, and bind minerals within the body. In some individuals oxalates may cause kidney stones, and has been proposed as a trigger for vulvodynia. Unfortunately there are only 2 studies looking at oxalates and vulvodynia. 

A 1991 study concluded that urinary oxalates may be nonspecific irritants that aggravate vulvodynia, but they are unsure if oxalates are the true instigators. And a 2008 study concluded that dietary oxalate consumption does not appear to be associated with an increased risk of vulvodynia. 

Elimination Diet

One case study looked at the elimination diet in the treatment of vulvodynia and found it to be helpful, as the woman noticed a relief of symptoms.

An elimination diet is when you avoid all foods containing allergens for at least 3 weeks (although it should be 4-6 weeks), and reintroduce foods one by one to see if they cause any distressing effects. 

When to consider Food Sensitivity Testing

As you can see, there are at least 4 diets on the table for vulvodynia. If you have this condition, and are looking to see if food can make a difference, you can certainly try each of these diets and see if they help. This may, however, take a couple of months with the avoidance and reintroduction periods. One of the benefits of doing this, is that you are able to experience the effects of a particular food. 

A faster way to determine which foods may not jive well with your system is through food sensitivity testing. This is an IgG test, which is a delayed reaction (in this case, to food). Collected via a blood draw, an IgG test can tell you how reactive you are to 120 or 200 foods and herbs. Once you have the results you can stay away from the ‘elevated’ foods, or you can test how exactly they affect you through a diet challenge (where you would consume a serving of food twice in a day, and wait 48 hours to see which symptoms present).

Next Steps

Whether you choose to go the diet or blood test route, having support is always helpful. Book an appointment with a Naturopathic Doctor who is well versed in pelvic health, so you can finally achieve relief! 

References

Baggish M, Sze E, Johnson R. Urinary Oxalate Excretion and Its Role in Vulvar Pain Syndrome. Obstet Gynecol Surv. 1998;53(2):80. doi:10.1097/00006254-199802000-00012.

Harlow BL et al. Influence of dietary oxalates on the risk of adult-onset vulvodynia. J Reprod Med. 2008;53(3):171-8.

Drummond J, Ford D, Daniel S, Meyerink T. Vulvodynia and Irritable Bowel Syndrome Treated With an Elimination Diet: A Case Report. Integrative Medicine. 2016;15(4):42-47.

Friedlander J, Shorter B, Moldwin R. Diet and its role in interstitial cystitis/bladder pain syndrome (IC/BPS) and comorbid conditions. BJU Int. 2012;109(11):1584-1591. doi:10.1111/j.1464-410x.2011.10860.x.