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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.

How To Choose Lube

October 1, 2018
how to choose lube, toronto naturopath, naturopathic doctor toronto

Lubricant is a product designed and used to help mimic the body’s natural lubrication. It even provides lubrication to areas of the body that don’t naturally produce any. It’s important to pay attention to lubricant and its ingredients because there many types of lubricant, and the vaginal and anal surfaces are highly permeable. This means that anything that is applied to it, can be absorbed into the body.

Why consider lubricant?

  • Pleasure: Sometimes there is not enough lubricant externally, or internally

  • Body changes: This includes hormones, life changes (ie. menopause), stress, alcohol, cancer treatments, pain (and more!)

  • Safety: May lead to fewer internal tears, less condom breakage (based on which lube you choose), and potentially fewer infections

Ingredients to be aware of:

  • Parabens: Used to prevent bacterial overgrowth in products. Also found to be endocrine disruptors, as they have an estrogenic effect in the body – binding to the same cell receptors as our body’s estrogen and interfere with the hormonal process

  • Petroleum: coats the skin and does not allowing it to function properly, changes the pH which may contribute to infections

  • Glycerin: can convert to sugar in the vagina, which may contribute to more infections (ie. yeast); found in water-based lubricants

  • Propylene glycol: may be a skin irritant

  • Chlorhexidine gluconate: antimicrobial in nature and may kill healthy bacteria thereby altering the vaginal pH

  • Phenoxyethanol: may be a skin irritant

  • Fragrance: may conceal hundreds of toxic chemicals

How to choose lube

Water-based lubricant

Compatible with: all safe sex supplies and sex toys 
Usually contains
: glycerine, parabens, propylene glycol

This type of lubricant is safe with latex condoms and all types of sex toys. Water-based is easily absorbed by the skin, and may help to hydrate tissues. However, it may dry up quickly and thus might need to be reapplied often. Clean up is relatively easy, at the very minimum a simple rinse is all that is needed. In terms of ingredients, this type is likely to contain parabens and glycerin, so pay attention to the ingredients list when purchasing.

Water-based options:

Sliquid Organics Natural Personal Lubricant, Sliquid H2O Natural Intimate Lubricant, YES Water Based Organic Lubricant, Good Clean Love Restore Moisture Lubricant, Good Clean Love Almost Naked Organic Personal Lubricant 

Silicone-based lubricant

Compatible with: Almost everything (sex supplies and toys)
Not compatible with: Some silicone toys
Infection potential: Does NOT trap bacteria

This is a synthetic type of lubricant that is safe with latex condoms (in fact, most lubricated condoms are coated with this type of lubricant), but should not be used with silicone sex toys. Silicone stays on longer and does not come off in the water. Clean up is easy with soap and water. Because it is synthetic it may cause slight skin irritation, however it’s often less allergenic than water and does not contain many additives.

Silicone-based options:

Sliquid Silver, Pjur Eros, Pink

Oil-based lubricant

Compatible with: silicone, metal and glass
Not compatible with: Latex toys and latex condoms
Usually contains
: coconut oil. jojoba oil, castor oil
Infection potential: Traps bacteria! 

This type of lubricant can degrade latex condoms, thereby making them ineffective against pregnancy and sexually transmitted infections. In addition, they may not be compatible with certain sex toys. Formulations may be thick or thin, and may be made with natural plant oils (some of which may be nourishing to the skin).

Sometimes oil may be more difficult to clean off (and inside) the body, and so a fear is that the vaginal pH may be affected potentially giving rise to infections. Nevertheless, soap and water will do the trick for the external skin. Because coconut oil is a popular choice as a lubricant, it should be mentioned that it also has antimicrobial properties and therefore may impact the vaginal pH.

Oil-based options:

Sex Oil (Province Apothecary)

Cleaning up

Friendly reminder that the vaginal canal (NOT to be confused with the vulva) is self-cleaning. When you douche, use antibiotics or try to clean the area using soap it can disturb the natural balance of bacteria and cause pH changes. The change in pH may be the reason why you’re experiencing infections. 

Final Thoughts

Now that you’re familiar with the different types of lubricant and the ingredients to steer clear of, shopping should hopefully not be much of a problem! Keep in mid that you may need to try a few options to see which lube is best for you, and if you are someone who constantly gets UTIs or yeast infections (& used lube), it’s time to assess those ingredients!

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