Updated Definitions

Vulvar pain can begin at any age, said Dr. Lamvu, and what’s important for clinicians to know now is that there is a new classification for the specific type of vulvar pain known as vulvodynia. This type of vulvar pain must last 3 months or more without a clear identifiable cause, with potential associated factors. The International Society for the Study of Vulvovaginal Disease (ISSVD) and the IPPS updated the definition in 2018 to differentiate vulvodynia from general vulvar pain. The idiopathic condition must be a diagnosis of exclusion.

Another updated definition, this one in the DSM-5, is for vaginismus. This term captures vaginal pain that lasts longer than 6 months and that is associated with intense fear or anxiety around intercourse and the tensing of pelvic and lower abdominal muscles. The prior definition was more psychogenic, noted Dr. Lamvu. We know now that vaginismus may have a musculoskeletal dysfunction component. Further, this condition cannot be attributed to PTSD, domestic violence, or other life stressors. “We are really looking at an intense psychological fear accompanied by musculoskeletal issues—anything else is not ‘vaginismus.’

Then there is GSM, which was previously known atrophic vaginismus, vulvovaginal atrophy, or urogenital atrophy. Although the disorder was described by the International Society for the Study of Women’s Health and the North American Menopause Society in 2014, and further explained by Gandhi J in an AJOG paper in 2016, many providers are still catching up with the fact that GSM is disease that progresses over time. The syndrome groupslower urogenital tract signs and symptoms associated with a low-estrogen state.

The GSM pathophysiology has to do with changes in tissue integrity and the acidity of the vagina, and thus, reduced protection against vaginitis and urinary tract infections. Symptoms may include dyspareunia, incontinence, prolapse, thin vaginal epithelium, impaired smooth muscle proliferation, loss of vascularity, dryness, and itching—all occurring in the hyposterogenism state. Risk factors may include bilateral salpingo-oophorectomy, ovarian failure, chemotherapy, smoking, and alcohol use.

“When you see someone with vaginal atrophy, you have to screen for urinary and sexual dysfunction, but now you can avoid any negative connotations associated with the term” said Dr. Lamvu. “Menopause may be identified as the cause of both vulvar andurinary symptoms with this condition.”

Genitourinary Syndrome of Menopause—On the Chronic Progression Continuum

Sharing the stats, Dr. Lamvu noted that 15% of premenopausal women experience GSM and 40 to 54% of postmenopausal women have GSM. Most of the symptoms have to do with declining estrogen levels, which change most rapidly between ages 45 and 55.

Of interest, a review of 64 studies over the course of 2000 to 2014 around the world on menopause symptom prevalence found that 30 to70% of women experience GSM symptoms worldwide (see Makara-Studzinskia MT, Prz Menopauzalny, 2014). Sexual dysfunction post-menopause may go up to 92% prevalence. Women do not often mention sexual dysfunction in particular—they may mention dryness, said Dr. Lamvu, but providers need to talk to them about this symptom as well.

The median vasomotor duration in another study was 7.4 years for symptoms of menopause; symptoms may go on 4.5 years after menopause as well (see Avis NE, et al, JAMA Intern Med, 2015). “Essentially, the earlier a woman starts perimenopause, the longer her GSM symptoms may last, possibly for 11.8 years in total,” said Dr. Lamvu.

GSM is considered to be chronic, progressive, and unlikely to resolve without treatment—this, on top of its long timeframe and the fact that chronic pain may increase with age, make effective assessment and management crucial.

In fact, one VA study showed that women who had menopause had twice as high odds of also having a chronic pain syndrome and twice as high odds of having multiple pain diagnoses, even after adjusting for age, race, BMI, mental health, and so forth, noted Dr. Lamvu. “This means our screening process for these patients has to go way beyond asking patients, ‘Is your vagina dry?’”

“Pain specialists may see myalgias and neuralgias in their patients, and guess what,” continued Dr. Lamvu, “Women get those symptoms in the vagina too… Clinicians may not automatically associate these diagnoses with the vagina but they need to.”

As an example, she shared that she often sees chronic pain conditions in her GSM patients—including fibromyalgia, temporomandibular disorder, low back pain, and migraine. Anxiety and depression are also common with GSM.

Sometimes clinicians focus on vaginal atrophy and forget that other things in the pelvis can cause pain, from bladder pain syndrome to myofascial pelvic pain to neuralgia to IBS. There are commonly missed conditions associated with vaginal pain and dyspareunia. As a result, many patients go through a primary care doctor, a gynecologist, and a psychologist and are told they have vaginal atrophy, but GSM is much more than that. Evaluations of vulvovaginal pain need to go outside of a doctor’s typical comfort zone to include a biopsychosocial evaluation. Gynecological screenings must also include trauma-informed care.

How to Manage GSM

There is good news for patients with GSM—despite being a chronic condition, symptoms can be managed based on severity, said Dr. Lamvu. Education and lifestyle modifications can be very beneficial, including: 

Genitourinary Syndrome of Menopause—On the Chronic Progression Continuum

Sharing the stats, Dr. Lamvu noted that 15% of premenopausal women experience GSM and 40 to 54% of postmenopausal women have GSM. Most of the symptoms have to do with declining estrogen levels, which change most rapidly between ages 45 and 55.

Of interest, a review of 64 studies over the course of 2000 to 2014 around the world on menopause symptom prevalence found that 30 to70% of women experience GSM symptoms worldwide (see Makara-Studzinskia MT, PrzMenopauzalny, 2014). Sexual dysfunction post-menopause may go up to 92% prevalence. Women do not often mention sexual dysfunction in particular—they may mention dryness, said Dr. Lamvu, but providers need to talk to them about this symptom as well. 

The median vasomotor duration in another study was 7.4 years for symptoms of menopause; symptoms may go on 4.5 years after menopause as well (see Avis NE, et al, JAMAIntern Med, 2015). “Essentially, the earlier a woman starts perimenopause, the longer her GSM symptoms may last, possibly for 11.8 years in total,” said Dr. Lamvu. 

GSM is considered to be chronic, progressive, and unlikely to resolve without treatment—this, on top of its long timeframe and the fact that chronic pain may increase with age, make effective assessment and management crucial. 

In fact, one VA study showed that women who had menopause had twice as high odds of also having a chronic pain syndrome and twice as high odds of having multiple pain diagnoses, even after adjusting for age, race, BMI, mental health, and so forth, noted Dr. Lamvu. “This means our screening process for these patients has to go way beyond asking patients, ‘Is your vagina dry?’” 

“Pain specialists may see myalgias and neuralgias in their patients, and guess what,” continued Dr. Lamvu, “Women get those symptoms in the vagina too… Clinicians may not automatically associate these diagnoses with the vagina but they need to.”

As an example, she shared that she often sees chronic pain conditions in her GSM patients—including fibromyalgia, temporomandibular disorder, low back pain, and migraine.  Anxiety and depression are also common with GSM.

Sometimes clinicians focus on vaginal atrophy and forget that other things in the pelvis can cause pain, from bladder pain syndrome to myofascial pelvic pain to neuralgia to IBS. There are commonly missed conditions associated with vaginal pain and dyspareunia. As a result, many patients go through a primary care doctor, a gynecologist, and a psychologist and are told they have vaginal atrophy, but GSM is much more than that. Evaluations of vulvovaginal pain need to go outside of a doctor’s typical comfort zone to include a biopsychosocial evaluation. Gynecological screenings must also include trauma-informed care.

How to Manage GSM

There is good news for patients with GSM—despite being a chronic condition, symptoms can be managed based on severity, said Dr. Lamvu. Education and lifestyle modifications can be very beneficial, including:

• Avoid overwashing of the vagina (most patients think more washing is better; it is not)
• Try to have regular intercourse if not painful
• Cease smoking
• Wear looser undergarments.

In terms of pharmacological approaches, nonhormonal lubricants may be recommended to relieve dryness and itching temporarily; these should be water or silicone based and irritant free.

Low dose vaginal estrogen is also a first-line option. The research is definitive on low dose vaginal estrogen as being effective and safer than systemic or oral hormonal therapy, said Dr. Lamvu, who noted that it typically takes 8 to 12 weeks to work. The patient may opt to use an inserted capsule, a cream, etc. Other treatment methods may involve dilators, physical therapy (PT), topical lidocaine, SERMS, vaginal DHEA, laser treatment for vascularity and collagen, oxytocin gel, and more. In cases of sexual dysfunction, Cognitive Behavioral Therapy (CBT) may be used to help with desensitization.

In those patients with GSM and other chronic pain syndromes, multimodal treatment is necessary. For instance, a vaginal estrogen, with perhaps a lidocaine ointment, with perhaps PT and CBT, as well as treatment of sleep,  mood or fatigue disorders may be warranted. Sometimes, a patient assumes that insomnia or mood changes are just symptoms of menopause, but they should be screened for a true sleep or mood disorder on top of menopause.

Practically speaking, Dr. Lamvu shared that the number one obstacle she sees in GSM management is patient compliance. Patients do not like to use the creams or fail to finish the full therapy. For this reason, patient education and involvement in the decision-making process is key. Remind patients that while 8 to 12 weeks is a typical time for noticeable improvement, a return to normal sexual function may take longer than 3 months.

Overall, emphasized Dr. Lamvu, the percentage of women experiencing and living with GSM is staggering. “We cannot focus on what we don’t know—we cannot ignore the vagina,” she said. “We have to put her in the same chronic conundrum as the other chronic pain conditions.”

Avoid overwashing of the vagina (most patients think more washing is better; it is not)
Try to have regular intercourse if not painful
Cease smoking
Wear looser undergarments

In terms of pharmacological approaches, nonhormonal lubricants may be recommended to relieve dryness and itching temporarily; these should be water or silicone based and irritant free.

Low dose vaginal estrogen is also a first-line option. The research is definitive on low dose vaginal estrogen as being effective and safer than systemic or oral hormonal therapy, said Dr. Lamvu, who noted that it typically takes 8 to 12 weeks to work. The patient may opt to use an inserted capsule, a cream, etc. Other treatment methods may involve dilators, physical therapy (PT), topical lidocaine, SERMS, vaginal DHEA, laser treatment for vascularity and collagen, oxytocin gel, and more. In cases of sexual dysfunction, Cognitive Behavioral Therapy (CBT) may be used to help with desensitization.

In those patients with GSM and other chronic pain syndromes, multimodal treatment is necessary. For instance, a vaginal estrogen, with perhaps a lidocaine ointment, with perhaps PT and CBT, as well as treatment of sleep, mood or fatigue disorders may be warranted. Sometimes, a patient assumes that insomnia or mood changes are just symptoms of menopause, but they should be screened for a true sleep or mood disorder on top of menopause.

Practically speaking, Dr. Lamvu shared that the number one obstacle she sees in GSM management is patient compliance. Patients do not like to use the creams or fail to finish the full therapy. For this reason, patient education and involvement in the decision-making process is key. Remind patients that while 8 to 12 weeks is a typical time for noticeable improvement, a return to normal sexual function may take longer than 3 months.

Overall, emphasized Dr. Lamvu, the percentage of women experiencing and living with GSM is staggering. “We cannot focus on what we don’t know—we cannot ignore the vagina,” she said. “We have to put her in the same chronic conundrum as the other chronic pain conditions.”

The IPPS Board of Directors would like to express its sadness that APS has filed for dissolution via Chapter 7 Bankruptcy. In light of the fact that APS was a chapter of IASP and that IASP also serves as the management company for IPPS we are taking this opportunity to clarify IPPS’ status and independence.

Regarding the relationship between APS and IASP, you can read IASP’s statement about APS here. All IASP chapters have independent governance, legal and financial structures from IASP and as a result, any chapter’s financial or legal issues have no impact on IASP.

In 2018 IPPS engaged IASP to provide management services for IPPS, however, the IPPS is an independent, autonomous organization and has independent governance, legal and financial structure from IASP.IPPS has strong reserves and is fiscally sound. Furthermore, IPPS revenue is derived from membership dues and annual conference revenue with very little support from any industry.

IPPS has always been a strong advocate for multi-modal, inter-disciplinary and integrated management of chronic pain. We advocate for pain research, for provider and patient education and for improved access to care. As long as we have support from our members we will continue this important work.

Everyone has an experience of gender, not only transgender and gender diverse folks. For cisgender people, too, gender can shift and be extremely nuanced. When a person identifies as cisgender it means that their gender identity corresponds to gender norms associated with the sex that they were assigned at birth, for example, a person who was assigned male at birth and identifies as a man. Transgender or ‘Trans’ is an umbrella term to describe the many ways that people identify and experience gender that differs from societal norms regarding gender and gender identity.

By: Renee Dumaresque, MSW, Ph.D. Student

You may already be dedicated to building a gender inclusive pelvic pain practice, and, perhaps, have your own ideas about how to provide safe and accessible care for transgender and gender diverse patients. This post is not meant to be exhaustive, and, of course, I am unable to speak on behalf of every transgender and gender diverse person living with pelvic pain. Hopefully, this piece can provide an entry point into learning more, or will contribute a thing or two to your existing knowledge about gender-inclusive healthcare. Based on my lived experience as a gender non-binary person with vulvodynia, and my professional experience as a social worker who is pursuing their Ph.D. in relation to queer and trans healthcare, I hope to offer some thoughts that may be helpful in making your practice more inclusive for transgender and gender diverse folks.

Chronic pelvic pain impacts people across the gender spectrum, but, for many transgender people, healthcare is not safe or accessible. Too often, this results in patients being denied appropriate care, withdrawing from care, or not engaging with healthcare at all. Healthcare holds the potential to be a transformative space of healing, support and affirmation, and there are initiatives all over the world that model dedication to gender-inclusive healthcare. What’s important, is your desire to learn, the courage to make mistakes, apologize, and try again.

Dominant understandings of health, pathology, and treatment, as well as the delivery of healthcare services, are often approached and practiced based on mainstream ideas about gender as binary and as biological. Within “women’s health”, for example, research, diagnostics, and treatment equate gender identity with biological ideas about sex. Gender does impact a person’s health and health care, but gender identity does not determine a person’s body parts or the health issues that lead a person to seek health-related support. There is no such thing as a “woman’s body” or a “man’s body”. For example, a man can have a uterus, a vulva, or breasts; and, a woman can have a prostate and testes.

A person’s gender identity relates to the way that they perceive their own experience of gender, which may or may not correlate to the sex that they were assigned at birth, for example, male and female. Mainstream ideas about gender suggest that there are only two genders and that a person must identify as a man or as a woman. However, gender exists on a spectrum, meaning that there are many ways that a person might experience gender, and for lots of people, gender is fluid throughout the course of their life.

Everyone has an experience of gender, not only transgender and gender diverse folks. For cisgender people, too, gender can shift and be extremely nuanced. When a person identifies as cisgender it means that their gender identity corresponds to gender norms associated with the sex that they were assigned at birth, for example, a person who was assigned male at birth and identifies as a man. Transgender or ‘Trans’ is an umbrella term to describe the many ways that people identify and experience gender that differs from societal norms regarding gender and gender identity.

The term ‘Trans’ does not suggest that all Trans people identity in the same way and it is not meant to erase the differences that exist between people’s unique experiences and understandings of gender. Trans includes transgender men and women, but it also includes people who don’t necessarily identify as either a man or a woman, and who may or may not identify as transgender, for example, non-binary, agender, gender fluid, and Two-Spirit folks, etc. Ideas about gender also vary within and between cultures, where people may or may not identify with Trans identity.

Transgender identity is not dependant on physical transition, for example, hormones or surgery. Gender transition may or may not involve physical aspects, but it can also include emotional, spiritual, and many other shifts. Be mindful of the language that is used by your patients to describe their bodies and experiences. For some patients, labels such as “pre-operative” and “post-operative” will be problematic because of the assumption that transition must include physical change, but for others, these terms might feel right. It is important to remember, for both cisgender and transgender individuals, that the words people use to describe their experiences and their identities can mean many different things for different people. There are no generalizable rules about gender.

You cannot assume a person’s gender by looking at them. Gender expression is different than gender identity - it relates to the way that a person presents, such as masculine, feminine, androgynous, etc. Like gender identity, gender expression is often fluid, it might change day to day, and it is not dependent on gender identity.

With respect to pelvic pain healthcare, consider who is currently left out of the conversation? Which bodies and identities are not included in research, treatment, and support? What assumptions exist related to gender? Although there are many structural barriers to gender-inclusive healthcare, there is a lot that you can do to make your practice safer and more accessible to transgender and gender diverse folks. Increasing access and inclusivity does not mean implementing special practices for Trans patients that differ from the practices that you use with cisgender patients. By providing gender-inclusive care, to all patients, you will contribute to the development of new norms in mainstream healthcare. You will help to address the structural issues that result in marginalization and erasure of transgender and gender diverse patients.

Trans patients live whole lives that don’t always center their gender identity. For the most part, people want to visit their healthcare provider and be treated just like everyone else – to feel included, considered, and like their experiences and bodies are equal to other patients. Below are some ideas about how you can increase accessibility within your pelvic pain practice.

1. Consider the advertisements, signage or other materials that you display in your clinic.
   
   Avoid placing material in your clinic that equates specific experiences and medical issues with a specific gender. For example, frameworks of women’s health often exclude and erase transgender and gender diverse people and their experiences. Consider displaying a sign or a poster in your clinic which communicates to patients that your clinic values transgender and gender diverse patients. Remember that signage, alone, is not helpful and must be accompanied by a thoughtful practice dedicated to gender inclusivity.
   
   
2. Understand that building trust takes time.
   
   Recognize that patients are often coming into your practice having had negative experiences in healthcare. It is normal and reasonable that Trans patients might enter from a place of distrust. In fact, for a lot of people, having their guard up is a safety precaution that has been both smart and necessary. For this reason, be patient, avoid making judgments, and understand that you are in a unique position to provide a different and positive experience of healthcare. Communication and transparency is key to building trust. Always communicate what you intend to do, check in with patients about their comfort level, and ask for consent along the way.
   
   
3. Respect patients chosen name.
   

   Ask patients to share their name and don’t assume that the name they provide will be the same as what you see listed on their health identification. Safety concerns, legal and financial barriers, social and family issues, and personal choice are some of the many reasons that a patient’s name might differ from their legal name or the name that appears on their health identification.  Ask patients what name appears on their health-card, and also ask patients if they prefer a different name be used in your clinic. If so, make sure to document their chosen name.
   
   

4. Ask all patients to share their pronouns.
   
   Like gender identity, you cannot assume a person’s pronouns based on how they look or based on their gender identity. For example, some gender non-binary people choose to use she/her or he/him, and some people use different pronouns in different settings. By asking all patients what their pronouns are you will avoid making assumptions and it will quickly feel like your new norm. Start by introducing yourself and sharing your own pronouns, then you can ask your patient if they feel comfortable sharing theirs.
   

    

5. Ask about body parts instead of assigned sex.
   

   Within society, gender and sex are often conflated, meaning that ideas about sex are hardly ever gender neutral in social institutions. Many people do not identify with the sex that they were assigned at birth. Instead of asking people about their assigned sex, ask people to identify the specific body parts that they have or that are relevant to their healthcare.

6. Don’t make assumptions about sexual orientation or sexual practices.
   
   Sexual orientation is different than gender identity. A persons gender identity does not dictate or limit a person’s sexual orientation. Knowing a person’s sexual orientation does not tell you what sexual practices that they engage in, just as knowing what sexual practices that a person engages in does not tell you their sexual orientation. Avoid making any assumptions about a patient’s sexual orientation and their sexual practices. If having this information is necessary for providing certain aspects of health care, then, inform patients as to why having the information will be helpful and ask them if they are comfortable sharing.
   

    

7. Review (and possibly revise) your patient intake form.
   

   Your intake form is one of the first interactions that a patient has with your practice. Thoughtful design can ensure that you share and obtain the necessary information that you need to run your business and provide quality, gender-inclusive healthcare. Review your intake form in relation to the information and the suggestions listed above. Do the questions that you ask on your intake form make assumptions about gender identity or equate gender with certain body parts? What questions might you consider adding? Are there questions that can be removed or rephrased? Reflect on the reasons that you ask each of your questions and consult with others if you need advice or if you are struggling with revisions. 

   Like any big change, moving toward gender-inclusive pelvic pain healthcare will come with lots of learning and you may have lots of questions. Changes in your practice might also come with questions from others, including patients and colleagues. Taking a few moments to explain your approach to providing care or to clarify the questions that you ask in your intake form shouldn’t take long, but it will make a big difference for Trans people who engage with your practice and who see themselves reflected in your day-to-day operations. Many people and organizations have put tons of thought into developing gender-inclusive healthcare - you do not need to reinvent the wheel! Remember that not everything that you do will work for every patient - be open to feedback, try new things, and know that you are engaging in life-saving and life-affirming work. More resources must be put into learning more about the unique ways that pelvic pain impacts Trans folks, about effective treatment, and effective support. People with pelvic pain carry huge amounts of knowledge related to health, survival, coping, healing, and resistance. Within your work, centre the knowledge of people living with pain. Continue to acknowledge that we all have something to learn from one another as we reimagine what it means to live with pelvic pain, and in some cases, how to live without it.

By Sigourney Cross
Pelvic Health and Rehabilitation Center, Berkeley, CA
www.pelvicpainrehab.com

The Integrated Systems Model

Dr. Lee poses the question, “Would you race a car that had its wheels out of alignment around a racetrack?” Most people would answer no. Many people who are seeking relief from their pelvic floor symptoms have comorbidities or other conditions that can be contributing factors. When clinicians are deciding whether to start treatment at the pelvic floor or to look elsewhere first and see how the pelvic floor responds, Dr. Lee suggests using the Integrated Systems Model (ISM). Learn more about the ISM approach on Dr. Lee’s website here. The ISM is an “evidence informed clinical reasoning framework to optimize strategies for function and performance.”⁴ This approach helps clinicians in their clinical decision making in the assessment and treatment of patients. It helps identify which patients need specific training of the muscles of the trunk and pelvic floor and those who do not by assessing motor control.

The ISM and Motor Control

Motor control is the process of how humans and animals use their brain to activate and coordinate muscles to perform a task or skill. The motor control response to pain varies from person to person because the following three dimensions influence it.

1. Sensorial Dimension-Location and behavior of primary complaint
2. Cognitive Dimension-Beliefs and attitudes about their experiences
3. Emotional Dimension-Feelings associated with experiences

Because motor control varies based on an individual’s thoughts, beliefs, and experiences surrounding that task, this makes it challenging for clinicians to assess. There is not one universal strategy of muscle activation for control. Each strategy is unique to not only the individual but also to the task itself. Some people may brace and stiffen during pain while others can loosen and destabilize. The goal of rehabilitation or using motor learning strategies is to remove, modify or enhance an individual’s adaptation based on the unique solution adopted from the patient.³ Physical Therapists must take a thorough history to understand which of the above dimensions is creating the largest barrier to changing their motor control strategy. We can then implement this change through patient education, building trust, movement, and touch to change the sensory input in order to change the motor output.

Before focusing on the pelvic floor in isolation, it’s important look at the patient’s overall alignment and motor control. Some patients may only need motor control training strategies to re organize their muscle recruitment dys-synergies. These dys-synergies can come from the pelvic floor reacting to varying processes in the body including the following:

1. Excessive intra-abdominal pressure–This can be caused by varying factors whether it be an abdominal trauma, an acute syndrome such a pancreatitis or different exercises.
2. Poor foot control creating an ascending force up the lower extremities-This causes internal rotation of the leg, which put forces on the obturators’, which are connected to the pelvic floor.
3. A descending force from the thorax-This can cause a rotation within the thorax.
4. Pulls from the coccyx on the dura-This can come from an old spinal concussion or disc protrusion.
5. Twists in the trunk

What is a twist in the trunk?

A twist in the trunk occurs when there is an incongruent rotation between the thorax and the pelvis or to put it simply, when the pelvis and thorax are going in opposite directions. This is a significant finding because all of the multi segmental muscles of the trunk are important in motor control and movement.²

There is a significant correlation between the presence of pelvic floor diagnoses and movement diagnoses of the spine and hip. In a study by Wente & Spitznagle, 2017, they found that out of 225 patients with urinary urgency and frequency almost 50% of them had hip or spine impairments and 18% had either thoracic or pelvic girdle impairments.

Consider a very common case. A 31-year-old mother, five months postpartum, feels persistent pelvic girdle pain that increases with large steps. Using the ISM approach, you would start by picking a meaningful task. This could be a task that causes pain, a movement the patient finds difficult, or a task the patient avoids altogether. Once the task is picked you then analyze the task and identify areas of the body with suboptimal alignment and poor biomechanics. The goal with this type of analysis is to find the driver or the patient’s sub optimal movement strategy. The driver is what is going to be the most impactful impairment you can change. While analyzing this new mom’s posture (Learn more about posture here), thorax rotation, single leg stance and active bent SLR a common suboptimal strategy was found. As shown in the picture above, this is an over-activation of the iliocostalis (one of the deep muscles of the back that connects from your ribs to your hip) and an under activation of the deep abdominals.⁵ This imbalance of your muscles pulling your ribs one direction and your pelvis the other causes twists in the trunk. Physical therapists can correct misalignments with varying techniques including manual therapy techniques and therapeutic exercise. Correcting this patients alignment and getting the “twists” out of her trunk, allowed her to restore control at her thorax and use a more optimal movement pattern. It changed her motor control strategy, therefore allowing her to perform her meaningful tasks without pelvic girdle pain.

What do we do with this information?

This lecture has been very meaningful to my clinical practice in the sense that it helps explain why some patients may still feel lingering pelvic floor symptoms when there is no longer impairment at the tissue level. I think it is important to understand that examining the pelvic floor in isolation may not reveal all the contributing factors causing patients symptoms. Although there are many individuals who require specific isolated pelvic floor muscle training, It’s important to be cognizant of identifying the individuals who do not, and who would benefit more from treating misalignment of the trunk and creating more optimal biomechanics, motor control and recruitment strategies. If you are struggling with pelvic floor symptoms the physical therapists at the Pelvic Health and Rehabilitation Center can help!

We thank Dr. Diane Lee for a fantastic lecture. To view the presentation in its entirety please start on page 185 here.

~~~

References:

¹Hodges & Smeets. Contemporary theory of motor adaptation in pain. Clin J pain. 2015
²Hodges, P W. Pain and motor control: From the laboratory to rehabilitation. Journal of Electromyography and Kinesiology: Official Journal of the International Society of Electrophysiological Kinesiology. 2011;21(2): 220–228
³Hodges, Van Dillen, McGill, Brumagne, Hides, Moseley. Consensus from the Evidence. Pain and motor control. Journal of electromyography and Kinesiology. 2013; 21.
⁴Lee D, Lee LJ. The Pelvic Girdle. An integration of Clinical Expertise and Research. 2007-2013.
⁵Macintosh JE, Bogduk N. The attachments of the lumbar erector spinae. Spine Phila Pa. 1991;(7):783-92.
⁶Wente KR, Spitznagle TM. Movement-Related Urinary Urgency: A Theoretical Framework and Retrospective, Cross-sectional Study. Journal of Women’s Health Physical Therapy: May 2017; 41(2) 83–90.

By Malinda Marshall
Pelvic Health and Rehabilitation Center, Los Gatos, CA
www.pelvicpainrehab.com

When I first looked through the schedule of the 3rd World Congress on Abdominal and Pelvic Pain for October 2017, I was excited to see that there was a session on vulvar pain and a talk scheduled for Caroline F. Pukall, Ph.D, entitled “Vulvodynia: A Biopsychosocial Approach.” Dr. Pukall is a professor of Psychology and the director of Sex Therapy Service at Queen’s University in Kingston, Ontario, Canada. In 2015, Stephanie wrote a blog post on the International Consensus Conference on Vulvodynia Nomenclature. Dr. Pukall was one of the 28 participants in this consensus meeting. She is well versed in the terminology of vulvodynia. Her presentation turned out to be every bit as interesting as I hoped it would be: she discussed the terminology of vulvodynia, the biopsychosocial indicators for vulvodynia, and the various levels of pathophysiology of vulvodynia. She also came to the conclusion that treatment for vulvodynia needed to include doctors, physical therapists, and psychologists.

Vulvodynia is diagnosed as pain in the vulva for more than three months without an identifiable cause. However, there is a difference between vulvodynia and persistent vulvar pain: Dr. Pukall states persistent vulvar pain has an identifiable cause, such as an infection, inflammation, neoplasm (tissue grow such as a tumor), neurological, traumatic, iatrogenic (caused by a medical procedure), and/or hormonal cause. Vulvodynia is diagnosed by exclusion of these causes.

Within vulvodynia, there are many subgroups of the pain. It can be localized to one area, generalized throughout the vulva, or a mixture of the two. It can be provoked, such as with sexual intercourse, spontaneous, or both. The pain can be constantly there or intermittent. The onset of pain may be primary, meaning the pain was always there to begin with, or it can be secondary, meaning it developed later on. Dr. Pukall pointed out an important fact in her talk, which is that a patient can have vulvar pain from a specific disorder, such as lichen sclerosus, at the same time as having vulvodynia. This is important for us to keep in mind when treating vulvar pain.

As Dr. Pukall pointed out, its complex and patient-specific causes and features mean that treating vulvodynia is not simple and clear cut. It’s important to address all contributing factors; the biological, psychological, and social elements. The biological components of vulvodynia include hormonal changes, inflammation, genetics, comorbidities (such as diabetes, obesity, high blood pressure, etc. ), and musculoskeletal, neurological, structural symptoms — all the physical things that are happening in the pelvic area, that one might expect to provide clues as to how to treat the condition. Just as important, though, are the psychological contributing factors to vulvar pain. These include mood, behavior, and self-perception. Dr. Pukall discussed how anxiety and avoidance are associated with decreased sexual function, and how hypervigilance, catastrophizing, and fear of pain can all cause increased pain. According to Dr. Pukall, women with lower “self-efficacy” (one’s belief in one’s ability to succeed) tend to have increased pain and poorer sexual function.

The last part of Dr. Pukall’s “biopsychosocial approach” refers to social factors that contribute towards vulvodynia — that is, things going on with the people around you that can feed into your pain. These social factors include problematic arousal, low desire, attachment, intimacy, communication, emotional expression, goals, abuse, and partner responses. A partner who suggests stopping all sexual activity may actually be causing more harm than good. This response can cause increased pain and lower couple sexual wellbeing. Having a partner who encourages adaptive coping and expresses positive feeling about engaging in any sexual activity, not penetrative sex, tends to bring benefits for both members of the couple. Pain seems to be modulated by the partner’s response to pain.

The take-home message for the practitioners in the audience was that the pathophysiology of vulvodynia includes pain, musculoskeletal, psychological, social, and interpersonal factors, and that the treatment for vulvodynia should include a medical doctor, a physical therapist, and a psychologist. I came out of the lecture hall determined to pass on Dr. Pukall’s message. In fact, looking at Dr Pukall’s list, I can’t help thinking that a biopsychosocial approach to vulvodynia could probably do us all a power of good!

We thank Dr. Caroline Pukall for a fantastic lecture. You can view her powerpoint lecture here. Please scroll down to page 155. You can also follow Dr. Pukall on Twitter at @QSexLab.

By Britt Van Hees
Pelvic Health and Rehabilitation Center, Berkeley, CA
www.pelvicpainrehab.com

Three Camps

Pain, pain, pain. There are three camps of pain chronification:

Cortical reorganization: occurring in the brain

Spinal central sensitization: occurring at the spinal cord

Nociceptive sensitization: occurring at the sensory nerve level

Each of these camps have their own combination of modifiers that can lead to sensitization.

Pause- so this is where one can get overloaded with information, so I took some creative liberties and decided to draw a picture.

As you see from the drawing, there are several areas where our brain and our body can modify signals related to pain. At the “nociceptor sensitization camp” the sensory nerves can become extra excited, and maybe throw too much input into the nervous system. For example, do you remember the last sunburn you had? Remember how sensitive your skin was- even the slightest touch was immensely painful. Well, now imagine that you don’t have a sunburn but your nerves are sending that same intense signal, as if your tissue was still burned. This nervous system mix up is called allodynia, when normally non-painful stimulus is extremely painful.

At the “stream of spinal central sensitization” the spinal cord can send information upstream, to the brain, or downstream, to the peripheral nerve, to modify signals related to pain. For example, #1 on the list, prolonged dorsal horn firing, is similar to an echo. This is when your hand-nerve yells “watch out” to your spinal cord, and your spinal cord yells to your brain “watch out….watch out….watch out….watch out….watch out… watch out…watch out….” well you get the idea. A single signal potentiates into multiple.

Finally we have the “lake of cortical reorganization”, or in layman’s terms, brain change. Here you can have tidepools of emotional distress or reefs of prior history or insert another water-based metaphor here. Essentially, upcoming signals are then interpreted within the framework of the brain where it decides if it’s enough to produce a pain response. How this all works is a bit murky, pardon the pun, but we do know that our interpretation of nociceptive signals greatly impacts how the brain choose to deal with them.

Somatic vs. Visceral: Crosstalk

Dr. Farmer also touched on the differences between somatic and visceral pain and the crosstalk that can occur between the two.

When comparing sensations from somatic (aka your body) and visceral structures (aka your organs), there are several differences. Somatic pain has a distinct quality, like a sharp or pinching sensation. It correlates specifically to the intensity, duration and location of the stimulus and is caused by tissue injury and inflammation. One easy example of somatic pain is the ankle pain one might experience following a sprain. Conversely, visceral pain is diffuse in quality and generally is found along the midline of the body. It doesn’t have the same on/off switch and tends to correlate very poorly with its stimulus. Just think how you felt the last time you had food poisoning…yah not fun.

Okay, that seems reasonable, now we have some ways to separate out different types of pain. However, sometimes messages can get muddled when somatic and visceral structures start to talk to one another – called crosstalk. This can happen when sensory fibers of pelvic organs synapse close by where other somatic or visceral structures synapse at the spinal cord. You can see how it can get confusing when a problem in one organ might feel like a problem in a completely separate organ or body part.

One case of this is viscero-somatic pain, when a visceral structure creates body pain. A well-known example of viscero-somatic pain is when during a heart attack someone might report significant left arm pain. In the pelvis however, this would look like a patient complaining of low back pain when the stimulus is actually coming from uterine contractions.

This crosstalk can also go the opposite direction, somato-visceral pain. This could happen with vulvar inflammation. A patient may have multiple yeast infections leading to inflammation of the vulva (somato-), but then also experience bladder pain (visceral). And it doesn’t stop there.

Viscero-visceral pain, yup that happens. Stimulus from one organ can be confused with stimulus from another organ. This can even lead to changes in how the organs function. This type of viscero-visceral pain is one explanation for the high prevalence of irritable bowel syndrome in women with endometriosis.

What does this mean for patients?

So now what? All of this can be quite overwhelming. It’s important for both patient and practitioners to educate themselves regarding the different facets of pain. Great resources including Dr. Farmer’s research and books like Explain Pain or Pelvic Pain Explained can be very helpful in help navigating these uncertain waters. Since knowledge is power, the more we understand the cause, the better we can treat pain together.

Thank you again for the enlightening presentation Dr. Farmer! If you want to check out the whole presentation, which we recommend, look here.

By Melinda Fontaine
Pelvic Health and Rehabilitation Center, Berkeley, CA
www.pelvicpainrehab.com

The autonomic nervous system is made up of the brain, the parasympathetic and sympathetic nervous systems, and the enteric (gut) nervous system. The autonomic nervous system works without us having to think about it, and helps with things like keeping our heart beating and digesting our food. The parasympathetic nervous system is affectionately called the “rest and digest” system because it is active when we are relaxed and helps with digestion. When you add stress to the equation, big changes occur. Stress can be in any form: deadlines, anxiety, drama, attack on your health, lack of sleep, not enough self care, etc. When stress is applied to the system, the peripheral nervous system releases neurotransmitters which dock on the immune cells and increase the inflammatory immune response through the vagus nerve.

Now if all that sounded like scientific mumbo-jumbo, the important piece to remember is “through the vagus nerve”. The vagus nerve is part of the parasympathetic “rest and digest” nervous system and innervates the heart, lungs, and digestive system.

A number of studies have been done on the role of the peripheral nervous system and vagus nerve. Decreased peripheral nervous system/vagus nerve activity has been found in patients with irritable bowel syndrome,¹ functional dyspepsia,² and delayed gastric emptying after meals.³ Could we increase the vagus nerve activity to eliminate these and other symptoms? Possibly! There are three treatments being explored to stimulate the vagus nerve and decrease pain and inflammation.

1. Cognitive Behavioral Therapy increased vagus nerve/parasympathetic activity in patients with irritable bowel syndrome over the course of 24 weeks.⁴
2. Deep Breathing increased vagus nerve/parasympathetic activity and decreased pain in the esophagus in response to acid.⁴
3. Vagus Nerve Stimulation improved movement of food through the digestive system,⁵ reduced abdominal pain,⁶ and decreased inflammation.⁷

Cognitive Behavioral Therapy is a common method of psychotherapy and Deep Breathing has been around for ages, but Vagus Nerve Stimulation is new, and I would like to explain it a little here. For more information about how this idea relates to chronic pelvic pain, see Liz’s post about Dr. Chelimsky’s presentation.

Applying electrical current to the vagus nerve through an implantable or external device amplifies the signals sent through the nerve. The devices work by attaching electrodes to the vagus nerve either at the ear or the neck. Not all these devices are available in the United States, and they currently require a doctor’s prescription. These devices have also been studied for use on headaches, seizures, depression, fibromyalgia and chronic pelvic pain.⁸ These treatment are relatively new and are still being studied, but the research is promising.

Of course this information made me very excited about this new vagus nerve treatment idea.  I want to run right out and get my hands on a stimulator. After some research, I learned that the FDA released the first non-invasive vagus stimulator in 2017, gammaCore. This device applies stimulation at the neck for the acute treatment of pain associated with episodic cluster headache in adult patients. It is available by physician prescription only, and the list price of gammaCore therapy is $575.00 per month.

Thus, for now I will have to use the treatment strategies most available to me. I like to remind patients that pelvic pain is rarely ever caused by one thing, so a multimodal approach that includes physical therapy is necessary. This research shows us how the parasympathetic nervous system needs to be considered in our treatment approach. I teach patients to breathe deeply during our sessions and encourage them to practice on their own. I use Nicole’s blog about diaphragmatic breathing to teach the technique. Sometimes I encourage patients to seek out psychotherapy, such as cognitive behavioral therapy, as a piece of their treatment. One day, I may also be able to recommend vagal nerve stimulation as part of a complete treatment approach.

We thank Professor Qasim Aziz for a fantastic lecture. Please click here to view his entire lecture.

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References:

¹Liu Q, et al. Autonomic functioning in irritable bowel syndrome measured by heart rate variability: A meta-analysis. Journal of Digestive Diseases 2013; 14: 638-646
²Dal K, et al. Decreased parasympathetic activity in patients with functional dyspepsia. European Journal of Gastroenterology & Hepatology 2014, 26:748-752
³Guo WJ, et al. Impaired vagal activity to meal in patients with functional dyspepsia and delayed gastric emptying. J Int Med Res 300060517726442. 2017
⁴Botha C, Farmer A, et al. Preliminary report: modulation of parasympathetic nervous system tone influences oesophageal pain hypersensitivity. GUT 2015, 64:611-7
⁵Frokjaer JB, et al. Modulation of vagal tone enhances gastroduodenal motility and reduces somatic pain sensitivity. Neurogastroenterol Motil 2016; 28, 592-598
⁶Kovacic et al. Neurostimulation for abdominal pain-related functional gastrointestinal disorders in adolescents: a randomised, double-blind, sham-controlled trial. Lancet Gastroenterol Hepatol 2017; 2: 727-737
⁷Beckers AB, et al. Gastrointestinal disorders in joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type: a review for the gastroenterologist. Neurogastroenterol Motil 2017; 29: doi: 10.1111/nmo.13013. Epub 2017 Jan 13
⁸Chakravarthy, et al. Review of vagal nerve stimulation in use of chronic pain management. Current Pain and Headache Reports Journal 2015; 19:54

By Rachel Gelman
Pelvic Health and Rehabilitation Center, San Francisco
www.pelvicpainrehab.com

In addition to some randy rats, we had the pleasure of hearing Dr. Andrew Goldstein’s presentation “When Sex Hurts: A Diagnostic Algorithm.” You may remember Dr. Goldstein from a prior post that discussed the relationship between oral contraceptive pills and vulvodynia.

At #WCAPP17, Dr. Goldstein discussed the vicious cycle of pain with sex. In the image below taken from his presentation one can see how dyspareunia (pain with sex) can lead to anxiety surrounding these symptoms, which can lead to pelvic floor dysfunction that can contribute to further sexual dysfunction and relationship dysfunction which can therefore cause more pain with sex. Due to this common cycle developing, Goldstein recommends some form of therapy for any patient that presents with dyspareunia.

While Dr. Goldstein believes most patients benefit from counseling, he acknowledges that treatment for patients with painful sex should not be one size fits all. He emphasized that determining the driver behind the symptoms helps create an individualized treatment plan. His presentation focused on vulvodynia and vestibulodynia as these two conditions are often the cause of painful sex. Often vestibulodynia is a result of multiple factors and his presentation focused on the following three: hormonal, neuroproliferative and musculoskeletal.

Hormonal

As you may recall from prior posts, the vestibule is rich in androgen and estrogen receptors. Testosterone is actually responsible for producing mucin, a component of lubricant. So if a patient presents with pain with initial penetration during sex, or pain in the vaginal opening with any form of penetration as well as vaginal dryness, it would be important to check if there is a hormonal imbalance. Other than doing lab work to assess hormone levels, specifically looking at Sex-hormone binding globulin (SHBG), free testosterone,¹ your health care provider may perform a Q-tip test, not to check for ear wax, but to assess sensitivity of the vestibule. Dr. Goldstein reports that if there is allodynia of the entire vestibule that is more indicative that the symptoms are coming from a hormonal imbalance or an inflammatory driver.² Whereas, if the posterior region of the vestibule is the only area tender upon palpation the driver is most likely overactive pelvic floor muscles, which will be discussed more in-depth shortly. Certain medications such as oral contraceptives, tamoxifen or spironolactone have been shown to cause hormonal imbalances in patients that could potentially cause dyspareunia and/or vulvodynia. Dr. Goldstein also discussed research that certain diseases and surgical procedures such as breast Cancer and/or oophorectomy could impact hormone levels and again lead to vulvodynia or sexual dysfunction.³ If a hormonal imbalance is the primary driver for a patient’s symptoms, treatment should focus on trying to improve hormone levels which may consist of stopping a certain medication or using a topical estrogen/testosterone. Again, Goldstein stressed the importance of understanding the pathophysiology behind the symptoms before determining a treatment.

Neuroproliferative

Neuro-what? If I was studying for the SATs I would really hope this word would be on the test because it came up a lot during this presentation. Neuroproliferative basically means too many nerves, and you may be surprised to hear that having too many nerves in the vestibule is a bad thing. Not all nerve fibers are created equal and there are several types in the human body. In patients with proliferative vestibulodynia they may present with an increased amount of a certain type of nerve fiber: C-afferent nociceptors.⁴ (For a quick review about nerve fibers or to help you prep for going on Jeopardy this site from my alma mater University of Washington breaks it down). To be brief, c-afferent nociceptors communicate pain. As mentioned earlier, if a patient presents with sensitivity around the entire vestibule this can be a sign that an individual’s condition is neuroproliferative in nature. Goldstein points out that neuroproliferation could be congenital or acquired. If a patient also presents with hypersensitivity in the umbilical region it may indicate that a patient has congenital neuroproliferative vestibulodynia due to the fact that the umbilicus and the vestibule are derived from the same tissue during development.⁵ Patients with congenital neuroproliferative vestibulodynia may have specific subjective reports such as pain with first attempt at intercourse or tampon use. Patients with acquired neuroproliferative vulvodynia may report a history of chronic yeast infections or an onset of symptoms after an allergic reaction.⁶ These patients may also demonstrate elevated levels of immune mediators such as mast cells,⁷ and proinflammatory cytokines such as TNF, IL-1b, IL-6 and IL-8.⁸ The causation of the symptoms and the length of time since symptom onset will determine appropriate treatment which can range from medications such as capsaicin, oral SNRIs, TCAs or topical gabapentin, botox injections or in some cases a vestibulectomy.

Musculoskeletal

Obviously here at The Pelvic Health and Rehabilitation Center, the myofascial cause of sexual dysfunction is what we treat on a daily basis. If you have read prior posts, you may recall that inside the pelvis is a bowl of muscles known as the pelvic floor. If these muscles become restricted or hypertonic it will restrict blood flow to the area. A lack of blood flow means there is a lack of oxygen and a build up of lactic acid which is a perfect storm for: pelvic pain. Dr. Goldstein reports patients with overactive pelvic floor muscles may present with sensitivity at the posterior portion of the vestibule only. Patients with hypertonic pelvic floors will present with tenderness upon palpation of the muscles and may report vaginal fissures in the posterior vestibule post-coitus. An individual may also report a variety of symptoms including: constipation, urinary frequency, urgency and or hesitancy. A provider may check your pelvic floor tone using an EMG, along with an internal examination to assess if hypertonus is present. Pelvic floor physical therapy has been shown to be an effective treatment for patients with musculoskeletal dysfunction as a cause of their symptoms!⁹ Other treatment may include medications such as diazepam, yoga, hypnosis and cognitive behavioral therapy which can help facilitate relaxation of the pelvic floor.

In conclusion, Dr. Goldstein advocates for a multidisciplinary approach when it comes to treating patients with sexual dysfunction. Most patients require more than one provider and require an individualized treatment plan. It is important to choose a treatment plan based on the cause of a patient’s symptoms, and there may be several factors involved in a patient’s presentation. As always, Goldstein stressed the need for more studies looking at women’s sexual health so that clinicians can provide better evidence-based medicine to their patients.

We thank Dr. Andrew Goldstein for a fantastic lecture!

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References:

¹Burrows LJ, Goldstein AT. The Treatment of Vestibulodynia with Topical Estradiol and Testosterone. Sexual Medicine. 2013;1(1):30-33. doi:10.1002/sm2.4.
²Bornstein J, Goldstein AT, Stockdale CK, et al. 2015 ISSVD, ISSWSH, and IPPS consensus terminology and classification of persistent Vulvar pain and Vulvodynia. The Journal of Sexual Medicine. 2016;13(4):607–612. doi:10.1016/j.jsxm.2016.02.167.
³Tucker, P. E., Saunders, C., Bulsara, M. K., Tan, J. J. S., Salfinger, S. G., Green, H., & Cohen, P. A. (2016). Sexuality and quality of life in women with a prior diagnosis of breast cancer after risk-reducing salpingo-oophorectomy. Breast, 30, 26-31.
⁴Bohm-Starke N et al. Neurochemical characterization of the vestibular nerves in women with vulvar vestibulitis syndrome. Gynecol Obstet Invest 1999; 48:270.
⁵Burrows LJ, Klingman D, Pukall CF, et al. : Umbilical hypersensitivity in women with primary vestibulodynia. J Reprod Med. 2008;53(6):413–6
⁶Harlow BL, He W, Nguyen R. Allergic Reactions and Risk of Vulvodynia. Annals of epidemiology. 2009;19(11):771-777. doi:10.1016/j.annepidem.2009.06.006.
⁷Bornstein J, Cohen Y, Zarfati D, Sela S, Ophir E. Involvement of heparanase in the pathogenesis of localized vulvodynia. Int J Gynecol Pathol. 2008;27:136–41.
⁸Foster DC, Piekarz KH, Murant TI, et al. Enhanced synthesis of proinflammatory cytokines by vulvar vestibular fibroblasts: Implications for vulvar vestibulitis. Am J Obstet Gynecol 2007;196;346.e1-346.e8.
⁹Morin M, Carroll M-S, Bergeron S. Systematic Review of the Effectiveness of Physical Therapy Modalities in Women With Provoked Vestibulodynia. Sex Med Rev 2017;5:295–322.