Vestibulodynia is defined as pain at the vestibule, which is the area around the opening of the vagina (introitus). Being diagnosed with vestibulodynia can leave patients feeling frustrated because it doesn’t explain WHY they have pain at the vestibule. There are several types of vestibulodynia including infection, inflammation, neoplastic, neurologic, trauma, and hormonal deficiencies.

The most common type of vestibulodynia is caused by hormonal deficiencies known as Hormonally-Mediated Vestibulodynia. This type is caused by hormonal changes including taking birth control, breast feeding, postpartum, estrogen blockers, and peri or post menopause.

The most common cause of Hormonally-Mediated vestibulodynia in younger women (under the age of 25) is systemic birth control (i.e. oral contraceptive pills (OCPs), depo-shot, NuvaRing). Side effects of birth control (BC) such as breakthrough bleeding, nausea, headaches, increased risk of stroke, and abdominal cramping are more commonly discussed among doctors and patients.

However, what is NOT often discussed with patients prior to starting birth control, especially OCPs, is that systemic BC use causes vestibulodynia, decrease vaginal lubrication, decrease thickness of labia minora, and decreased vaginal introitus size, all leading to dyspareunia (painful sex). These changes can occur as early as 90 days after starting OCPs or with long-term use.

Unfortunately, if the onset of birth control was before the age of 17, there’s even a higher risk of developing hormonally associated vestibulodynia.¹

So, WHY and HOW, does this happen?

Systemic birth control gets processed through the liver which INCREASES a protein called the Sex Hormone Binding Globulin (SHBG). SHBG binds to the free testosterone in the blood, so even if your body is making testosterone, high levels of SHBG (from the BC) DECREASE the testosterone in your body. This inhibits testosterone from getting to the tissue that needs it to be healthy—–the vestibule. The vestibule is rich with androgen receptors! If those receptors aren’t getting the testosterone (and estrogen) they need because of the increased SHBG then the vestibular tissue can become painful (vestibulodynia)!

Most commonly patients will complain about pain at the opening upon entry, dryness, friction, feeling of tearing, and actual tissue tearing resulting in bleeding, or inability to tolerate penetration at all.

Vestibulodynia can also lead to pelvic floor muscle overactivity which contributes to even more pain! Join the Sexual Medicine in Pelvic Rehab class on the weekend of  June 15th-16th to learn how to identify, treat, and differentially diagnose different causes of sexual dysfunctions to get your patients better faster!

Reference:

1. Goldstein, A, Burrows L, and Goldstein I. Can oral contraceptives cause vestibulodynia? J Sex Med 2010; 7: 1585-1587

AUTHOR BIO

Tara Sullivan, PT, PRPC, WCS, IF

Dr. Tara Sullivan, PT, PRPC, WCS, IF started in the healthcare field as a massage therapist practicing for over ten years, including three years of teaching massage and anatomy & physiology. During that time, she attended college at Oregon State University earning her Bachelor of Science degree in Exercise and Sport Science, and she continued to earn her Masters of Science in Human Movement and Doctorate in Physical Therapy from A.T. Still University. Dr. Tara has specialized in Pelvic Floor Dysfunction (PFD) treating bowel, bladder, sexual dysfunctions, and pelvic pain exclusively since 2012. She has earned her Pelvic Rehabilitation Practitioner Certification (PRPC) deeming her an expert in the field of pelvic rehabilitation, treating men, women, and children. Dr. Sullivan is also a board-certified clinical specialist in women’s health (WCS) through the APTA and a Fellow of the International Society for the Study of Women's Sexual Health (IF).

Dr. Tara established the pelvic health program at HonorHealth in Scottsdale and expanded the practice to 12 locations across the valley. She continues treating patients with her hands-on individualized approach, taking the time to listen and educate them, empowering them to return to a healthy and improved quality of life. Dr. Tara has developed and taught several pelvic health courses and lectures at local universities in Arizona including Northern Arizona University, Franklin Pierce University, and Midwestern University. In 2019, she joined the faculty team at Herman and Wallace teaching continuing education courses for rehab therapists and other health care providers interested in the pelvic health specialty, including a course she authored-Sexual Medicine in Pelvic Rehab, and co-author of Pain Science for the Chronic Pelvic Pain Population. Dr. Tara is very passionate about creating awareness of Pelvic Floor Dysfunction and launched her website pelvicfloorspecialist.com to continue educating the public and other healthcare professionals.

In March 2024, Dr. Tara left HonorHealth and founded her company Mind to Body Healing (M2B) to continue spreading awareness on pelvic health, mentor other healthcare providers, and incorporate sexual counseling into her pelvic floor physical therapy practice. She has partnered with Co-Owner, Dr. Kylee Austin, PT.

In an excerpt from a conversation with The Pelvic Rehab Report, Tara Sullivan discusses her course, Sexual Medicine in Pelvic Rehab. She imparts, "As rehab professionals, we are in a unique position to bridge the gap between disciplines with our extensive time for exams and differential diagnoses. Many causes of dyspareunia, vestibulodynia, and IC-type symptoms can be diagnosed by careful observation and testing of the vestibule. This is often the missing link in resolving the patient's symptoms of burning, itching, urgency, and pain."

Sexual Medicine in Pelvic Rehab covers lecture topics that are often taboo in Western cultures, such as hymen myths, female squirting, G-spot, sexual response cycles, hormone influence on sexual function, anatomy and physiology of pelvic floor muscles in sexual arousal, and orgasm. She also discusses vaginismus, dyspareunia, erectile dysfunction, hard flaccid, prostatitis, and post-prostatectomy issues.

So what is Vestibulodynia? Vestibulodynia is a localized form of vulvodynia. The Baylor College of Medicine defines vestibulodynia as "chronic pain or discomfort that occurs in the area around the opening of the vagina, inside the inner lips of the vulva. This area is known as the vestibule."

Tara Sullivan shares, "The vestibule is considered the forgotten organ. Most disciplines completely bypass it in their exams." So how is vestibulodynia treated, especially if there are no visible symptoms? The patient should discuss their symptoms with their primary practitioner to rule out medical issues such as yeast infection or cancer. Pelvic specialists can perform a physical pelvic exam, with patient consent, to examine the vestibule, vulva, and vagina. A cotton swab touch test can also be used to pinpoint areas of sensitivity.

The treatment strategies for vestibulodynia focus on relieving the pain and discomfort of the patient. These strategies include lifestyle changes (looser clothing, changing personal routines), including the use of lubrication or local anesthetic creams for intercourse, and therapy or sexual counseling. Vestibulodynia patients can be referred to a pelvic rehab therapist to learn how to relax the affected muscles and control painful spasms. This therapy can include the use of diaphragmatic breathing, biofeedback, pelvic wands, or pelvic dilators.

Vestibulodynia is only one of the topics that Tara Sullivan discusses in her course, Sexual Medicine in Pelvic Rehab. Participants will learn how to confidently treat sexual dysfunction related to the pelvic floor, refer to medical providers as needed, and instruct patients in the proper application of self-treatment and diet/lifestyle modifications. 100% of participants surveyed in the last class answered YES to "Do you feel this course instructed immediately-applicable knowledge and skills that could be used in the clinic with patients?"

Sexual Medicine in Pelvic Rehab is scheduled for 2022 on January 8-9, April 9-10, July 16-17, and October 15-16.

I recently assisted at a Pelvic Floor Level 2B course which has been updated with recent research, new sections, and less repetition from Pelvic Floor Level 1. In the course they mentioned this article which sparked a lively discussion and I had to learn more. It is rare to see a study with a large number of participants in pelvic health and especially with a vaginismus diagnosis.

Vaginismus is defined as a genito-pelvic pain/penetration disorder along with dyspareunia under the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders; Fifth Edition) in which penetration is often impossible due to pain and fear. Vaginismus is both a physical and psychological disorder as it exhibits both muscle spasms and fear/anxiety of penetration. Symptoms vary by severity. Common presentation is an inability or discomfort to insert/remove a tampon, pain with penetration, and complaints of “hitting a wall” in attempted penetration; and inability to participate in gynecological exams.

The authors of this study evaluated the severity of vaginismus. The penetrative history was used in addition to presentation at pelvic exam, and then given a level. There are 2 grading systems, Lamont and Pacik, that indicate the level of fear and anxiety about being touched. They found that those with severe vaginismus were Lamont levels 3 and 4, and Pacik level 5. For example, a Pacik Level 5 includes Lamont grade 4 “generalized retreat: buttocks lift up; thighs close, patient retreats” plus a visceral reaction such as “palpitations, hyperventilation, sweating, severe trembling, uncontrollable shaking, screaming, hysteria, wanting to jump off the table, a feeling of going unconscious, nausea, vomiting and even a desire to attack the doctor”.

241 patients participated in this study, with a mean duration of 7.8 years. 70% of participants were a Lamont level 4 or Pacik level 5 at baseline. The authors looked at previous treatments tried and coping strategies; 74% had tried lube, 73% had tried dilators, 50% had tried Kegels, 28% had tried physical therapy, 3% had tried a surgical vestibulectomy. The full table 2 is in the article. Most participants had a mean of at least 4 failed treatments.

The aim was to help these women to achieve pain free intercourse after treatment. In order to tolerate the treatment, many were sedated with midazolam before the Q-tip test, and more sedation given as needed. The treatment lasted for about 30 minutes and consisted of:

• Q-tip test with as minimal sedation as possible to rule out vulvodynia and provoked vestibulodynia
• Digital exam of tolerance in order to assess the level of spasm in introitus. Graded 0 (no spasm) to 4 (severe spasm where digital insertion was difficult)
• Botox 50 U injections to right and left submucosal space near the bulbospongiosus muscle administered with a pediatric speculum placed. Additional Botox was injected submucosally into levator ani muscles if also in spasm/tight
• Injections 0.25% bupivacaine (a numbing agent) 1 mL increments along right and left lateral vaginal walls (9 mL per side) from cervix to introitus
• Progressive dilation; circumference 3 inches (#4), 4 inches (#5), 5 inches (#6)
• Reassessed with digital examination
• Re-insert #5 or #6 dilator and patient was awakened and taken to recovery

If the patient consented, her partner could be present during the procedure and was allowed to palpate the level of spasm with gloved digit and was educated on dilator insertion. The authors noted that many partners had a ‘profound’ experience.

A nurse worked with the couple for about two hours in the recovery room to help them be more comfortable moving the dilator in and out with minimal-to-no pain as the numbing agent lasts 6-8 hours. Three participants were treated each time and consented to meet each other. Patients were discharged with #4 dilator in place and asked to keep in until the next day. They were given Ibuprofen and sleeping aids as needed.

Day 1
Participants return with partners and progress up to larger sizes (#5 and #6). They participate in group counseling with the primary researcher Dr. Pacik. This lasted about 5 hours; and consisted of education of dilator progression, returning to intercourse and lubricants. If participants wished to have private counseling instead that was granted. Many exchanged contact information. They were encouraged to continue seeing their healthcare clinicians as indicated; sex therapists, physical therapists, psychologists.

Dilator Progression

Month 1
- 2 hours of dilator per day. Either in 1 sitting or 1 hour of dilator work x2 per day
- Progress to bigger sizes until #5 or #6 is comfortable

Month 2
- 1 hour of dilator use per day and continue toward larger sizes

Month 3
- 15-30 minutes of dilator use per day

Months 4-12
- 10-15 minutes of dilator use per day or every other day

During the counseling session post-procedure, the recommendations for returning to intercourse included:

• Delaying intercourse until #5 dilator was able to be easily inserted
• It is helpful to do 1 hour of dilator work before attempting intercourse for the first time
• If partner’s penis is larger progress to larger dilators (#7 - 6 inch circumference or #8 7 inch circumference)
• Goal of the first few attempts is to insert tip of dilator only
• Once tip can be inserted easily then progress to full penetration; restrain from thrusting
• Try “spooning position” if ‘leg lock’ occurs
• Try different positions with dilator work and intercourse to see what works best

71% of participants achieved pain-free coitus 5 weeks after the procedure. 2.5% could not achieve coitus within one-year period although they could use #5 or #6 dilators. The participants were given a validated outcome tool, the Female Sexual Function Index (FSFI), before and after the procedure and at 1-month, 3-months, 6-months, and 1-year; with significant improvement at each interval. The patients were followed for one year, and often remained in contact with the authors for much longer ranging from 16-months to 9-years.

The authors propose that use of dilators at the time of botox and post procedure counseling and support help participants ‘break through’, whereas previous treatment may not be as multidimensional and limit efficacy. Botox lasts 2-4 months and allowed for dilation progression.

Initially after reading this article the treatment seemed a little drastic to me, but then I considered the women with this level of vaginismus are often not coming into my clinic. They may need this level of structure, consistently, and multidimensional treatment as half measures have failed them. I am so glad they were persistent and found the help they needed.

Pacik, P., Geletta, S. Vaginismus Treatment: Clinical Trials Follow Up 241 Patients. Sex Med 2017;5:e114-e123

Pelvic pain is a common diagnosis that we see as pelvic floor therapists. Pelvic pain is pain located in the lower abdomen, but above pubic symphysis, and is associated with various causes; myofascial pain, neuropathies, endometriosis, painful bladder, and irritable bowel syndromes. A common symptom of pelvic pain is deep dyspareunia or pain with deep vaginal penetration. Vulvar pain is different, as it is below pubic symphysis, and has several sub-classifications. These sub-classifications can often be confusing. The National Vulvodynia Association has a free online education that explains the different sub-types very succinctly. This article focuses on provoked vestibulodynia, which is the most commonly studied.

PVD or Provoked Vestibulodynia often has superficial dyspareunia which can negatively affect sexual functioning, which can lead to changes in psychological function and quality of life. Women with PVD often complain of greater pain during and after intercourse, pain catastrophization, and allodynia when compared to women with superficial dyspareunia but without PVD. These symptoms indicate central nervous system upregulation or sensitivity. This study sought to investigate the impact of these symptoms.

Pelvic pain encompassed a variety of complaints: “dysmenorrhea, deep dyspareunia, dyschezia, chronic pelvic pain, back pain, or diagnosed or suspected endometriosis”. Participants were excluded if postmenopausal or if self reported never sexually active.

One hundred twenty nine participants were divided into those with pelvic pain and PVD (43), and those with pelvic pain alone (87). For this study PVD was diagnosed as superficial dyspareunia (>4/10) and positive Q-tip test with a fixed pressure of 30g. Those with did not meet this criteria were considered to have pelvic pain alone.

The two groups were compared for superficial and deep sexual discomfort severity, sexual quality of life; fear avoidance, feelings of guilt, frustration, etc, physical examination of trigger points along abdominal wall (positive Carnett test), and numeric pain scale of various painful lumbo-pelvic regions.

Of the 129 participants notable findings in both the two groups include 31% had confirmed endometriosis, 40% suspected of endometriosis, and in the remaining 18% had no confirmed or suspected endometriosis. The authors found that the pelvic pain + PVD group had significantly more superficial dyspareunia (p=<.001) and deep dyspareunia (p=.001) which was rated >7/10 for both. This group was also had greater (3x more likely to have) depression symptoms, greater anxiety, and catastrophizing, and was more likely to have painful bladder syndrome than the pelvic pain alone group. There were no differences between the two groups for irritable bowel syndrome or abdominal wall tenderness.

This research is consistent with other research findings. The authors explore various causes of the findings including; cross- sensitization - where there may be cross talk of nerve signals from viscera to viscera and viscera to muscular structures that converge in the spinal cord. The authors note that the poor relationship between PVD and irritable bowel and PVD and abdominal wall tenderness limit that theory. They explore the psychological symptoms may be a consequence of pelvic pain or it may be that having anxiety/depression may make women more sensitive to developing pelvic pain and PVD. This sounds like a little chicken or egg theory. The authors suggest that those with PVD and pelvic pain may benefit from a more intensive multi-disciplinary approach including; “medical, surgical, psychological, or physical therapy approaches”.

Bao, C., Noga, H, Allaire, C. et al. “Provoked Vestibulodynia in Women with Pelvic Pain” Sex Med 2019; 1-8