So you have a diagnosis. What now? Reading through all of the treatment options for pelvic pain issues can be very overwhelming. Where do you start? Well, in order to know which direction to move in you must first know what initially caused the pain, which is at times easier said than done, but I'm here to help guide you through that trajectory.
For some of us, we have a fear of penetration, which can stem from trauma, a lack of feeling like we’re in control, or even just a fear of the unknown. People are blown away when I explain how deep my penetration issues go. I don’t have any piercings, can’t dive into a pool, and couldn’t even use the tool to clear food out of the holes in my gums from my wisdom teeth removal. So although there are definite physical causes which led to my Vulvodynia and Vaginismus, there is an undeniable mental aspect as well. If you can’t come up with any accident, injury, or other physical condition which would cause issues in your pelvis then seeking out a therapist is a good place to begin your healing journey.
Vaginismus stems from a mind body connection where the brain’s anticipation of pain sends the message to the PC muscle to close that shit down. Basically, it’s your body’s fight or flight response choosing flight by creating a barrier (the “wall” people describe hitting) to prevent your body from being harmed. This is why the pattern is so hard to break. It’s your body’s natural response to protect you, which in many cases would be considered a good thing, but in this instance it’s rather inconvenient. Below is my favorite representation of Vaginismus in action. The lightning bolts get me every time (and the fact that it appears more painful for the man than the woman, which is not the case).
Behavioral therapists are another type of counselor which focus on helping you change your behavior by reframing your thought processes. This may be recommended for you if you struggle with severe sensitivity to pain or have control issues that prevent you from allowing a partner to insert anything. My gyno had asked that I seek out this type of therapist, but I didn't simply because I actually found it easier to trust my partner to insert something than to do it myself. That often sounds odd to others, but my first tampon and dilator were put in by my ex, not me, because I was absolutely terrified to do it myself. Allowing him to take the control and seeing it turn out alright actually gave me the confidence to try it on my own in the future.
On the physical end, many other conditions can lead to some form of Vulvodynia and/or Vaginismus, including Pudendal Neuralgia, Endometriosis, Adenomyosis, Interstitial Cystitis, Vaginitis, Lichen Planus or Sclerosis, or a hormone imbalance. These conditions often travel in pairs and sometimes you could even have 3 or more, but don’t jump to that conclusion, just start with what you know. If you experience pain in your vulva it’s important to ask yourself these questions:
- When did it start?
- Does it hurt more in certain parts of the vestibule, like the perineum?
- Is it provoked from touch or does it hurt all the time?
- Are there certain triggers which make it worse, like foods, clothing, or environmental factors?
- Is it worse at a specific time of the month, like when your estrogen level peaks?
- Is it worse at a specific time of day, like after a BM or right before bed?
- Are there any noticeable changes in the skin, like patches or ulcers?
These are examples of questions that a doctor will probably ask you in a survey about your pain. They will also probably ask you to rank the level of pain or describe it as either “stabbing”, “burning”, “radiating” or “dull” (I personally struggle with this one). It can be difficult to think so precisely about your pain, which is keeping a journal can be quite helpful. I am currently using an app called “My Symptoms” to track everything I consume, my exercise, BM’s, you name it, and any reactions that I have. Then I can share it with my doctor so they can analyze the graph and see any correlations. I prefer pen and paper because I’m old school, but if you’re a digital type then this app could be very handy for you.
If you haven't picked up a copy of When Sex Hurts yet, get on that, because this book will change your life. I think this chart is extremely helpful in identifying what manifested your pain and then reading the chapter you can find out what action to take to treat it accordingly. For example, I chose to get a Vestibulectomy because I had Congenital Neuroproliferative Vestibulodynia, which had always been there and I can't STAND someone trying to touch my belly button. I had tried all of the other options first, but since this particular type of Vestibulodynia stems from an overgrowth of nerves from the way the vulva forms out of the umbilical cord during birth, there is no treatment to improve the nerves. The skin must be cut out and replaced with fresh, new skin with a normal amount of nerves. However, if you only suffer from Vaginismus, also known as Hypertonic Pelvic Floor Muscle Dysfunction or Levator Ani Syndrome, physical therapy and dilators may be all you need. If your pain comes from Menopause or taking birth control pills, a hormonal cream or gel may be your best bet. Doctors often recommend a combination gel with estradiol and testosterone made at a compounding pharmacy, because first off, it's important to keep these hormones in balance with each other, and secondly, even after estrogen levels return to normal from stopping contraceptives, the calculated free testosterone often stays low for even years of time.
All in all, the journey to achieving a pain free sex life can be a long one, when there are often multiple factors playing into your pain cycle, and the trek is usually one step forward two steps back, but don't give up. Any steps forward are better than none, and when you start making progress it's easy to ask yourself "why didn't I begin trying to tackle this sooner?" because it's easy to hide it away and pretend it isn't there. But it is there and always will be if you let it. There are just too many adventures waiting for you on the other side of chronic pelvic pain so find your root cause and start treating accordingly. :)