Episode 60 - Laura Brodzinsky, MD: Treating Vulvodynia and Women’s Genital Pain

Transcript

Chip August: Welcome to Sex, Love, and Intimacy.  I am your host, Chip August and today on the show we are going to be talking about certain kinds of female genital pain, that are commonly called, or medically called vulvodynia. My guest is Dr Laura Brodzinsky.  Dr Brodzinsky was born and raised in the Boston area and did her undergraduate work at Brandeis and then went to med school at the Eastern Virginia Medical School, she did a residency in OBGYN at Kaiser San Francisco and she is the clinical professor of OBGYN at Stanford.  She has been running the Vulvodynia clinic at Stanford since 2002.

Laura Brodzinsky: Vulvodynia is pain in the vulvar area even without intercourse.  So some women with vulvodynia have pain at rest, while others have pain during sex.  Very simplistically, there is 3 main causes for the pain.  One is a skin problem, like dermatitis, [unintelligible] sclerosis, even pre-cancerous conditions.  The other cause can be musculoskeletal pain, in a similar way to staining a muscle anywhere else in your body, and the third cause of pain is nerve pain, so neuropathic pain, as it is also known which can be caused from a variety of different reasons.  If you have ever had a chronic vulvar or vaginal infection that was intensely painful for even a short period of time, that can lead to persistent and recurrent symptoms even after the infection is cleared up.  Trauma, trauma from surgery, from childbirth, from injury to the pelvis or lower back, falls that involve the tailbone for example, can put people at risk for this.  There is a condition called pelvic guarding, which is sort of akin to tightening your neck and shoulder muscles, but happens in the pelvis, people who sort of tighten them up chronically can put themselves at risk for pelvic floor muscle dysfunction and can end up with pain.  Well, pelvic floor guarding or guarding in general is similar to the feeling you might feel in you body if something were to startle you.  It is usually involuntary, it’s not really in your head, sometimes stress and fear of intercourse or other issues with intimacy and intercourse, or touching of the female genitalia can put you at risk for having pain with intercourse later.

Chip August: Welcome to the show, Dr Brodzinsky.

Laura Brodzinsky: Thank you very much.

Chip August: So, as a man, obviously I don’t have a vulva and I don’t have a vagina.  But I have been hearing about women who complain about pain during intercourse and so, since I have been sexually active.  So, I’m kind of curious, can you tell me like, what exactly is vulvadynia? What is the thing that you specialize in?  What is it we are talking about?

Laura Brodzinsky: So, vulvodynia is pain in the vulvar area, very briefly.  Importantly, it can be pain even without intercourse.  So some women who suffer from vulvodynia have pain at rest while others just have pain during sex.  Vulvodynia has many different causes, as you might imagine.  It is important to identify what the cause is before seeking treatment.  Just briefly, very simplistically, there is three main causes for the pain.  One is a skin problem.  Many people have skin conditions such as dermatitis, ___ sclerosis, even pre-cancerous conditions can sometimes cause pain in the vulvar area.  The other cause can be musculoskeletal pain, so in a similar way to straining a muscle anywhere else in your body, the pelvic floor muscles can be abnormally tightened and can cause pain on contact or pain all the time.  And the third cause of pain is basically a nerve pain, neuropathic pain as it is also known and can be for a variety of different reasons.

Chip August:  I know that women, many women experience menstrual pain.  Is it similar to menstrual cramps?

Laura Brodzinsky: Well, the difference is in the location.  So, menstrual cramps tend to be in the lower abdomen or pelvis.  So, in the uterine area as you would.  Vulvodynia pain is essentially pain that is mostly confined to the outside.  So the vulva, the entrance to the vagina.

Chip August: So, at the entrance to the vagina a woman is feeling, now, it’s  not discomfort, it’s real pain, right? I don’t even know where the line is between discomfort and pain.

Laura Brodzinsky: Yeah, that’s a hard one to say.  Women that have this condition, they will describe symptoms that range from burning to knife-like stabbing pain, to tingling, to achy pain.  So, the symptoms can vary in terms of intensity as well as different types of descriptions of pain.

Chip August: And do the symptoms vary with where a woman is in the menstrual cycle, for instance? Are they related to the menstrual cycle at all?

Laura Brodzinsky: Some women’s symptoms can be more ramped up, or more intense at different times during the menstrual cycle.  That’s not true for everybody.

Chip August: And, are do prepubescent girls experience this?

Laura Brodzinsky: Prepubescent girls do complain of vulvar and vaginal pain sometimes.  If you are talking about very young children, they most likely wouldn’t be sexually active, so they would not complain of symptoms in the same way as an adult.  But children do sometimes have reasons for vaginal pain as well as adults.

Chip August:  So, basically most women find this through some form of sexual activity.  Either pleasuring themselves or with a partner, they suddenly are touching some part of their body that shouldn’t hurt and suddenly it hurts.  Is that kind of how woman find out about this?

Laura Brodzinsky: Yes, that is generally the way it presents.

Chip August: And then, okay, so  I assume the first presentation of pain probably the person thinks they are just doing something wrong and it takes awhile to figure out that they actually have an ongoing problem.

Laura Brodzinsky: Right, the important thing about vulvodynia is that is it chronic.  So, we are not talking about one episode of pain with intercourse that comes and then doesn’t show up again.  This is a chronic recurrent pain, either with touch, with intercourse, or persistent pain that is there on its own.

Chip August:  Is there like a typical age? If you are going to have this is there a typical onset age?

Laura Brodzinsky:  It‘s really variable, I see, you know, women as young as 18, 19 complaining of pain since their first sexual activity.  I also see menopausal women present with new onset of pain.  So the age range is quite variable.

Chip August: The women who come to you later, it’s not just that they have endured for a long time? It’s just a later onset of this thing?

Laura Brodzinsky: It depends, it could be a later onset or they could have suffered for years before they come to see a specialist.

Chip August: Okay, so I think I might have this, well obviously not me, but I’m a woman listening to this and I think I might have this.  I mean, if you were going to say to me, here’s a list of symptoms, is this true? Is this true? It this true?  Oh, yeah it sounds like you might have this.  What would you look for?

Laura Brodzinsky: What would you?

Chip August: What would those symptoms be? Just that I have pain? Is that it?

Laura Brodzinsky: Yeah, I mean basically if you have persistent or recurrent pain, either with intercourse, with touch, with tampon use, or pain sitting, walking, pain that wakes  you up at night.  Then you would consider getting an evaluation.  Have someone do an exam and assessment.

Chip August: Ok, so now, when you are doing this exam, this assessment.  What are you looking for?  What is it you are examining for? Are you looking for skin conditions? Are you looking for? I mean, what are you looking for?

Laura Brodzinsky: We are looking for changes in the skin, because I’d say about 10% of women who come into my clinic complaining of this do have some sort of underlying skin condition that is painful.  We’ re also looking for abnormal tightening in the pelvic floor muscles, which accounts about 90% of the causes for pain in the pelvic area in the patient population that I see.  We also do a neurological assessment of the skin in the vulvar area as well, to assess neuropathic pain.

Chip August: So, is this a disease that somebody can catch.  How does somebody  develop this?

Laura Brodzinsky:  Well, there’s many, many different ways to end up with chronic vulvar or vaginal pain.  There’s so many different ways it’s probably impossible to list them here.  But, certainly if you have ever had a vulvar or vaginal infection that was intensely painful, for even a short period of time that recurrent symptoms even after the infection is cleared up.  Trauma can cause this, trauma from surgery, from childbirth, from injury to the pelvis or lower back, falls that involve the tailbone, for example, can put people at risk for this.  There is a condition called pelvic guarding, which is sort of akin to tightening your neck and shoulder muscles, but happens in the pelvis, and people who sort of guard their pelvic muscles chronically, or tighten them up chronically can put themselves at risk for pelvic floor muscle dysfunction and end up with pain.

Chip August: Okay, so now I am a person that has this pain.  Clearly depending on  which of the 3 types of pain it is, will kind of tell me the different types of treatment here.  But, what I notice you are not saying for awhile years and years, and years ago, I was working in corporate America and I developed like really severe stomach trouble and a little irritable bowel syndrome and what my doctors kept trying to say to me really gently was, there is no like cause of this, like you ate the wrong thing or you were subject to some germ.  This is in your head, you are just stressed out about your job and your body is reacting to your stress. But I notice you are not saying that about vulvodynia.

Laura Brodzinsky: Yeah, that’s very true.  For a long time the medical establishment told women that is was in their heads.  That started to change about the 1970s, 1980s they began to think of this as a physical disease, not just a psychological condition.  And that’s a really important point to get across to women who suffer from this, that it’s not in your head, there is a definite physical cause and it’s our job to figure out what that is.

Chip August: I notice, well before I ask you this next question, let’s take a break.  This is really good stuff, but I’m sure everybody needs to breathe for a moment here and take a break.  We’re going to pause.  We’ll listen to our sponsors.  And listeners I just want to remind you that there are all kinds of good deals that you can get, sponsors so you might want to check out the episode page of Sex, Love, and Intimacy at personallifemedia.com, www.personallifemedia.com.  No spaces, all one word and where you are asked for a promotion code you could try the word love, l-o-v-e, that will certainly work on the audible site, ice.com jewelry.  If you are looking at the Tantra Chair, that is one of my new sponsors, there the promotion code is free, f-r-e-e.  But my point is there is a lot of really good stuff, you might want to check the episode pages, and please do listen to these messages from our sponsor. We’ll be right back.

Chip August:  We’re back, you are listening to Sex, Love, and Intimacy, I am your host, Chip August.  I am talking to Dr Laura Brodzinsky.  Dr Brodzinsky is an expert on the subject of vulvodynia and has been running the vulvodynia clinic at Stanford University, Stanford Hospital since 2002.  And when we went to a break, we were talking about the different types. This isn’t just in a woman’s head, it isn’t just a nervousness thing.  One of the things you said, what triggered me asking that question, I want to pursue this a little longer, you said, guarding, I think you called it. That sounded to me like, oh, you are just too tense, you need to relax.  So can you say more about what that really is?

Laura Brodzinsky: Well, pelvic floor guarding, or guarding in general is a tensing up of the muscles, similar to the tension that you might feel in your body if something were to startle you.  This is sort of a tightening of the pelvic floor guarding is the tightening of the pelvic floor muscles, that is usually involuntary.  There have been some studies of vulvodynia in young women that have been abused, either neglected or physically abused as children.  And there is a higher percentage of vulvodynia to come from that background.  One of the theories is that they live in the state of constant tension as children and guard the pelvic floor muscles, which over time puts them at risk for pelvic floor tension myalgia, or pelvic floor spasm or tightness, also known as vaginismus, which is  condition that develops gradually over time and then causes pain with intercourse.  So, while it’s not really in your head, sometimes stress orfear of intercourse or other psychological issues with intimacy or intercourse or touching of the female genitalia can put you at risk for having pain with intercourse later.

Chip August: And is the treatment more in the realm of physical therapy for something like that? Learning how to just relax those muscles?

Laura Brodzinsky: Right so, what you alluded to before, depending on what we think the cause is of vaginal pain there is different treatment.  So that if you have a skin condition then treatment is geared towards treating the skin condition, whatever that might be.  If there is a pelvic floor dysfunction then physical therapy might be one of the treatments used to address that.

Chip August:  But, I notice and I want to say this again because I know some people listen really selectively and they listen to hear what they want to hear.  I heard in what you  were saying that this is a involuntary tightening or spasming that is caused by a lifelong pattern that the person is not really aware of.  It’s almost as if the body has a habit of doing this in a way that’s not just going to stop by having someone else say, oh just relax.

Laura Brodzinsky: Right, that’s correct.  I mean it’s similar to the tension some people carry in their neck and shoulders that causes chronic migraines, or neck pain, or TMJ for those people that clench their teeth at night.  That sort of similar analogy can be extended to the vulvar area.  The other important thing is that that is not the only cause of pelvic muscle floor dysfunction.  So, people who have pelvic floor injuries, or from trauma, or from surgery, or from a wide variety of causes other than pelvic floor guarding certainly can develop pelvic floor muscle tension as well.

Chip August: And here in the United States about what percentage of women develop this? Develop vulvodynia is some form or another?

Laura Brodzinsky: It is estimated that 15% of women in the average gynecologic practice will have had or will develop this condition at some point in their lives.

Chip August: 15%?

Laura Brodzinsky: That’s correct.

Chip August: That’s a lot of women, that’s a lot of women.  So this is a relatively common phenomenon that women experience?

Laura Brodzinsky: Yeah, it’s much more common than one would think.  Mostly because people don’t tend to talk about it too much.

Chip August: And once you have it, I think I am hearing you say that is not a life sentence.  It doesn’t automatically imply that you will always have pain in your genitals.

Laura Brodzinsky: Yup, that’s correct.  There’s definitely people that get better completely.  There are some people that get better slowly, there are some people that get better very quickly.  But, in general most people will get better.

Chip August:  I guess because I’m not a woman I want to know like, so how do I be a supportive partner if my partner suddenly starts telling me that things hurt.

Laura Brodzinsky: Believe her, don’t just assume it’s in her head and help her do some research and find a medical professional that will help her.

Chip August: Okay, so, could happen at any age. It happens to what did you say, 15 out of 10 women, so it’s not rare.

Laura Brodzinsky: 15% of women that present to a gynecologic practice, so that’s not 15% of the female population.  So, somewhere between 2 and 4 million women annually, so that’s not 10% of the population, but it’s still a sizeable.

Chip August: Yeah, 2 to 4 million women, that’s not to be ignored.  Are there…there’s all sorts of associations working to raise money  for breast cancer, there’s associations working to raise money for leukemia.  Are there people working for a cure for this?

Laura Brodzinsky: Absolutely, the National Vulva Association is actively supporting research and fundraising.  The International Society for Pelvic Pain is also supportive and interested in research.

Chip August: And are there many doctors that specialize in this? Is it pretty easy to find somebody who knows about this?

Laura Brodzinsky:  It depends on where you are.  If you are in a major metropolitan area you will have better success than you will if you are not.  But if you look on the websites which I’m sure you’ll give later on in the program or maybe put on your website they have directory listings of professionals that will see women with this condition.

Chip August: Okay, so those of you listening, we will actually put those links on the episode page.  But also, I’m going to…get a pencil, get a pencil and a piece of paper because we will ask Laura to just mention some of those and I’m vamping right now so you have enough time to get something to write something down with.  So, Laura, if you were going to direct someone to look for some of these site where would you send them?

Laura Brodzinsky: So, the National Vulva Association has a website it’s nva.org.  There is also pelvic pain.org, which is the International Pelvic Pain Society website.  Those would be the two places I’d start.

Chip August:  And I assume from those you’ll start following the paper chase about what’s actually happening for you and the possible treatments  and where and who to see, yeah?

Laura Brodzinsky: Yeah, that’s correct.

Chip August: Now, so I’m aware that the problem has been around a long time and medicine changes over time.  Are there like traditional approaches to dealing with this? Are there alternative medicine approaches to dealing this that you have heard of that work?

Laura Brodzinsky: There are theories that low-sugar diets, low in oxylate containing foods can help.  Over time the more recent studies don’t really support these types of treatment, but since there are so many different causes for vulvodynia, it is possible that for some women these changes might work.

Chip August: Oxylate, is that what you said? What are oxylate foods? I don’t even know what the word is, what does the word mean?

Laura Brodzinsky: It’s a chemical compound found in certain foods, like beets, for example.

Chip August: Okay, well, I’ll have to google that word, oxylate and figure out which foods.  It seems like the best thing to do is to talk to a doctor.  It seems like the best thing we can do right now is take a short break.  So, we’re going to pause, we’re going to take a break, we’ll be right back.  You’re listening to Sex, Love, and Intimacy.  We’re talking about vulvodynia and vulva pain.  I want to just remind you that if you have comments or you want to suggest guests or show topics you can send email to me at [email protected], or we do have a voicemail line, 206-350-5333.  If you leave a message please mention your name, the name of the show, Sex, Love, and Intimacy and your question or your comment and just know that when you leave something on the phone line you are also indicating your permission for us to use it for promotions if we would like to. We’ll be right back.

Chip August: Welcome back, you are listening to Sex, Love, and Intimacy.  We’ve been talking about vulvodynia, we’ve been talking about vulvar pain.  We’ve been talking with Dr Laura Brodzinsky learning a whole lot.  I want to say that as I listen to all of this I notice that in our culture we have so much shame about talking about our bodies and so much shame about being sexual beings and I think some of us if we feel pain during sexuality we think it’s the wrath of God or we think it’s just because we are being sinful or we are doing something bad and it hurts my heart a little bit when I do shows like this, when I think about all of the people that don’t speak up because they are embarrassed, they are ashamed, because they don’t have language, because they don’t know, because they think maybe this is just the way it is for everybody.  I don’t know why, they just don’t speak up and I think of all the men and women who have shamed people, telling them they don’t feel what they really feel.  So maybe you do speak up and you tell your mother, or your father, or a friend, or your lover or your partner and they tell you it’s all in your head, you just need to relax, you need a couple glasses or wine, we need a different lubricant, we just need to try a different position.  And you have this experience with this chronic pain that’s there, it’s always there and yet it’s really hard to get anybody to take it seriously or listen to you.  So I just want to say, if you are listening to this show, if you are listening to any of my shows, I am a really, really, really strong advocate for open, fearless, shameless communication.  And it’s my experience that it takes practice, it really takes practice.  We think well, alright, when we get to the doctor, I’ll be able to talk to the doctor.  But, my experience has been, if we don’t practice talking then we don’t get good at talking.  If we don’t find language to talk about our bodies then we don’t know how to talk about our bodies and if we don’t have an expectation that somehow pleasure is sinful or bad, then I notice we withstand pain we don’t need to withstand and I don’t know.  You know, my partner, Kat and I , we have our family motto is on the top it says, pleasure is healing and on the bottom it says no pain, no pain.  And I’m really an advocate, I mean I understand that there are some kinds of pain which help us grow and help us deepen our compassion.  But, I don’t think being physically hurt, feeling physical discomfort every time we are doing something that other people talk about as pleasurable.  I don’t think that’s the kind of pain that deepens our soul, or makes us wiser, or makes us more compassionate.   I think that’s the kind of pain that we want to go talk to a professional and find an answer to.  So, now with that in mind I have to say, Dr Brodzinsky is not the kind of doctor that has like exercises for couples to do for communication and intimacy, but I am.  I’m not a doctor, but I am that kind of person.  And so, as you listen to this show today, I really want to encourage you to, this is a great thing to practice is to talk about your body and what you feel in your body, to talk about your genitals and to talk about what you feel in your genitals.  If you have a lover or a partner, I want to suggest that maybe after you listen to this show you sit with your lover or your partner and try to describe to them in detail what it feels like inside your body when they touch you in different places or when you feel them enter you if they enter you or when you enter your partner.  To actually talk in, not particularly prurient, not to say something that’s dirty.  But try to actually describe, what does it feel like on the entrance to your vagina, what does it feel like, can you feel something inside the vaginal walls. What does it feel like outside, on your vulva, what does it.  Men, what does it feel like on your penis, what feels good, what feels bad?  What sensations are you having and just notice, you’re going to giggle and laugh and notice that you don’t have much of a vocabulary.  And that’s my point, exactly.  I want to invite the two of you and a partner to begin to develop a vocabulary about your body.  It’s really funny, I notice that parts of our body that we’re not afraid to talk about, we have a million words for, we have a whole vocabulary for.  If you actually are a fan of comedy or of old movies, you could just make a list of all the different words that people have for a nose.  It’s you know, you don’t think about it too much , until you watch a Marx Brothers movie or Abbot and Costello and next thing you know it’s a beezer and it’s a bulb, and it’s a nose and it’s a bulboscus next thing you know there is 20, 30 different names for eyes.  They are peepers, they are winkers, they’re eyes.  You know, there’s names for things, there’s words for things and then we get to our genitals. And it’s, down there, you know it’s my private parts and we don’t talk and we’re embarrassed.  So, my invitation to you is to combat embarrassment.  I am a believer in shamelessness and I want to take a moment to thank Laura for coming on the show here and talking about something that I think women are often ashamed to talk about.  And I hope listening to Laura you kind of get a sense that maybe you don’t need to be ashamed and you don’t need to be in pain.  And I hope that if you are one of those 2 to 4 million women that experience this that you do go talk to your OBGYN or go look up some of those organizations that Dr Brodzinsky just said.  And really there is a opportunity to maybe have the pain go away and have a kind of healthy, happy kind of life.  And I want to thank you Dr. Brodzinsky for coming on the show

Laura Brodzinsky: Thanks, it was great to be here.

Chip August: And thank you listeners for listening, this brings us to the end of another show.  You know that we make transcripts or every single show, you can also find that on my episode pages on the personallifemedia.com site.  And so if you heard something today that you noticed,  you wanted to sort of pick up those words and send them to a friend. Or you wanted to cut and paste something and send it to somebody. You can, you can go look up the transcript and pull the words and send them.  And one of the ways my show grows, of course, is you tell more people about the show and more people will listen and that’s better for me and better for Personal Life Media and I really, really, thank you for your support.  That brings us to the end of another show, thank you for listening and I hope you’ll listen in again.