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Delving into the Vulva Vestibule: Insights with Dr. Rahman

Delving into the Vulva Vestibule: Insights with Dr. Rahman

Do you know about the vulval vestibule?

In today’s episode, I delve into the intricate anatomy of the vulvar vestibule and its significance in sexual health. I discuss how this unique area, formed from the endodermis, contains an increased concentration of nerve endings which can result in heightened sensitivity and pain for some individuals. 

I explain the curious case where patients with too many nerve endings at the vestibule also report an unusual sensitivity at their belly button upon touch. Additionally, I touch upon neuroproliferative vestibulodynia, a condition that can be acquired due to inflammation or allergies, leading to hypertonic pelvic floor muscles and even secondary vaginismus. 

I emphasize the complexity of treating such conditions, noting that while therapies targeting vaginismus and pelvic floor issues can be effective, they may not entirely eliminate the pain. I recommend a q-tip test for severe pain evaluation and a vestibular anesthesia test using topical anesthetics for diagnosis. 

It’s worth noting that many patients, after treatment, report a significant pain reduction in their vestibule, which can be initially triggered by activities such as wearing tight clothes or swimming. 

Options for treatment, I mention include pelvic floor therapy, topical anesthetic agents, and capsaicin—known for its receptor desensitization properties. For severe cases, vestibulectomy is a surgical option, where the entire vestibule is removed, replaced with a vaginal flap, and followed by a recovery phase that includes pelvic floor therapy and potentially vaginal botox administration, eventually allowing for pain-free sexual experiences. 

Throughout the episode, I stress the importance of pelvic floor therapy in comprehensively managing sexual pain and vaginismus, the utility of cognitive behavioral therapy, and the value of mind-body connection techniques as outlined in ‘The Pleasure Prescription.’

I share how challenging it can be for patients to navigate sexual pain but also provide hope and point to resources available for assistance, including directing listeners to a website where clinicians are available to aid in dealing with sexual pain. 

Furthermore, I advocate for patient education and empowerment in handling their own sexual health needs. I also clarify the causes of vestibulodynia by highlighting its sensitivities and hormone-related fluctuations. I discuss the three main categories—hormonally mediated, neuroproliferative, and inflammatory—each with distinct diagnostic markers and symptoms, like the hormonal deficiencies leading to vulvar tissue changes in hormonally mediated vestibulodynia. 

Additionally, I address the impact of birth control pills on sexual health, and potentially necessary genetic need for more testosterone in some patients. I pinpoint other medications and conditions that can result in hormonal deficiencies and underline how these deficiencies can manifest in symptoms like dryness, urinary frequency, UTIs, and pain during sexual activity. 

In treating pelvic pain, I describe the approach of assessing pain on a scale of one to ten and considering hormonal levels via blood work. The treatment strategy includes a biopsychosocial approach, combining pelvic floor therapy, cognitive behavioral therapy, and sex therapy. Special attention is given to patients with a history of lifelong pelvic pain and trauma, recognizing their uniquely complex treatment needs. 

I round up the episode by reaffirming my commitment as a board-certified gynecologist and an advocate for health issues often stigmatized and shamed, with a focus on educating and addressing conditions related to painful sex and the side effects of contraception on libido. My aim is to equip my listeners with knowledge and empathy towards these delicate health matters.

Mentioned:

The Pleasure Prescription

ISSWSH

Get in Touch with me:

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GynoGirl Website

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Transcript

Dr. Sameena Rahman [00:00:01]:

Hey, y'all, it's Dr. Samina Ramon Gynogirl. I'm a board certified gynecologist, a clinical assistant professor of OBGYN at Northwestern Feinberg School of Medicine, and owner of a private practice for almost a decade that specializes in menopause and sexual medicine. I'm a south asian american muslim woman who is here to empower, educate, and help you advocate for health issues that have been stigmatized, shamed, and perhaps even prevented you from living your best life. I'm better than your best girlfriend and more open than most of your doctors. I'm here to educate so you can advocate. Welcome to Gynogirl Presents sex, drugs and hormones. Let's go.

Dr. Sameena Rahman [00:00:53]:

Hello.

Dr. Sameena Rahman [00:00:54]:

Welcome to another episode of Gyno. Girl presents sex, drugs and hormones. I'm Dr. Samina Raman. I'm a sexmed gynecologist in downtown Chicago.

Dr. Sameena Rahman [00:01:05]:

And a menopause specialist.

Dr. Sameena Rahman [00:01:08]:

And I own my own practice.

Dr. Sameena Rahman [00:01:09]:

And I see patients every day with all the conditions that I'm talking about these days.

Dr. Sameena Rahman [00:01:13]:

And today I am going to speak to you guys solo. We're going to do a one on one session here because I really want you guys to understand some of the.

Dr. Sameena Rahman [00:01:22]:

Conditions that are going to be discussed in future episodes.

Dr. Sameena Rahman [00:01:26]:

And one of those is painful sex. And not only just painful sex or dysperunia, but specifically pain at initial penetration. And so this means we're going to have a great discussion about a little.

Dr. Sameena Rahman [00:01:42]:

Piece of tissue called the vulvar vestibule. Now, maybe you've never heard of this. Maybe you're a gynecologist and you never heard of this.

Dr. Sameena Rahman [00:01:51]:

I've met many, and maybe you're in medicine and maybe you're not.

Dr. Sameena Rahman [00:01:56]:

But we are going to discuss what the vestibule has to do with all.

Dr. Sameena Rahman [00:02:00]:

Of this and how it really can.

Dr. Sameena Rahman [00:02:03]:

Wreak havoc on so many patients'lives. So let's get into it right now.

Dr. Sameena Rahman [00:02:09]:

In January, actually, there was an article that came out in the New York.

Dr. Sameena Rahman [00:02:13]:

Times, and this article stated there was a link between birth control pills and sex drive.

Dr. Sameena Rahman [00:02:22]:

Now, I think that most of you.

Dr. Sameena Rahman [00:02:25]:

Who read this article were intrigued, but.

Dr. Sameena Rahman [00:02:29]:

This article actually goes deeper into just libido and how the birth control pill.

Dr. Sameena Rahman [00:02:34]:

Can affect your libido.

Dr. Sameena Rahman [00:02:35]:

It's by Nita Gupta. It's a very well written article, an.

Dr. Sameena Rahman [00:02:38]:

Article that many of my colleagues were quoted in. And basically it discusses how oral contraceptive pills or the birth control pill can.

Dr. Sameena Rahman [00:02:49]:

Impact your sexual function.

Dr. Sameena Rahman [00:02:51]:

And is that why the birth control pill works? We always used to talk about. No, actually, first of all, I want to talk about what it affects and.

Dr. Sameena Rahman [00:03:01]:

Why, and then we will get into.

Dr. Sameena Rahman [00:03:03]:

That a little bit more. Okay, so the culprit in the situation.

Dr. Sameena Rahman [00:03:09]:

When it comes to pain with initial.

Dr. Sameena Rahman [00:03:12]:

Penetration, basically, pain at any provocation, any.

Dr. Sameena Rahman [00:03:17]:

Kind of touching, any kind of placing a tampon, any kind of attempt at penetration can cause vestibulo dimia. And many times, people get this diagnosis.

Dr. Sameena Rahman [00:03:30]:

Vulvodya vestibulody.

Dr. Sameena Rahman [00:03:32]:

Vestibulitis. Vulvar vestibulitis.

Dr. Sameena Rahman [00:03:34]:

What the frick does that mean?

Dr. Sameena Rahman [00:03:35]:

These are descriptive terms, right?

Dr. Sameena Rahman [00:03:38]:

Vulvar vestibulodynia just means pain in the vestibule. And what we have is.

Dr. Sameena Rahman [00:03:44]:

Vestibulody is a general term that describes that pain. The vestibule, if you've never met her, is a very unique piece of tissue in the vulva. It sits right at the opening. So imagine a vestibule that you enter, to enter into a building or into a church or into another room. This vestibule is something you have to encounter before you enter the vagina. And so, like any other vestibule, we have to worry about what's inside of it and what might inhibit us from getting. So there's vulvodymia, which means just pain in the vulva, or chronic pain in.

Dr. Sameena Rahman [00:04:19]:

The vulva, and then there's vestibulodenia.

Dr. Sameena Rahman [00:04:21]:

So that goes a little deeper. Now, the vulvar vestibule is an area of tissue. It's a thin, circular area of a.

Dr. Sameena Rahman [00:04:28]:

Tissue that is very biologically unique.

Dr. Sameena Rahman [00:04:31]:

If your outer lips are your labia.

Dr. Sameena Rahman [00:04:33]:

Majora and your inner lips are your.

Dr. Sameena Rahman [00:04:35]:

Labia menorah, it's from the inner labia menorah. There's a line in the inner labia menorah called the heart's line. It goes from that line, and it extends all the way to the hymen remnant. So we're talking about this little, thin piece of tissue, and it goes all the way from the top of the.

Dr. Sameena Rahman [00:04:51]:

Urethra and to the bottom of the perineum.

Dr. Sameena Rahman [00:04:53]:

It's a circular piece of tissue.

Dr. Sameena Rahman [00:04:54]:

It's a unique piece of tissue.

Dr. Sameena Rahman [00:04:58]:

We say that because it's really fundamentally.

Dr. Sameena Rahman [00:05:00]:

Different than the outer external labia menorah.

Dr. Sameena Rahman [00:05:04]:

The outer external labia menorah develops differently embryologically. The inherent difference in this tissue is what? Which allows us to understand the cause of the pain for some patients, because.

Dr. Sameena Rahman [00:05:18]:

This tissue, like I said, is different. The outer labia menorah is derived embryologically. When you're a little embryo in your mother's uterus in your mother's womb, you're developing, and you start with three layers.

Dr. Sameena Rahman [00:05:31]:

Of tissue, the mesoderm, the ectoderm, and the endoderm. Now, the inner labia menorah, the tissue right outside of the vestibule, is derived from the ectoderm, and the vestibule is derived from tissue called the endoderm. And that's the same tissue that's in your bladder and the same tissue that's.

Dr. Sameena Rahman [00:05:48]:

In your urakus for your umbolicus, your belly button.

Dr. Sameena Rahman [00:05:53]:

And this all derives from this eurogenital sinus, which, for those of you in science, may have heard of this. The reason it's unique is that this tissue is very sensitive. It's sensitive to nerve endings. It's sensitive to hormonal fluctuations and deficiencies. And that is the culprit in many of the causes of provoked vestibulodynia. Provoked means something is happening to you. You're getting touched.

Dr. Sameena Rahman [00:06:22]:

It's on provocation. Right.

Dr. Sameena Rahman [00:06:24]:

So we have is.

Dr. Sameena Rahman [00:06:26]:

Let me start with one type of ideology or reason for this. Only until about 2015, that the International.

Dr. Sameena Rahman [00:06:33]:

Society for the Study of Women's Sexual.

Dr. Sameena Rahman [00:06:34]:

Health, Ishwish, which I talk about a.

Dr. Sameena Rahman [00:06:36]:

Lot on this podcast, along with ISSVD.

Dr. Sameena Rahman [00:06:40]:

The Society for, International Society for the.

Dr. Sameena Rahman [00:06:43]:

Study of Vulval Vaginal Diseases, really came up with reasons for why people get pain in the vestibule.

Dr. Sameena Rahman [00:06:49]:

And these terminologies started to exist. And we know there are three, actually four, probably subcategories of why people get the pain in the vestibule. One is related to hormonal deficiencies, and.

Dr. Sameena Rahman [00:07:01]:

We call that hormonally mediated vestibulody.

Dr. Sameena Rahman [00:07:04]:

The other is cut from neuroproliferative vestibulodynia or increased in nerve endings at the vestibule, and the final one, and then inflammatory vestibulodynia from inflammatory conditions. And then all of these conditions can.

Dr. Sameena Rahman [00:07:21]:

Concurrently lead to pelvic floor dysfunction, which.

Dr. Sameena Rahman [00:07:24]:

Can primarily cause that pain with the vestibule, too. And let me explain this. Let's first get into, when we're evaluating the vestibule, what we're looking for and why we think sometimes it's hormonally mediated and sometimes it's not. The vulvar vestibule, like I said, is from that inner labia menorah to your.

Dr. Sameena Rahman [00:07:43]:

Hymen remnant extending up through the urethra.

Dr. Sameena Rahman [00:07:45]:

And down to the perineum.

Dr. Sameena Rahman [00:07:46]:

It's delineated from the outer labia through.

Dr. Sameena Rahman [00:07:49]:

This line called hearts line, h a r t, hards line. And so we look at the vestibule, and I examined the vulva very every.

Dr. Sameena Rahman [00:07:58]:

Day, I examine the vulva. I'll look at the outer labia menorah.

Dr. Sameena Rahman [00:08:01]:

The inner labia menorah, the outer labia.

Dr. Sameena Rahman [00:08:03]:

Menorah, the labia majora, and the inner lips of the labia. The labia menorah can sometimes look like they're getting smaller. We call that regression. Oh, my God, they're getting small or they're disappearing.

Dr. Sameena Rahman [00:08:15]:

Sometimes they do look like they've almost disappeared. Sometimes the clitoris shrinks down when all of this is happening, and the vulvar.

Dr. Sameena Rahman [00:08:21]:

Vestibule looks angry and red and inflamed, and. No, I touch it with a soft part of the qtip. A patient tells me, oh, my God, are you touching me with a knife, or why are you ripping my skin apart?

Dr. Sameena Rahman [00:08:33]:

Like, what's going on?

Dr. Sameena Rahman [00:08:35]:

And I'm literally touching them with the soft part of the qtip. That's a big sign that there's a hormonal deficiency.

Dr. Sameena Rahman [00:08:40]:

You see, the vulvar vestibule needs both estrogen and androgens.

Dr. Sameena Rahman [00:08:45]:

It needs testosterone.

Dr. Sameena Rahman [00:08:47]:

It needs estrogen.

Dr. Sameena Rahman [00:08:48]:

And when you're on something that diminishes.

Dr. Sameena Rahman [00:08:51]:

It or you are in a hormonal.

Dr. Sameena Rahman [00:08:56]:

Situation where it's diminished, this vestibule can be affected.

Dr. Sameena Rahman [00:09:00]:

And what patients, they feel like it's.

Dr. Sameena Rahman [00:09:02]:

Tearing or it's ripping or it's burning, all of these sensations at once. And so you're dealing with this. A patient that may have never been.

Dr. Sameena Rahman [00:09:11]:

Able to use a tampon, a patient.

Dr. Sameena Rahman [00:09:12]:

That maybe never has been able to have full penetrated sex, or they used to have it, and now they don't. Something happened, right? So we in the ishwich world, like to consider ourselves sex detectives.

Dr. Sameena Rahman [00:09:24]:

And what do we do?

Dr. Sameena Rahman [00:09:25]:

We try to figure out what the root cause is. So by doing that, we have to take a history. We have to take a very thorough history. We have to spend time with our patients. And then we look closely at the vulva.

Dr. Sameena Rahman [00:09:35]:

We look for these subtle changes that.

Dr. Sameena Rahman [00:09:37]:

Other people might not pick up.

Dr. Sameena Rahman [00:09:38]:

Like what happened to your labium menorah?

Dr. Sameena Rahman [00:09:40]:

They've shrunk down your clitoris, looks less than the size of this qTip. What's going on here, guys?

Dr. Sameena Rahman [00:09:45]:

And then we touch with the qtip.

Dr. Sameena Rahman [00:09:47]:

And if someone's having ten out of ten pain around the urethra, around the lower vestibule, around. And then what inevitably happens is they will clench their pelvic floor. But along with that tearing sensation and the kind of symptoms that you have sharp, stinging, burning, hypersensitivity. You can also get urinary symptoms because.

Dr. Sameena Rahman [00:10:07]:

Of that top part of that vestibule.

Dr. Sameena Rahman [00:10:09]:

Is really right next to the urethra.

Dr. Sameena Rahman [00:10:12]:

Right?

Dr. Sameena Rahman [00:10:12]:

It's right there.

Dr. Sameena Rahman [00:10:13]:

And you can get this feeling of urgency.

Dr. Sameena Rahman [00:10:16]:

You can get urgent continents.

Dr. Sameena Rahman [00:10:17]:

I got to go.

Dr. Sameena Rahman [00:10:17]:

I got to go. I got to go.

Dr. Sameena Rahman [00:10:18]:

Dribble, dribble, dribble. You can get symptoms of frequency of feeling like a UTI. Maybe you're even getting UTIs. This all happens because of hormonal deprivation.

Dr. Sameena Rahman [00:10:30]:

We are in a deficient hormonal environment.

Dr. Sameena Rahman [00:10:33]:

And your liver, like I said, when.

Dr. Sameena Rahman [00:10:35]:

You ingest the birth control milk makes a sex hormone binding globulin, SHBG. And this protein goes up when you take birth control pills, it's making a lot of it. It's churning out a lot of sHBG. And what that does is it binds to your testosterone so that your cells can't see it and then they can't use it. And when you're binding that much testosterone up, the vestibule needs that testosterone. It needs that estrogen. It's not getting it. And so the other compounding factor is that there are some birth control pills.

Dr. Sameena Rahman [00:11:10]:

That actually have a progesterone that is.

Dr. Sameena Rahman [00:11:15]:

Antiandrogenic, meaning that it also competes with that androgen receptor site, and it binds to that site so that the testosterone can't get there.

Dr. Sameena Rahman [00:11:25]:

Right.

Dr. Sameena Rahman [00:11:26]:

So something like a yaz that has drospirinone, it's known to lower your testosterone even more because it's binding to that site so that your testosterone can't get there, you compound that. So now you're making less testosterone, you're seeing less free testosterone. And then on top of that, there.

Dr. Sameena Rahman [00:11:43]:

Are some patients who have a genetic susceptibility to needing more testosterone at the.

Dr. Sameena Rahman [00:11:49]:

Receptors to make a difference. So if you don't have that because it's all gotten bound up to this liver protein, that SHBG, then you're in trouble. And so that's why patients that say, you're 15 years old, you go on birth control pills for acne. You're 15 year old, you go on birth control pills because you have severe pain with your menstrual cycle, maybe endometriosis, you go on these medications to help you, and then nothing comes without potential side effects.

Dr. Sameena Rahman [00:12:15]:

So years may go by, and all.

Dr. Sameena Rahman [00:12:18]:

Of a sudden you say, oh, it gets a little dry when I have sex. And then you have straight out pain with sex. And every time you try to have intercourse, you have pain. And then of course, your libido goes down. So that is a hormonal deficient state.

Dr. Sameena Rahman [00:12:30]:

Other hormonal deficient states or other medications.

Dr. Sameena Rahman [00:12:32]:

That can cause this. Sprinalactone, also a treatment for acne and hypertension. It can cause that lower testosterone state.

Dr. Sameena Rahman [00:12:39]:

Patients that are lactating, you have really.

Dr. Sameena Rahman [00:12:42]:

High levels of prolactin.

Dr. Sameena Rahman [00:12:43]:

When you lactate, you have really low levels of estrogen.

Dr. Sameena Rahman [00:12:46]:

You can also get that state of low estrogen. When your ovaries don't work as hard in that lactating state, they kind of take rest, right? They're taking a day off.

Dr. Sameena Rahman [00:12:58]:

You're lactating, you don't need to ovulate.

Dr. Sameena Rahman [00:13:00]:

All right, I'm taking a day off.

Dr. Sameena Rahman [00:13:02]:

Same thing happens when your ovaries go into retirement, right?

Dr. Sameena Rahman [00:13:05]:

You're going into retirement and perimenopause heading there. Menopause happens. You stop making estrogen, you stop making 50% of your testosterone. And again, we call that when you have the itching, the burning, the dryness, the urinary frequency, the utIs, the pain with sex, we call that the genital urinary syndrome of menopause.

Dr. Sameena Rahman [00:13:23]:

We should actually call all of it.

Dr. Sameena Rahman [00:13:25]:

The genital urinary syndrome of hormone deficiency.

Dr. Sameena Rahman [00:13:29]:

At ishwish this year, someone presented on the genital urinary syndrome of lactation. So we do have these issues that come up because of hormonal deficient status.

Dr. Sameena Rahman [00:13:38]:

And homers really rule our lives.

Dr. Sameena Rahman [00:13:41]:

These patients, they have a lot of pain with sex. And so what happens is they're starting.

Dr. Sameena Rahman [00:13:44]:

To develop this pain with sex. They start clenching.

Dr. Sameena Rahman [00:13:47]:

They start clenching. They start clenching.

Dr. Sameena Rahman [00:13:49]:

What happens when you touch a hot stove?

Dr. Sameena Rahman [00:13:51]:

Your muscles contract automatically, right, to try to get your hand away from the stove.

Dr. Sameena Rahman [00:13:55]:

You don't even think about it.

Dr. Sameena Rahman [00:13:57]:

The same thing happens when you're feeling.

Dr. Sameena Rahman [00:13:58]:

This burning sensation down there.

Dr. Sameena Rahman [00:14:00]:

Maybe you're wearing tight clothes and it's hitting up against your vestibule.

Dr. Sameena Rahman [00:14:03]:

It's irritating you.

Dr. Sameena Rahman [00:14:04]:

Maybe you've tried to put a tampon in. You're hitting against the vestibule.

Dr. Sameena Rahman [00:14:06]:

It's irritating you.

Dr. Sameena Rahman [00:14:07]:

Whatever the case may be, all of.

Dr. Sameena Rahman [00:14:09]:

A sudden you're having this pain sensation.

Dr. Sameena Rahman [00:14:12]:

Your muscles are going to clench in response.

Dr. Sameena Rahman [00:14:14]:

When they clench like that, they become shorter.

Dr. Sameena Rahman [00:14:17]:

They go tighter. They develop these little knots. Have you ever felt the back of your neck or the back of your lower back?

Dr. Sameena Rahman [00:14:22]:

When you feel like a spasm bat.

Dr. Sameena Rahman [00:14:24]:

Back there and you're having a lot of pain, and all of a sudden you feel a knot? That's a trigger point. We feel those in the pelvic floor all the time.

Dr. Sameena Rahman [00:14:30]:

And so to compound the fact that.

Dr. Sameena Rahman [00:14:32]:

You have this burning and sensation or tearing sensation at the vestibule, you now.

Dr. Sameena Rahman [00:14:37]:

Have pain related to the pelvic floor.

Dr. Sameena Rahman [00:14:41]:

That's now dysfunctional, because now it's weaker because the muscles are tighter, and you.

Dr. Sameena Rahman [00:14:47]:

Get this lactic acid that builds up.

Dr. Sameena Rahman [00:14:49]:

And so it causes even more burning. And there's a subset of patients, actually.

Dr. Sameena Rahman [00:14:53]:

Who just have a lot of anxiety.

Dr. Sameena Rahman [00:14:55]:

And they have high anxiety, and they're clenching all the time.

Dr. Sameena Rahman [00:14:59]:

They have TMJ, or they've been really.

Dr. Sameena Rahman [00:15:02]:

Stressed out, and as a result, they clench, they have TMJ, whatever. They're clenching their jaw, they're clenching their pelvis, and they get vestibulodynia or pain of the vestibule just from a hypertonic pelvic floor. We call this pelvic floor hypertenicity.

Dr. Sameena Rahman [00:15:16]:

Again, what we do is that little qtip test.

Dr. Sameena Rahman [00:15:18]:

I feel all around the clock. 12:00 01:00 02:00 03:00 04:00 05:00 06:00 07:00 08:00 09:00 10:00 11:00 12:00 and patient tells me what they feel on a scale of one to ten. Oh, I'm in so much pain.

Dr. Sameena Rahman [00:15:31]:

Oh, my God.

Dr. Sameena Rahman [00:15:31]:

Are you touching me with a knife?

Dr. Sameena Rahman [00:15:32]:

What's happening down there?

Dr. Sameena Rahman [00:15:33]:

And if the pain is limited to.

Dr. Sameena Rahman [00:15:35]:

Say, four anyway, so you're clenching.

Dr. Sameena Rahman [00:15:38]:

If your pain is limited to, say.

Dr. Sameena Rahman [00:15:41]:

The 04:00 to the 07:00 position or 05:00 to 07:00 or 08:00 just in the lower part of your vestibule, then.

Dr. Sameena Rahman [00:15:50]:

That pain is likely related to a hypertonic pelvic floor. And what we do is we treat you with pelvic floor therapy and sometimes.

Dr. Sameena Rahman [00:16:00]:

Vaginal Botox, which does wonders for the pelvic floor.

Dr. Sameena Rahman [00:16:04]:

It forces the muscles to relax, but.

Dr. Sameena Rahman [00:16:06]:

It also decreases pain and nociception in that area.

Dr. Sameena Rahman [00:16:10]:

So that's the hormonal aspect. What do we do?

Dr. Sameena Rahman [00:16:14]:

Like I said, to diagnose it, we take a history.

Dr. Sameena Rahman [00:16:16]:

We're sex detectives, right?

Dr. Sameena Rahman [00:16:17]:

We take a history.

Dr. Sameena Rahman [00:16:18]:

We listen to what you're saying.

Dr. Sameena Rahman [00:16:20]:

We take an exam, do a qtip.

Dr. Sameena Rahman [00:16:23]:

Test, and then to feel your pelvic floor muscles.

Dr. Sameena Rahman [00:16:26]:

We look at your vulva closely, we.

Dr. Sameena Rahman [00:16:27]:

Look at your clitoris.

Dr. Sameena Rahman [00:16:28]:

We do all the good things that.

Dr. Sameena Rahman [00:16:29]:

Need to be done.

Dr. Sameena Rahman [00:16:30]:

We determine sometimes we may get blood work.

Dr. Sameena Rahman [00:16:33]:

We may see what your total t.

Dr. Sameena Rahman [00:16:34]:

Is, your free tea, which is your total testosterone.

Dr. Sameena Rahman [00:16:37]:

Your free testosterone. We may see how high your sex.

Dr. Sameena Rahman [00:16:40]:

Hormone binding globulin is.

Dr. Sameena Rahman [00:16:41]:

And then what we do is we.

Dr. Sameena Rahman [00:16:43]:

Figure out, is there an inciting agent.

Dr. Sameena Rahman [00:16:44]:

That we can stop?

Dr. Sameena Rahman [00:16:45]:

Right when we're talking about medications, the.

Dr. Sameena Rahman [00:16:48]:

Sprinactone, the birth control pill, can we stop those?

Dr. Sameena Rahman [00:16:51]:

We can't stop perimenopause. We can't stop menopause, lactation.

Dr. Sameena Rahman [00:16:55]:

Again, you don't want to stop.

Dr. Sameena Rahman [00:16:56]:

Maybe you don't want to stop.

Dr. Sameena Rahman [00:16:57]:

Maybe you want to stop.

Dr. Sameena Rahman [00:16:58]:

Depending on how it's affecting your lifestyle. Most patients are having a lot of.

Dr. Sameena Rahman [00:17:02]:

Sex after they have babies because they're freaking tired.

Dr. Sameena Rahman [00:17:05]:

But you do that.

Dr. Sameena Rahman [00:17:06]:

We decide. Okay, the other cases when patients have.

Dr. Sameena Rahman [00:17:10]:

Been on, like, tamoxifen or.

Dr. Sameena Rahman [00:17:14]:

Medication that really diminishes their hormones for breast cancer therapy. And obviously those usually can't be stopped.

Dr. Sameena Rahman [00:17:21]:

So we're talking about these patients. Is there an inciting agent we can remove?

Dr. Sameena Rahman [00:17:25]:

If there is, if you're on the.

Dr. Sameena Rahman [00:17:27]:

Birth control pill, maybe I'll have you.

Dr. Sameena Rahman [00:17:29]:

Do an IUD, an intrauterine device instead. There's the progesterone ones, there's the copper ones.

Dr. Sameena Rahman [00:17:34]:

Or maybe you try like a barrier method.

Dr. Sameena Rahman [00:17:36]:

Maybe you try something that's not going.

Dr. Sameena Rahman [00:17:38]:

To affect your ovulation, your ovarian function.

Dr. Sameena Rahman [00:17:42]:

So that it doesn't secondarily impact your sexual function. So then maybe we remove that, and then what we'll do is we'll compound.

Dr. Sameena Rahman [00:17:49]:

An estrogen cream that's either zero, one.

Dr. Sameena Rahman [00:17:52]:

To zero, 3%, as well as a.

Dr. Sameena Rahman [00:17:56]:

Testosterone mix, and we will apply that to the vestibule.

Dr. Sameena Rahman [00:18:01]:

And by six to twelve weeks, you.

Dr. Sameena Rahman [00:18:03]:

Should see some diminished pain, along with.

Dr. Sameena Rahman [00:18:06]:

Pelvic floor therapy, along with sometimes cognitive behavioral therapy, along with sometimes sex therapy.

Dr. Sameena Rahman [00:18:11]:

All of those things need to be.

Dr. Sameena Rahman [00:18:13]:

In the biopsychosocial approach to treating this disorder.

Dr. Sameena Rahman [00:18:16]:

This provoked vestibulodynia secondary to hormonal mediation. But what if it's not your hormones?

Dr. Sameena Rahman [00:18:23]:

What if you come in and you're like, I've had this pain my whole life.

Dr. Sameena Rahman [00:18:26]:

I've never been able to use a tampon. I've never had pain free sex.

Dr. Sameena Rahman [00:18:29]:

I actually can't insert anything down there. I've had a very traumatic pelvic exam.

Dr. Sameena Rahman [00:18:33]:

Where I was forced to have a.

Dr. Sameena Rahman [00:18:34]:

Pap, even though I've never had intercourse.

Dr. Sameena Rahman [00:18:37]:

Or anything surrounding that.

Dr. Sameena Rahman [00:18:40]:

So I see patients like this all the time, and sometimes they're like almost 50 years old by the time I see them. And they've been living with something like.

Dr. Sameena Rahman [00:18:47]:

This their whole life.

Dr. Sameena Rahman [00:18:48]:

And that's when that whole idea of the nerve endings that have increased at the level of the vestibule.

Dr. Sameena Rahman [00:18:56]:

Remember how unique that tissue is.

Dr. Sameena Rahman [00:18:58]:

Remember it's from the endodermis. Remember that some people have a birth defect, and they're born with too many.

Dr. Sameena Rahman [00:19:05]:

Nerve endings down there.

Dr. Sameena Rahman [00:19:06]:

Okay?

Dr. Sameena Rahman [00:19:07]:

That's the bottom line.

Dr. Sameena Rahman [00:19:08]:

And they may.

Dr. Sameena Rahman [00:19:09]:

60% of these patients have pain at.

Dr. Sameena Rahman [00:19:12]:

Their belly button if you touch it.

Dr. Sameena Rahman [00:19:13]:

Or sensitivity of their belly button.

Dr. Sameena Rahman [00:19:15]:

And that's one thing that we always.

Dr. Sameena Rahman [00:19:17]:

Ask patients to do, like fill your belly button.

Dr. Sameena Rahman [00:19:19]:

Let me fill your belly button.

Dr. Sameena Rahman [00:19:20]:

Is that discomforting?

Dr. Sameena Rahman [00:19:22]:

Because, again, the same tissue embryologically. Okay, so then you have someone that.

Dr. Sameena Rahman [00:19:26]:

Has this neuroproliferative vestibulody.

Dr. Sameena Rahman [00:19:29]:

You can acquire it, too.

Dr. Sameena Rahman [00:19:30]:

We think that we're still learning about this. Maybe there's inflammatory factors.

Dr. Sameena Rahman [00:19:34]:

Maybe we're now learning there might be some mass cell.

Dr. Sameena Rahman [00:19:37]:

The mass cell proliferation. Patients with endometriosis that have been living.

Dr. Sameena Rahman [00:19:41]:

With this painful periods their whole life.

Dr. Sameena Rahman [00:19:44]:

Can develop this increased nerve density at.

Dr. Sameena Rahman [00:19:47]:

The vestibule, as well as mass cells. And so it might be something related.

Dr. Sameena Rahman [00:19:55]:

To inflammation or allergies.

Dr. Sameena Rahman [00:19:57]:

We're learning more about it, but you.

Dr. Sameena Rahman [00:19:59]:

Can acquire and get it secondarily.

Dr. Sameena Rahman [00:20:01]:

You can have pain free sex, and then all of a sudden, not because, hey, I've been having yeast infections forever.

Dr. Sameena Rahman [00:20:05]:

I have an endometriosis.

Dr. Sameena Rahman [00:20:06]:

I have all these potential things that.

Dr. Sameena Rahman [00:20:08]:

Have caused so much inflammation that I now have new nerve endings that have.

Dr. Sameena Rahman [00:20:12]:

Decided to house themselves at my vestibule.

Dr. Sameena Rahman [00:20:16]:

What?

Dr. Sameena Rahman [00:20:16]:

We have that either situation again.

Dr. Sameena Rahman [00:20:19]:

We go back to the history.

Dr. Sameena Rahman [00:20:21]:

We delve deep into your history.

Dr. Sameena Rahman [00:20:23]:

Okay?

Dr. Sameena Rahman [00:20:24]:

This has been happening since I was 16.

Dr. Sameena Rahman [00:20:25]:

I couldn't put in a tampon.

Dr. Sameena Rahman [00:20:27]:

This has been happening since the first.

Dr. Sameena Rahman [00:20:28]:

Time I tried to have intercourse.

Dr. Sameena Rahman [00:20:30]:

I've never had penetration.

Dr. Sameena Rahman [00:20:31]:

What happens to a lot of these patients with vestibulody is because they're contracting.

Dr. Sameena Rahman [00:20:35]:

Their pelvic floor all the time.

Dr. Sameena Rahman [00:20:37]:

Becomes hypertonic, like I told you before, but you also start getting involuntary contractions.

Dr. Sameena Rahman [00:20:42]:

And that's when we get that whole idea of secondary vaginismus, where all of.

Dr. Sameena Rahman [00:20:46]:

A sudden, you've developed vaginismus and nothing.

Dr. Sameena Rahman [00:20:49]:

Is coming your way because you'll not let anything enter.

Dr. Sameena Rahman [00:20:52]:

Okay.

Dr. Sameena Rahman [00:20:53]:

And so that makes it even more challenging.

Dr. Sameena Rahman [00:20:55]:

And these patients oftentimes have only been treated with vaginismus.

Dr. Sameena Rahman [00:20:59]:

They've been told to use dilators.

Dr. Sameena Rahman [00:21:00]:

Go home and use dilators.

Dr. Sameena Rahman [00:21:01]:

You'll be okay.

Dr. Sameena Rahman [00:21:02]:

Go home.

Dr. Sameena Rahman [00:21:04]:

Or they'll see a pelvic floor therapist.

Dr. Sameena Rahman [00:21:05]:

And get pelvic floor therapy till the cows come home.

Dr. Sameena Rahman [00:21:08]:

But they're still not pain free, and.

Dr. Sameena Rahman [00:21:10]:

It'S because maybe they haven't had a qtip test.

Dr. Sameena Rahman [00:21:13]:

So back to the qTip.

Dr. Sameena Rahman [00:21:14]:

The soft part of the qtip, we put at twelve. 1234-5678 910 11:00 and patients, tell me.

Dr. Sameena Rahman [00:21:22]:

What is your pain scale? Do you feel pressured?

Dr. Sameena Rahman [00:21:24]:

Most people feel nothing.

Dr. Sameena Rahman [00:21:25]:

Or they feel a little pressured, or do you feel that shearing pain, that tearing pain, that.

Dr. Sameena Rahman [00:21:30]:

Oh, my God, I got to.

Dr. Sameena Rahman [00:21:30]:

Get off me.

Dr. Sameena Rahman [00:21:31]:

Pain.

Dr. Sameena Rahman [00:21:31]:

What are you doing to me down there?

Dr. Sameena Rahman [00:21:32]:

Pain.

Dr. Sameena Rahman [00:21:33]:

And most of the time they're seven, 8910 out of ten. And then we do what's called a.

Dr. Sameena Rahman [00:21:38]:

Vet, a vestibular anesthesia test.

Dr. Sameena Rahman [00:21:41]:

And we put something like a benzocaine.

Dr. Sameena Rahman [00:21:44]:

A lidocaine, a tetracrane cream, which is.

Dr. Sameena Rahman [00:21:47]:

Basically an topical anesthetic.

Dr. Sameena Rahman [00:21:49]:

And we place it at the vestibule.

Dr. Sameena Rahman [00:21:51]:

And we leave it on for a few minutes. We repeat the qtip test, and most.

Dr. Sameena Rahman [00:21:55]:

Of the time, patients are down to.

Dr. Sameena Rahman [00:21:56]:

A zero out of ten.

Dr. Sameena Rahman [00:21:57]:

They feel nothing.

Dr. Sameena Rahman [00:21:58]:

It's the first time in their life.

Dr. Sameena Rahman [00:21:59]:

That they don't feel pain in their vestibule when touched, because again, maybe when.

Dr. Sameena Rahman [00:22:02]:

They wear tight clothes, they feel it.

Dr. Sameena Rahman [00:22:04]:

Maybe they're inflamed when they're going swimming.

Dr. Sameena Rahman [00:22:08]:

All the different types of things where.

Dr. Sameena Rahman [00:22:10]:

Your vestibule can get touched.

Dr. Sameena Rahman [00:22:12]:

And so then we realize that, hey.

Dr. Sameena Rahman [00:22:15]:

We need to try something different.

Dr. Sameena Rahman [00:22:17]:

Okay, so pelvic floor therapy, big part of it. The next thing, some patients will try just topical anesthetic agents, like a lidocaine.

Dr. Sameena Rahman [00:22:25]:

That's a band aid, really, right?

Dr. Sameena Rahman [00:22:27]:

We're not curing it, we're just trying.

Dr. Sameena Rahman [00:22:28]:

To apply something to stop the pain.

Dr. Sameena Rahman [00:22:30]:

Many times I'll introduce the idea of capsaicin. Have you heard of this before? If you have, you know, it's just like, what's in a hot pepper? It's a compounded ingredient, and it is sort of like the active ingredient in hot peppers. And basically we tell patients they need to apply a hot pepper to their.

Dr. Sameena Rahman [00:22:48]:

Vestibule, which is already burning, which I.

Dr. Sameena Rahman [00:22:50]:

Know doesn't make any sense, but what we do is we give them sort of a protocol, like maybe you'll apply.

Dr. Sameena Rahman [00:22:56]:

For 10 seconds and then right off.

Dr. Sameena Rahman [00:22:58]:

And then put on some ICE, and maybe you apply to 20 seconds the next day. And we try to get them to where they can put it on there.

Dr. Sameena Rahman [00:23:05]:

For 20 minutes, 20 minutes a day for twelve weeks.

Dr. Sameena Rahman [00:23:08]:

And the studies are showing some great consistency with that, reducing their pain.

Dr. Sameena Rahman [00:23:13]:

And what we think is happening is we're overloading the receptors there, the pain receptors, the capsation is overloading it.

Dr. Sameena Rahman [00:23:20]:

All of a sudden you're getting desensitized to it.

Dr. Sameena Rahman [00:23:22]:

So this works.

Dr. Sameena Rahman [00:23:23]:

We don't know if it works forever.

Dr. Sameena Rahman [00:23:26]:

But for a lot of patients, it works for a very long time. For some patients, it works for just months to years. But for patients that can get on.

Dr. Sameena Rahman [00:23:35]:

Board with it, I mean, imagine telling.

Dr. Sameena Rahman [00:23:36]:

Someone who's had pain in their vestibule their whole life, or when they touch.

Dr. Sameena Rahman [00:23:40]:

Hey, can you now put some hot.

Dr. Sameena Rahman [00:23:41]:

Chili pepper down there?

Dr. Sameena Rahman [00:23:42]:

Because I think it's going to help you.

Dr. Sameena Rahman [00:23:44]:

Most patients aren't jumping for joy for doing that. We do that as an option.

Dr. Sameena Rahman [00:23:49]:

But what is really definitively the management.

Dr. Sameena Rahman [00:23:52]:

Is to remove the vestibule surgically.

Dr. Sameena Rahman [00:23:54]:

And we do that by removing the entire vestibule, not just the bottom part? Not just the top. We have to remove the entire vestibule, and that's called a vestibulectomy. And then we can advance the vagina to cover the bottom part of the vestibule.

Dr. Sameena Rahman [00:24:09]:

That's called a vaginal flap.

Dr. Sameena Rahman [00:24:11]:

But it is a procedure that many.

Dr. Sameena Rahman [00:24:12]:

Of us in sexmed do.

Dr. Sameena Rahman [00:24:14]:

And as a procedure as a whole, it doesn't take a lot of time. It's not such a complicated procedure.

Dr. Sameena Rahman [00:24:21]:

There's a lot of suturing and a.

Dr. Sameena Rahman [00:24:22]:

Lot of pain you experience afterwards. I think the recovery is the hardest.

Dr. Sameena Rahman [00:24:26]:

Cell for most patients because it can.

Dr. Sameena Rahman [00:24:28]:

Be weeks, it can be months for some patients because the tissue can get irritated. You don't have a vestibule anymore, so.

Dr. Sameena Rahman [00:24:36]:

Yeah, the pain is gone, but maybe.

Dr. Sameena Rahman [00:24:38]:

You can develop some irritation down there, but it is a procedure that works. Once you remove the vestibule, the first two weeks are pretty hellacious for most patients. They can't get up and move around that much.

Dr. Sameena Rahman [00:24:49]:

It's a dependent area. You're sitting on it.

Dr. Sameena Rahman [00:24:51]:

You get pain control. You have some ICE packs that you.

Dr. Sameena Rahman [00:24:55]:

Live on, all the stuff.

Dr. Sameena Rahman [00:24:57]:

Once you get through that, between four.

Dr. Sameena Rahman [00:24:59]:

And six weeks, you're doing better.

Dr. Sameena Rahman [00:25:01]:

Around eight weeks, what happens? Are you going to have sex then? Unfortunately not, because what's happening when you're in pain after a post vestibulectomy, you are clenching your muscles again. Your muscles are becoming totally hypertonic and tight again. So even if you wanted to have intercourse, you'd have severe vaginismus and you.

Dr. Sameena Rahman [00:25:21]:

Wouldn'T be able to get penetrated.

Dr. Sameena Rahman [00:25:23]:

So then once the area has healed up in six to eight weeks, we can then start pelvic floor therapy. And that pelvic floor therapy is very rigorous. We try to get you in there.

Dr. Sameena Rahman [00:25:35]:

A couple of times a week, and.

Dr. Sameena Rahman [00:25:37]:

Sometimes we have to use vaginal botox.

Dr. Sameena Rahman [00:25:39]:

Like I said, and it works very well for most patients.

Dr. Sameena Rahman [00:25:42]:

When you get in there, the vestibulectomy, the pelvic floor therapy, within a few.

Dr. Sameena Rahman [00:25:46]:

Months, you are able to have pain free sex.

Dr. Sameena Rahman [00:25:50]:

And then we all celebrate. I don't know if you guys know.

Dr. Sameena Rahman [00:25:52]:

That Saturday light live skit that came.

Dr. Sameena Rahman [00:25:55]:

On in the early two thousand s, I think with Adam Sandberg. I just had an acon.

Dr. Sameena Rahman [00:26:02]:

I just had sex and it feels so good.

Dr. Sameena Rahman [00:26:04]:

My pelvic floor therapist and I send each other that meme whenever a patient tells us they've had successful intercourse. And we're like, congratulations on all this.

Dr. Sameena Rahman [00:26:12]:

Sex, but you do need the pelvic floor therapy.

Dr. Sameena Rahman [00:26:16]:

What else you might need in that recovery period is you need cognitive behavioral therapy and possibly a shift in mindset, possibly as well as sex therapy. The reason is you are somebody that has lived with this potential pain for years and years, and all of a sudden your vestibule is removed and your.

Dr. Sameena Rahman [00:26:35]:

Pelvis is fine and you're supposed to.

Dr. Sameena Rahman [00:26:37]:

Believe that the pain has gone away. Sometimes it's hard to convince a patient of that. And so they get hesitant and they can't overcome the vaginismus aspect. And so that's when I'll prescribe to them. One of my friends and colleagues wrote a book, Dee Hartman.

Dr. Sameena Rahman [00:26:53]:

It's called the Pleasure Prescription, a guide.

Dr. Sameena Rahman [00:26:55]:

To overcoming sexual pain or something like that.

Dr. Sameena Rahman [00:26:59]:

But anyway, it's a healing guide. It really is. It gives you exercises and things to do at home for mind body connection.

Dr. Sameena Rahman [00:27:06]:

It's a wonderful book.

Dr. Sameena Rahman [00:27:07]:

But I also just have patients see a very good therapist that can work.

Dr. Sameena Rahman [00:27:11]:

With them on mind body connection.

Dr. Sameena Rahman [00:27:14]:

So that's in a nutshell.

Dr. Sameena Rahman [00:27:16]:

Vestibulodymia.

Dr. Sameena Rahman [00:27:18]:

I emphasize neuroproliferation, the nerve densities, the hormones and how it affects that very specific piece of tissue that really takes up so much of my life on a day to day basis. I love it. I love being a sex detective, let me tell you. But hopefully you guys learned something. These things are very difficult for patients to navigate, and it's very hard for patients to overcome most of this, to be honest with you, because they've been gaslit for years and the issues that recurrently come up.

Dr. Sameena Rahman [00:27:49]:

But what I will say is that there is hope and patients can find help.

Dr. Sameena Rahman [00:27:53]:

And if you go to www.isshiswish.org, there are many clinicians on there that perform these procedures that do these tests that can help you navigate your sexual pain journey. And so I'll leave you with that information and hopefully you remember how important the vestibule is to your sexual health. It is the piece of tissue standing between you and the external world and the vagina. And sometimes that tissue has to go. Sometimes that tissue needs to be gone.

Dr. Sameena Rahman [00:28:25]:

In order for you to have pain.

Dr. Sameena Rahman [00:28:26]:

Free sex, and that is a birth defect.

Dr. Sameena Rahman [00:28:29]:

Other times we got to look at.

Dr. Sameena Rahman [00:28:30]:

Why the hormones are deficient in that area and what we need to do about it. Can we remove a factor? Can we do anything about this? But in general, there is help and there is a cure and there are things that we can do for all of you that are suffering out there. I am here to educate so you can advocate for yourself and live your best sexual life. So please, please spread the word about the vestibule. If your clinician has never heard of it or knows how to examine it, send them to ishwish or find a new one anyway.

Dr. Sameena Rahman [00:29:05]:

So I'm here to educate so you.

Dr. Sameena Rahman [00:29:07]:

Could advocate for yourself. And please leave me some comments. Let me know what you think, what's your journey like and please subscribe to my channel. I'd love to have you guys continue to listen to my episodes.

Dr. Sameena Rahman [00:29:20]:

This is gynogirl presents sex, drugs and hormones.

Dr. Sameena Rahman [00:29:23]:

Please tune into my next episode and I will catch you guys later.

Dr. Sameena Rahman [00:29:27]:

If you have a second, please subscribe to this podcast.

Dr. Sameena Rahman [00:29:30]:

I'd love for you to be a follower and learn as much as you can about the things that we're going to talk about with all the people on our journey. Please review us on Apple or Spotify or wherever you listen to podcasts. These reviews really help review us. Comment tell me what else you want to hear to get more information. My practice website is ww cgcchicago.com. My website for Gynogirl is ww gynogirltv.com. My Instagram is girl so please follow me for some good content. Additionally, I have a YouTube channel, Gynogirl TV, where I love to talk about all these things on YouTube and please subscribe to my newsletter, Gynogirl News which will be available on my website.

Dr. Sameena Rahman [00:30:17]:

I will see you next time.