Accurate diagnoses important in alleviating pain

By Ginger Manley | Posted: Sunday February 10, 2013
Dear Ginger,

I have been reading your columns and have visited your web page (www.gingermanley.com) in search of an answer to my problem. I suffer from dyspareunia. I have seen numerous ob/gyn doctors over the years; I have had a complete hysterectomy; and I am still hurting. I don't know where to turn for help. I would appreciate any guidance you can render. Thank you.

Laura


Dear Laura,

I can well imagine how frustrated you are with the medical system, not to mention the disruption in your life from the pain you are having. Having a long-term chronic pain disorder is indeed a lonely and sometimes scary place to be.

Dyspareunia (dis-par-une-e-ah) is a medical term meaning pain occurring during sexual intercourse. Sometimes other types of pain in the genital area are called vulvodynia or vaginismus, depending on the exact location. Often these terms are applied broadly to mean any kind of painful event related to the vulva or vagina, like painful pelvic examinations or pain with inserting a tampon, or pain that occurs within the vaginal or pelvic area even in the absence of any activities.

As with most pain-type problems, the name of the pain tells us very little about its cause and gives little information about what may help relieve the pain. What is of greater importance is an accurate diagnosis of the cause of the pain. Finding someone who can do this is sometimes difficult, but nowadays most larger medical centers have clinicians on staff that specialize in female pain disorders. These specialists may be gynecologists, women’s health care nurse practitioners, gyneco-urologists, pelvic floor physical therapists or a combination of all of these. If you live in an area that does not offer such specialty practices, you may need to travel to a larger medical center and plan to be there a day or so to complete a comprehensive evaluation.

The first part of such an evaluation involves sharing as many pieces of your story as possible. You may be asked to complete a detailed history form with many questions. For instance, how long have you experienced this pain? What type of pain do you have – knife-like, pressure, jabbing, sticky, fluctuating or intermittent, throbbing, other? On a scale of zero to 10, with 10 being worst, what is your usual pain? What range of the 0-10 scale do you experience? Has anything made it better or worse? Is it there in every attempt at intercourse or with every type of vaginal insertion? Do certain sexual intercourse positions help or worsen the pain? Do you avoid those activities that bring on the pain? For what reasons did you have your complete hysterectomy? Did the dyspareunia get better or worse after surgery? What medicines, including replacement hormone therapy, are you taking? How is your health in general, including mental health (which often goes downhill when a person has chronic pain)? How is your relationship faring because of this pain disorder? How motivated are you both to getting this resolved?

You will then be seen by one or more of the above clinicians, each of whom brings a different perspective to the examination. Each of them will have specific questions in addition to those I listed above. Each will also need to examine you, paying special attention to anything that mimics the pain you are having. While an exam itself may be painful, they will do all they can to help you to be comfortable and to promote relaxation. In addition to doing a physical examination, including a complete pelvic exam, the gynecologist and/or nurse practitioner may need to examine some tissues under magnification or with special instruments. Occasionally an ultrasound or an MRI or CAT scan may be necessary to rule out any growths or other structural problems. The pelvic floor physical therapist will evaluate neuro-muscular strength or weakness in the vagina and inside the pelvis. Sometimes this is accompanied by use of diagnostic instruments that may be inserted into your vagina or with sensors that are placed on the skin in the vaginal area.

While none of us looks forward to any of these tests or examinations, they are essential for getting an accurate diagnosis, and only then can appropriate treatment be started. Most problems involve a combination of factors, and all of these need to be addressed. IN the last 10 years, treatment for pelvic pain disorders such as dyspareunia has improved greatly over what was available in earlier years. Today a woman may expect to begin regular pelvic muscle exercises, usually prescribed by the pelvic floor physical therapist and done initially under that person’s supervision, then in follow up on one’s own time. She will frequently be given pain medication or muscle relaxants or both specifically to manage the disorder. These may be given as vaginal inserts or occasionally by trigger-point injections directly through the vaginal wall. She may be asked to use progressive vaginal dilators as her level of pain will allow. Recently, Botox injections given into the vaginal wall have been found to cure one specific kind of dyspareunia – vaginismus, a painful spasm of the vaginal muscles.

Frequently a woman is asked to refrain from intercourse in the early stages of treatment, introducing this activity only when she has become comfortable accepting a dilator of similar size. If she is in a partnered relationship, it is very helpful for that partner to be present both during the evaluation and when the recommendations for treatment are made. An informed, loving, caring, and patient mate can be enormously helpful as a coach and supporter while a woman heals from her dyspareunia. The good news is that almost every woman who has dyspareunia can be helped – a far different picture than when a woman was expected to suffer in silence. Please keep me posted on your progress, Laura.

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