May Knowledge Drop
Each month for our newsletter, the Lady Blurb, we'll share answers to some pelvic health questions you've submitted. The questions below were taken directly from you! To submit a question for next month, comment below or email us at contact@ladybirdpt.com.
**The answers to these questions are not meant to be used as medical advice. These answers are not meant to take the place of a skilled physical therapist or discussion with your medical provider. If you are experiencing concerning symptoms, please contact your physician.**
This month, we’re answering:
How do I know if my vulvovaginal pain is hormonally mediated?
What’s the Q-tip test and why would my pelvic floor PT do one?
How can pelvic floor PT help folks experiencing infertility?
1. How do I know if my vulvovaginal pain is hormonally mediated?
First things first - let’s define vulvovaginal pain. Vulvovaginal pain is a relatively non-specific term that means pain anywhere in the vulva or vagina. This can mean pain in the labia majora, labia minora, clitoris, urethral or vaginal opening or deep in the vaginal canal.
There are quite a few common causes of vulvovaginal pain including:
pelvic floor, abdominal, adductor or diaphragm muscle tightness or dysfunction
infections like urinary tract infections, bacterial vaginosis, yeast infections or STIs
poor daily habits like staying chronically dehydrated, sitting for extended periods of time on hard surfaces, holding your pee or poop when you need to go
nerve injuries to the pudendal or other lumbosacral nerves
a reduction in available hormones, specifically estrogen and testosterone
Working with a pelvic floor physical therapist can help you determine the why behind your pain, and which of these common causes may be contributing to your symptoms. It’s always important to determine the cause of symptoms because this drives how we choose appropriate and effective treatments moving forward. We determine the cause by asking the right questions and performing the right tests, along with watching how your body responds to the treatment plan as we progress treatment.
Now let’s touch on why hormones matter in the first place. The tissue along your vaginal opening, also called your vestibule, is extremely hormonally sensitive. When your body experiences either a total or available reduction of estrogen or testosterone, your vestibule experiences a reduction of estrogen or testosterone. When these tissues are deprived of hormones, they get thin, dry and sensitive which leads to pain, tearing, bladder symptoms and a generally unhappy vestibule.
So how do we know if your vulvovaginal pain is caused by hormones? The best way to determine the cause of your pain is to come in and see us, but there are some signs that may mean you want to consider hormones while seeking treatment for your pain.
Here are some signs that your vulvovaginal pain may be hormonally mediated and you should see an experienced pelvic floor PT for further testing:
Your pain is right at your vaginal opening: Remember, it’s your vestibule that’s highly sensitive to hormones, not the vaginal canal. While folks can experience pain both at the vaginal openings AND deeper, those two pains are often driven by different causes. Pain at the vaginal opening is often a sign of hormonal symptoms.
Your pain started after childbirth: Estrogen levels drop immediately after the birth of the placenta. This dip has been shown to contribute to vestibular pain.
Your pain started while you were lactating: While estrogen levels drop with the birth of the placenta, they stay low while someone is lactating. Learn more about this connection here.
Your vaginal opening tears easily or is thin, pale and dry: These are all signs of hormonally deprived tissue.
You also have urinary urgency, urinary frequency or other UTI like symptoms: The vestibule is made of the same embryological tissue that lines your urethra and bladder. These tissues are also hormonally dependent. It’s common for folk with hormonally mediated vulvovaginal pain to also have urinary symptoms.
You’re perimenopausal or menopausal: This is another time in life that folks experience a reduction in estrogen, triggering hormonally mediated pain and bladder symptoms. It has been recommended by leading sexual medicine physicians that all post-menopausal people are placed on topical estrogen for long term health.
You have a history of using oral birth control pills, Spirnolactone or Tamoxifen: Each of these medications causes a reduction in available testosterone at the vestibule, contributing to vestibular pain. It’s important to note that these levels do not necessarily revert following stopping the medication and may require treatment to return to healthy levels.
So with all that said, if you’re experiencing vulvovaginal pain, hormones need to be considered. There are a number of common causes of pain, but accurately determining the driver of your pain is the only way to accurately treat your pain. If you’re hurting and you’re ready to start feeling better, message us to book an appointment.
2. What’s the Q-Tip Test and why would my pelvic floor PT do one?
This is a perfect follow up to our first question! The Q-Tip Test is one of the tests your pelvic floor physical therapist can use to determine whether the pain at your vestibule, or vaginal opening, is driven by your musculoskeletal system or hormone deprivation. You can watch this video for a quick tutorial!
This test is incredibly low tech and simple. All we do is take a Q-Tip and start by getting your body used to how it feels to be touched by it. We start by touching along your inner thighs and labia majora. Then we separate your labia minora and touch different parts of your vaginal vestibule right on the inside of an anatomical structure called hart’s line.
I don’t like to tell folks what to expect because of the risk of biasing results, but based on what you feel, which tissue is more or less sensitive, we’re able to determine whether your symptoms have a high or low likelihood of being hormonally driven.
3. How can pelvic floor PT help folks experiencing infertility?
Let’s start by defining infertility. Infertility is defined as trying to conceive unsuccessfully for 1 year for folks under the age of 35 and 6 months for those 35 and older. Infertility can further be broken down into primary, secondary and unexplained infertility.
Primary infertility is defined by being unable to conceive. Secondary infertility is defined as being able to conceive but unable to carry a pregnancy to term. And while there are a number of causes of infertility, unexplained infertility is the designation for folks who have no known reason for experiencing infertility.
Pelvic floor physical therapy has been shown to improve fertility outcomes for folks with:
endometriosis
history of prior abdominal surgery or scar tissue in the pelvis
inconsistent or painful menstrual cycles and/or ovulation
PCOS
unexplained infertility
If you’d like a research roundup outlining the impact of pelvic floor physical therapy for folks experiencing infertility, click here.
So what does pelvic floor PT for infertility look like?
We start with a detailed history of your menstrual cycle, medical events, pregnancies or journey trying to conceive. We also dive into your general health profile including diet, exercise, daily habits. We discuss what you’ve tried to modify so far and any fertility treatments you’ve undergone. We also discuss any underlying bladder, bowel or sexual concerns that may be impacting your pelvic health. It’s not uncommon for folks to come to physical therapy following multiple unsuccessful rounds if IUI or IVF.
Following our conversation, we start with a detailed full-body physical examination which can include assessing your uterine, ovarian and bladder mobility and positioning, peritoneal cavity and lymph system, soft and connective tissue throughout your abdomen and pelvic floor. The assessment continues as sessions progress.
Based on our findings and your history, we’ll start creating a plan to begin systematically optimizing your fertility and treatment outcomes. Treatment may include manual therapy like ovarian and uterine mobilization, lymphatic massage, soft and connective tissue work amongst other techniques. It can also include guiding dietary changes, activity modifications and referrals to other specialists we may need on board. Working with a pelvic floor physical therapist during fertility treatments like IUI and IVF can help support your body throughout treatment to optimize outcomes.
If you’d like to learn more about treatment for infertility, contact us here.
Working with a pelvic floor physical therapist can help address sexual dysfunction, bowel and bladder concerns and help you prepare for pregnancy, birth and postpartum recovery. Contact us here to learn more about setting up an appointment with us, today!
This post was written by Dr. Rebecca Maidansky, PT, DPT, owner and founder of Lady Bird Physical Therapy. Rebecca is a pelvic floor physical therapist in Austin, TX and founded Lady Bird Physical Therapy in 2019. She is the creator of Birth Preparation and Postpartum Planning, Baby Steps Fitness and the head writer and editor of The Pelvic Press.
Rebecca is a passionate writer and vocal advocate for pelvic health and the importance of improving access to perinatal care. She believes strongly that many common pregnancy pains and postpartum symptoms can be eased or even prevented with basic education and care.
She created this blog to help all birthing people manage common pregnancy pains, prepare for birth and recover postpartum.