Vulval Pain & Intimacy

BETWEEN THE COVERS

in Menopause

Cara Richmond Masters in Physio, Pelvic Health Normal Anatomy and Female Sexual Arousal

Perimenopausal changes to anatomy and arousal

Menopausal Pain with Intimacy

Sexual Health Questions

Content Normal

Anatomy & Female Arousal Normal Anatomy The Vulva

https://www.mayoclinic.org/vulva/img-20005974 Normal Anatomy

The Clitoris

www.formafgc.org/news ONLY 25-40% of women experience orgasm with Normal penile vaginal intercourse

Female Arousal BUT, 90% of women report an orgasm from some form of sexual stimulation

9, 11, 14, 15 Normal Female Arousal

1. Excitement 2. Plateau • ↑HR and RR • Further ↑ blood flow to vagina • ↑Vaginal lubrication • ↑ clitoris sensitivity • ↑Muscle tension • Further ↑ RR and HR • ↑Nipple hardening

7, 9, 11, 14, 15 Normal Female Arousal

3. Orgasm 4. Resolution • Pelvic Floor mm and uterus contracts • Body returns to normal slowly • Intense sensation of pleasure • Erect body parts return to previous size and colour

7, 9, 11, 14, 15 Menopausal

Anatomy and Arousal Menopause • ↓ Lubrication • ↓ Libido Hormonal Changes • ↓ Engorgement to vulva & clitoris • ↓ Intensity, frequency or ability to have a satisfying orgasm

• Pelvic Floor muscle atrophy 1,2,3,4,6,7,8,10,12,13,14,16 Menopause • Stress / Anxiety • Changes in body confidence, Self esteem

Psychological • Worries about partner’s satisfaction Changes • Fear of pain or failure to have an orgasm

• Relationship issues

7,9,11,14,15 Menopause • Excitement Phase

Changes to • Plateau Phase Arousal • Orgasm

• Resolution

7,9,11,14,15 Menopause Excitement Phase

Changes to • ↑ Time for excitement & arousal Arousal • ↓ Nipple sensitivity, and fullness

• ↓ Sensation of vaginal fullness

7,9,11,14,15 Menopause Plateau Phase

Changes to • ↓ Clitoral sensitivity Arousal • Plateau phase may be longer

• i.e. harder to get to orgasm

7,9,11,14,15 Menopause Orgasm • ↓ Intensity Changes to Arousal Resolution

• Less likely to achieve multiple

orgasms 7,9,11,14,15 Menopausal

Pain with Intimacy

6,8,10,13,18 Vulvovaginal Lichen Lichen Planus atrophy Sclerosus Menopausal Overactive Pain with Intimacy Vestibulodynia pelvic floor Vaginismus /clitorodynia muscles Vaginal Atrophy

https://vagifirm.com/natural-cure-for-vaginal-atrophy/ 4,6,8 Lichen sclerosis

6,8 Lichen Planus

Lichen Sclerosis VS Lichen Planus

https://www.semanticscholar.org/paper/Unexpectedly-high-frequency-of-genital- involvement/1 Non relaxing pelvic floor Usually tight and weakened Overactive Pain can refer Pelvic Floor Vaginal aching and heaviness Muscles Associated with bowel and bladder dysfunction

7,9,11,14,15 Vulvodynia Vestibulodynia / Clitorodynia

Vulvodynia Classification Location Pain Provoked / unprovoked

Neuropathic pain syndrome

Vestibulodynia Clitorodynia What does neuropathic pain mean?

18 Vulvodynia Vestibulodynia / Clitorodynia

What does it feel like? Location / sensations

Causes: • Multifactorial • More common in Caucasian women • Ass with co-morbities • Ass with Hypermobility • Possible hormonal, immune and genetic contributions Vaginismus

Involuntary spasms of the vaginal muscles which prevent any type of vaginal penetration

• Primary vaginismus

• Secondary vaginismus Treatment

Menopausal pain with intimacy Pelvic floor Dilators & Lubricants & Physio TENS Moisturizers Treatment Hormonal Replacement Counselling Referral therapy Pelvic Floor Normalisation

6,18 https://www.intimaterose.com/products/silicone-vaginal-dilator-set-8-pack Dilators

18 • Changes the way that the nerve fibers in the vulva respond to pain, touch, pressure and other sensation including hot/cold

• Time: 30 mins per day for at least 6-8 weeks

Vulval TENS • Frequency (Hz): 80 -100

• Pulse Width (s): 100 -120

• Intensity: as much as comfortably tolerated without any discomfort

19 Lubricants • Water based Sliquid

• Silicone based Uberlube

• Plant Oil Organic YES

• Natural based Sylk / Olive and Bee 3,4,6,8,18 Vaginal moisturisers Hormone replacement therapies

• Epithelial tissue of the vagina and urethra are very sensitive to oestrogen

• Systemic and topical vaginal oestrogens are available

• Guidance from gynes and GP’s re: who is suitable

6 8, 15, 16 Sexual Counselling

1, 2, 4, 10, 14 Further referrals

• If clinical suspicions indicate skin conditions e.g. lichen sclerosus

• Pain sensitisation e.g. chronic vulvodynia

• LUTS symptoms of vaginitis

• MDT works best at managing chronic pain e.g. GP’s, Dermatologists, Pain Specialists, Gyne’s Sexual Health Questions • Do you know about vaginal lubes & moisturisers? • Do you have any vaginal or vulval itching? • Do you have pain at rest in the vagina or vulval areas?

Sexual Health Questions Sexual Health Questions Summary Questions? • 1. Bancroft, J., Loftus, J. & Long, S. (2003). Distress About Sex: A National Survey of Women in Heterosexual Relationships. Arch or Sex Behav, 32(3), 193-208.

• 2. Basson, R. (2000). The Female Sexual Response: A Different Model Rosemary Basson. Journal of Sex &Marital Therapy, 26:1, 51-65.

• 3. Brody, S. (2007). Intercourse Orgasm Consistency, Concordance of Women’s Genital and Subjective Sexual Arousal, and Erotic Stimulus References Presentation Sequence. Journal of Sex & Marital Therapy, 33, 31–39. • 4. Davis, S. & Jane, F. (2011). Sex and Perimenopause Focus Menopause. Aust Family Physician,40(5), 274-278.

• 5. Jones, R. & Barton, S. (2004). Introduction to history taking and principles of sexual health. Postgrad Med Jou, 80, 444-446. • 6. Kao, A., Binik, Y.m Kapuscinski, A. et al. (2008). Dyspareunia in postmenopausal women: A critical review. Pain Res Manag, 13(3), 243-54.

• 7. Lloyd, E. (2005). The Case of the Female Orgasm: Bias in the Science of Evolution. Harvard University Press; Cambridge, MA.

• 8. Martin, K., Barbieri, R. & Crowley, W. ( Treatment of menopausal symptoms with hormone therapy (2019). UpToDate, retrieved from https://www.uptodate.com/contents/treatment-of-menopausal-symptoms- with-hormone-therapy, 29,04,2019.

References • 9. Masters, W.H. & Johnson, V.E. (1966). Human sexual response. Little Brown, Boston.

• 10. Nekoolaltak, M., Keshavarv, Z., Simbar, M., Nazari, M. & Baghestani, A. (2017). Women’s orgasm obstacles: A qualitative study. Int Jou of Reprod Biomed, 15(8), 479-490.

• 11. O’Connell, H., Hutson, J., Anderson, C & Plenter R. (1998). Anatomical relationship between urethra and clitoris. Journal of Urology, 159(6), 1892-7. . References

• 19 Murina, F., Bianco, V., Radici, G. et al. (2008). Transcutaenous electrical stimulation to treat vestibulodynia: a randomised controlled trial. International Journal or Obs and Gyne, 1165-1170.. Thank YOU

Cara Richmond Masters in Physio, Pelvic Health