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:

Practice

GynoGirl Website

Instagram

Youtube

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.

Hello.

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.

And a menopause specialist.

And I own my own practice.

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

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.

Conditions that are going to be discussed in future episodes.

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.

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.

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

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

Of this and how it really can.

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

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

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

Now, I think that most of you.

Who read this article were intrigued, but.

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

Can affect your libido.

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

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

Impact your sexual function.

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.

Why, and then we will get into.

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

When it comes to pain with initial.

Penetration, basically, pain at any provocation, any.

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.

Vulvodya vestibulody.

Vestibulitis. Vulvar vestibulitis.

What the frick does that mean?

These are descriptive terms, right?

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

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.

The vulva, and then there's vestibulodenia.

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

Tissue that is very biologically unique.

If your outer lips are your labia.

Majora and your inner lips are your.

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.

Urethra and to the bottom of the perineum.

It's a circular piece of tissue.

It's a unique piece of tissue.

We say that because it's really fundamentally.

Different than the outer external labia menorah.

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.

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.

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.

In your urakus for your umbolicus, your belly button.

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.

It's on provocation. Right.

So we have is.

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

Society for the Study of Women's Sexual.

Health, Ishwish, which I talk about a.

Lot on this podcast, along with ISSVD.

The Society for, International Society for the.

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

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.

We call that hormonally mediated vestibulody.

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.

Concurrently lead to pelvic floor dysfunction, which.

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.

Hymen remnant extending up through the urethra.

And down to the perineum.

It's delineated from the outer labia through.

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.

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

The inner labia menorah, the outer labia.

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.

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

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?

Like, what's going on?

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

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

It needs testosterone.

It needs estrogen.

And when you're on something that diminishes.

It or you are in a hormonal.

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

And what patients, they feel like it's.

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.

Able to use a tampon, a patient.

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.

And what do we do?

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.

We look for these subtle changes that.

Other people might not pick up.

Like what happened to your labium menorah?

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

And then we touch with the qtip.

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.

Of that top part of that vestibule.

Is really right next to the urethra.

Right?

It's right there.

And you can get this feeling of urgency.

You can get urgent continents.

I got to go.

I got to go. I got to go.

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.

We are in a deficient hormonal environment.

And your liver, like I said, when.

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.

That actually have a progesterone that is.

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.

Right.

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.

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

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.

So years may go by, and all.

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.

Other hormonal deficient states or other medications.

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

Patients that are lactating, you have really.

High levels of prolactin.

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

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.

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

All right, I'm taking a day off.

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

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.

We should actually call all of it.

The genital urinary syndrome of hormone deficiency.

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.

And homers really rule our lives.

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

To develop this pain with sex. They start clenching.

They start clenching. They start clenching.

What happens when you touch a hot stove?

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

You don't even think about it.

The same thing happens when you're feeling.

This burning sensation down there.

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

It's irritating you.

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

It's irritating you.

Whatever the case may be, all of.

A sudden you're having this pain sensation.

Your muscles are going to clench in response.

When they clench like that, they become shorter.

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

When you feel like a spasm bat.

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.

And so to compound the fact that.

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

Have pain related to the pelvic floor.

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

Get this lactic acid that builds up.

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

Who just have a lot of anxiety.

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

They have TMJ, or they've been really.

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.

Again, what we do is that little qtip test.

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.

Oh, my God.

Are you touching me with a knife?

What's happening down there?

And if the pain is limited to.

Say, four anyway, so you're clenching.

If your pain is limited to, say.

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.

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

Vaginal Botox, which does wonders for the pelvic floor.

It forces the muscles to relax, but.

It also decreases pain and nociception in that area.

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

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

We're sex detectives, right?

We take a history.

We listen to what you're saying.

We take an exam, do a qtip.

Test, and then to feel your pelvic floor muscles.

We look at your vulva closely, we.

Look at your clitoris.

We do all the good things that.

Need to be done.

We determine sometimes we may get blood work.

We may see what your total t.

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

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

Hormone binding globulin is.

And then what we do is we.

Figure out, is there an inciting agent.

That we can stop?

Right when we're talking about medications, the.

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

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

Again, you don't want to stop.

Maybe you don't want to stop.

Maybe you want to stop.

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

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

But you do that.

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

Been on, like, tamoxifen or.

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

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

If there is, if you're on the.

Birth control pill, maybe I'll have you.

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

Or maybe you try like a barrier method.

Maybe you try something that's not going.

To affect your ovulation, your ovarian function.

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.

An estrogen cream that's either zero, one.

To zero, 3%, as well as a.

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

And by six to twelve weeks, you.

Should see some diminished pain, along with.

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

All of those things need to be.

In the biopsychosocial approach to treating this disorder.

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

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

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

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

Where I was forced to have a.

Pap, even though I've never had intercourse.

Or anything surrounding that.

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.

This their whole life.

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

Remember how unique that tissue is.

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

Nerve endings down there.

Okay?

That's the bottom line.

And they may.

60% of these patients have pain at.

Their belly button if you touch it.

Or sensitivity of their belly button.

And that's one thing that we always.

Ask patients to do, like fill your belly button.

Let me fill your belly button.

Is that discomforting?

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

Has this neuroproliferative vestibulody.

You can acquire it, too.

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

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

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

With this painful periods their whole life.

Can develop this increased nerve density at.

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

To inflammation or allergies.

We're learning more about it, but you.

Can acquire and get it secondarily.

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

I have an endometriosis.

I have all these potential things that.

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

Decided to house themselves at my vestibule.

What?

We have that either situation again.

We go back to the history.

We delve deep into your history.

Okay?

This has been happening since I was 16.

I couldn't put in a tampon.

This has been happening since the first.

Time I tried to have intercourse.

I've never had penetration.

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

Their pelvic floor all the time.

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

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

A sudden, you've developed vaginismus and nothing.

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

Okay.

And so that makes it even more challenging.

And these patients oftentimes have only been treated with vaginismus.

They've been told to use dilators.

Go home and use dilators.

You'll be okay.

Go home.

Or they'll see a pelvic floor therapist.

And get pelvic floor therapy till the cows come home.

But they're still not pain free, and.

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

So back to the qTip.

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

What is your pain scale? Do you feel pressured?

Most people feel nothing.

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

Oh, my God, I got to.

Get off me.

Pain.

What are you doing to me down there?

Pain.

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

Vet, a vestibular anesthesia test.

And we put something like a benzocaine.

A lidocaine, a tetracrane cream, which is.

Basically an topical anesthetic.

And we place it at the vestibule.

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

Of the time, patients are down to.

A zero out of ten.

They feel nothing.

It's the first time in their life.

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

They wear tight clothes, they feel it.

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

All the different types of things where.

Your vestibule can get touched.

And so then we realize that, hey.

We need to try something different.

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

That's a band aid, really, right?

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

To apply something to stop the pain.

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.

Vestibule, which is already burning, which I.

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

For 10 seconds and then right off.

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.

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

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

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

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

So this works.

We don't know if it works forever.

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.

Board with it, I mean, imagine telling.

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

Hey, can you now put some hot.

Chili pepper down there?

Because I think it's going to help you.

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

But what is really definitively the management.

Is to remove the vestibule surgically.

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.

That's called a vaginal flap.

But it is a procedure that many.

Of us in sexmed do.

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

There's a lot of suturing and a.

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

Cell for most patients because it can.

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

Yeah, the pain is gone, but maybe.

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.

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

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

Live on, all the stuff.

Once you get through that, between four.

And six weeks, you're doing better.

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.

Wouldn'T be able to get penetrated.

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.

A couple of times a week, and.

Sometimes we have to use vaginal botox.

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

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

Months, you are able to have pain free sex.

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

That Saturday light live skit that came.

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

I just had sex and it feels so good.

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.

Sex, but you do need the pelvic floor therapy.

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.

Pelvis is fine and you're supposed to.

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.

It's called the Pleasure Prescription, a guide.

To overcoming sexual pain or something like that.

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

It's a wonderful book.

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

With them on mind body connection.

So that's in a nutshell.

Vestibulodymia.

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.

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

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.

In order for you to have pain.

Free sex, and that is a birth defect.

Other times we got to look at.

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.

So I'm here to educate so you.

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.

This is gynogirl presents sex, drugs and hormones.

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

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

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.

I will see you next time.