Vestibulodynia is a common sexual pain disorder that causes pain at vaginal inlet. ISSVD (International Society for the Study of Vulvovaginal Diseases) named the disorder as localized provoked vulvodynia disease instead of vestibulitis.

What are the Symptoms?

Pain is provoked when the vestibule is touched or tampon is used or by physical activities, such as cycling, and sexual intercourse. Pain and feeling of burn can persist for hours and it may make sexual intercourse impossible.

What causes vestibulondynia?

Analysis of tissue sampled from painful regions of women with vestibulondynia show numerous changes in comparison with the healthy tissue.

In vestibulitis, nerves are abnormal in count and appear enlarged.

Leukocyte influx to the tissue is found.

Recent studies demonstrated that mast cells play role in inflammation. Mast cells secrete various chemicals and starts inflammatory reaction.

What is the recently found relation between mast cells and depression and why is it important?
Glial cells support the nerve cells in brain and nervous system.

They play a key role in neuropathic pains and neurodegenerative diseases. As the mystery of mast cells and glial cells is solved, new hopes for treatments of patients with vestibulodynia arise.

Why is it so difficult to diagnose vestibulodynia?

Tissue changes cannot be seen with bare eye. Therefore, final diagnosis cannot be made for women who suffer from burn and pain in genital regions secondary to inflammation. Her partner, relatives and even she believe that she is caught by an imaginary disease.

What is the relation between depression and genital pain?

Vestibulodynia is mostly associated with depression. Genital tissue inflammation causes pelvic pain and neural inflammation and the depression aggravates the pain. Recent studies on the physiopathology of depression show that mast cells plays role by interacting with glial cells of the nervous system. Therefore, anti-depressant medication helps symptoms of the vestibulodynia.

Does every patient who cannot have sexual intercourse have vaginismus?

Before the vaginismus is diagnosed, it should necessarily be determined whether there is thickening and spasm in pelvic muscles secondary to pain. Anti-vaginismus therapies will not be efficient unless the pain is eliminated. Patients who cannot have sexual intercourse with her partner in spite of vaginismus therapy feels herself unsuccessful and lose self-confidence.

Result

Vestibulodynia is a chronic pain disorder that influences quality of life, career, relationships and sexual life of a woman. For this treatable conditions, patients and beloved ones experience the most difficult interval of time until the diagnosis is made. Unfortunately, many women suffer pain in their sexual life, since the diagnosis is missed or not made. Women with genital pain should necessarily be evaluated regarding vestibulodynia.

Pudendal syndrome secondary to trauma of the pudendal nerve due to falls is a condition that should be taken into consideration in winter days, since everywhere is covered by ice. Conditions that involve genital region, urinary tract, anus and many other systems can purely and simply start with fall on hip.
Pudendal syndrome is first manifested by a sudden ache or sensation of electric shock secondary to fall on buttocks or straining. Generally, complaints occur suddenly, but they may also develop slowly over the time.

What are the signs of the pudendal syndrome?

The most common sign of the pudendal neuralgia and pudendal nerve entrapment is pain.
Pain occurs in regions innervated by pudendal nerves and its branches.
Those regions are rectum, anus, urethra, perineum, clitoris, external genital region and one third caudal part of the vagina. Two thirds of the patients are women. In male subjects, penis and testicles are involved.

Sitting aggravates the pain. The skin is extremely tender to tactile or pressure stimuli. Most common signs in these regions:

Feeling of burn
Sensation of electric shock
Loss of sense
A sharp pain, similar to being stubbed
Ache
Sensation of pressure or foreign body in the vaginal canal or the rectum
Abnormal sensation of heat
Feeling of throbbing in response to bowel movements
Dysuria
Painful sexual intercourse
Involuntary persistent genital arousal
Pain after orgasm
Numbness
What are the other reasons of pudental syndrome?
Trauma after delivery
Intraoperative damages
Chronic mechanical pressure for years in cyclists
Diabetic peripheral neuropathy; diseases that cause vasculitis
Tumors that compress the pudendal nerve

How is the pudendal syndrome diagnosed?

The diagnosis is based on medical history and complaints of the patient. In the examination, tenderness in ischial spine is a typical finding. Mostly, patient specifies sacrococcygeal pain. It is necessary to rule out pelvic tumor and infections that can be confused with the pudendal syndrome.

3-Tesla MRI neurography, electromyography, pudental block and pudental nerve motor latency tests are used for diagnosis.

Treatment

It is necessary to eliminate the conditions that provoke the pain. It is necessary to avoid cycling, horse riding and sitting for a long time or other conditions that increase the pressure. Straining should be avoided while urinating or defecating.

Pudendal block is used for both diagnosis and treatment.

Tricyclic antidepressants, anticonvulsive agents and neuromodulators are oral preparations.
If pudendal nerve entrapment is found, surgical release of the nerve is a curative approach.

Cancer patients live longer thanks to developments in cancer treatments. When cancer is regarded as a CHRONIC disease, it is possible to better understand the importance of sexual life regarding well-being of cancer survivors.

Cancer poses hidden effects on the sexuality and anti-cancer treatment causes occurrence of sexual problems. The cancer has a strong negative influence on the sexual health and the sexual intercourse. Eighty percent of people with cancer experience a clear reduction in their sexual lives, while 44% live problems in their relationships with their partners. Even in Western countries, 84% of oncology patients seek help for changes in their sexuality and relationships during oncologic treatments. Mostly, patients do not feel comfortable talking about their sexual problems with the medical team, who administers the anti-cancer treatment, or even if they clearly express such problems, they cannot find well trained personnel.
Sexuality is a complex process that is regulated by effects of vascular system, secretory glands and neurological systems on the body. Age, general status of health and the medications used by the person play role in this process.

External factors of the sexuality are familial, social or religious beliefs and the person’s relationship with the partner. All those internal and external factors determine the personal sexual experience of an individual.

Cancer and anti-cancer treatments may cause sexual dysfunctions by impairing all those processes. Sexual drive, arousal, pleasure and orgasm may occur less frequently or even they may completely disappear.

WHY SEXUAL DYSFUNCTIONS OCCUR AFTER CANCER?

Breast cancer is the most common cancer for female subjects. One fourth of women with breast cancer are younger than age of 50 years (Burwell). Number of young women with breast cancer is increasing. Ever increasing number of women are diagnosed with breast cancer and they experience sexual problems that are secondary to anti-cancer treatments. Contrary to the popular belief, the problems are not seen only in acute period of the breast cancer. In 2009, Fobair and Spigel demonstrated that vaginal pain during the intercourse is very common in patients with chemotherapy-induced menopause even 1 year after the surgery.

Vaginal dryness and pain during sexual intercourse are important symptoms that are secondary to estrogen deficiency in female survivors of breast cancer (Graziottin). Ovaries secrete estrogen, testosterone and progesterone. Estrogens circulate in blood and bind to estrogen receptors that are found in breast and uterus. Estrogens ensure that vaginal epithelium stays moisturized and vaginal blood flow is regulated. Estrogen is responsible for making vaginal epithelium rich in glycogen and thickly lined.
Testosterone is related to arousal, sexual response and orgasm. Testosterone influences sexual emotions and libido. Progesterone is the hormone that makes the uterine wall ready for the fertilized egg. All those hormones play roles in sexual health.

Many chemotherapeutic agents cause dysregulated secretion of hormones. Chemotherapeutic agents decrease ovarian reserve and damages quality eggs. Alkylating agents pose toxic effect on ovary; they cause early menopause and sudden decrease in circulating levels of estrogen and testosterone.
Aromatase inhibitors and selective estrogen modulators are common adjuvant therapies used for breast cancer. Tamoxifen is a selective estrogen receptor blocker and influences female sexual health by causing vaginal dryness, vaginal tenderness, orgasm problems and decreasing the libido. Aromatase inhibitors prevent conversion of testosterones into estrogens and decrease circulating level of estradiol.
Chemotherapy-induced menopause is more traumatic than the physiological menopause process. Early menopause poses a severely negative effect on quality of the life. Libido decreases and women experience hot flashes, tiredness, vaginal dryness and pain during sexual intercourse secondary to low testosterone level. Moreover, hair loss and surgical removal of breast lead to sexual dysfunction based on emotional influences.

Pain during sexual intercourse, vaginal dryness, redness, tenderness, loss of elasticity of vaginal tissue, shortening and narrowing of vaginal canal, decreased vaginal secretions and change in vaginal pH are problems that women face with after breast cancer.

If sexual health examination is not ignored especially in young patients with breast cancer, quality of life is boosted.

Many women with breast cancer experience sexual problems and this condition causes changes in their relationships with their partners. Oncologic sexual medicine prepares the patients for the expected course and treatment and provides them with sexual health counseling, along with solution of sexual problems. No method that may pose a negative effect on the cancer treatment is used in this process.

HOW DO SEXUAL LIVES OF SPOUSES CHANGE?

When cancer is diagnosed and managed, spouse’s sexual life also changes. Many spouses do not mention about their own sexual problems while their spouses are having anti-cancer treatment. However, ignoring sexual problems helps neither the patient nor the spouse.
If the partner has a reproductive system cancer, 84% of the spouses specify that the cancer affects the sexual life negatively. This rate is 64% for non-reproductive system cancers. Treatments of breast cancer leads to ovarian dysfunction and therefore, it is in the group of cancer that influence the reproductive system.

Seventy nine of men with breast cancer in his spouse reported that the frequency of the sexual intercourse decreased (Hawkins).

When the breast cancer is diagnosed, 60% of the women are sexually active (Ganz PA). Accordingly, it is important that the sexual problems of patients with cancer are not ignored and they are managed for the sake of both the patient and the partner.

Breast cancer is the most common cancer in female subjects around the world. It is also the most common one of female cancers in Turkey. 1.7 million new cases of breast cancer are diagnosed every year and number of breast cancer survivors increases.

In the last quarter century, prevalence of the breast cancer increased by 50%. Thanks to early diagnosis methods and developments in treatment modalities, survival rates in breast cancer are around 90%. Breast cancer should be considered as a chronic disease; length of lifespan is longer than 10 years after diagnosis is made in 3/4 of cancer patients. Expectancy in quality of life increased since breast cancer became a chronic disease. 25% of women with breast cancer are premenopausal.

What is the prevalence of sexual disorders in women with breast cancer?

Sexual problems in women with breast cancer are too frequent to be ignored. Sexual function disorders in women with breast cancer within 2 years after the diagnosis are observed at a rate of 70%. Half of women with breast cancer experience sexual function disorders even after the period of 2 years.

Are sexual disorders of patients with breast cancer caused by psychological factors?

Undoubtedly, lack of sexual drive secondary to psychological problems is observed in women due to bodily changes and fear of recurrence and mortality. However, sexual problems that develop secondary to anti-cancer therapies are treatable conditions.

There are many sexual problems originating from physical factors that are caused by anti-cancer treatments.

Medicines that cease the ovulation causes a much more rapid and traumatic menopause than the physiological menopause. Night sweat prevents falling asleep and the priority of the tired and sleepless woman is to cope with the menopause. Lack of sexual drive is more frequent than the women in the group of physiological menopause.

Medicines that hinder estrogen secretion cause vaginal dryness, pain and irritation.

Chemotherapy agents cause decrease in estrogen and androgens. Decreased estrogen level is the underlying cause of the pain, loss of vaginal lubrication, reduction in sexual arousal and orgasmic problems during the sexual intercourse.

Chemotherapy can cause premature ovarian failure and infertility.

Loss of sensation may occur at radiotherapy target site. Tiredness secondary to radiotherapy leads to fatigue in woman for sexual activity.

Ovaries of the patients with breast cancer and BRCA mutation are surgically removed. These patients face sexual function disorders more frequently.

What should be advised to partners of women with breast cancer?

If your partner does not want to have sexual intercourse, this does not mean that she does not find you attractive or love you. She suffers from loss of sexual drive, pain during sexual intercourse and difficulty in arousal due to the adverse effects of treatments. Talking about sexual problems is the first step to solve them. These problems can be easily solved with sexual rehabilitation for breast cancer patients. 75% of married couples can overcome this process of fighting against this cancer with a stronger relationship.

Numerous Turkish women have concerns about sexual disorders and they suffer from pain and ache.
Healthy sexuality is the sexual satisfaction of the person without suffering emotional and physical pain. The person experiences sexual health and welfare both personally and in relationship with her/his partner.
In the presence of sexual problems, normal and healthy experiences are replaced with a sexual life in which the person feels unpleased.

Sometimes, sexual problems are so wearing that they reduce quality of life. It influences not only own life of the woman but also relationship with the spouse and sexual life of the partner.

Although sexual therapies for men are widespread throughout the world and novel medicines are continuously launched to the market continuously, medical community has knowledge and enthusiasm about treatments of male sexual dysfunctions. Unfortunately, sexual diseases of women, who account for half of the population, are ignored by doctors.

Sexual dysfunctions of women are diagnosed and managed by sexual medicine physician. Managing sexuality of women is to spend time and effort to understand the specific condition of each woman and to choose the most efficient and secure therapeutic option.

WHAT KIND OF RELATIONSHIP EXISTS BETWEEN DISEASES AND SEXUALITY?

Many diseases, including but not limited to hypertension, diabetes, hormonal disorders, neurologic disorders, cancers, gynecologic disorders and depression, affect sexual life. Moreover, radiotherapy, chemotherapy and medications, ranging from antihypertensive and anti-allergy medicines to oral contraceptives, pose negative effect on women’s sexuality.

– Effect of sexuality on diseases is an important subject that many women refrain from asking. For example, the right time to safely begin sexual life again for women who undergo cancer treatment, cardiac surgery, gynecologic surgery.

WHAT ARE THE MOST COMMON SEXUAL PROBLEMS OF WOMEN?

Poor sexual drive – hypoactive sexual desire disorder

It is characterized with decrease in or loss of sexual fantasies and sexual drive. Hormonal changes, menopause, antidepressants and contraceptive pills are the factors that cause loss of the sexual drive. If the condition persists over the time, women feel more stressed and mostly, they experience nervous relations with the spouse. There are therapies that help you find your lost sexual drive.

Sexual Arousal Disorder

Sexual arousal disorders account for 30% of female sexual disorders. Even if the sexual drive is intact, she experiences difficulty in arousal during intercourse or foreplay. Vaginal lubrication, vaginal swelling, which is necessary during sexual intercourse, increased blood flow and sexual arousal are lacking or minimal.

Many factors, such as diabetes, hormonal disorders, aging, radiotherapy and depression, impair the sexual arousal. Arousal disorders require personalized treatment.

Orgasm disorders

The term implies lack of or delay in the occurrence of the orgasm. If the woman never has an orgasm, it is a primary condition. Secondary disorder implies an orgasm problem that is experienced by a woman who has personal history notable for previous orgasm disorder.

For the primary orgasm disorders, major role is played by psychological factors, while physical factors are dominant in the secondary disorders.  Menopause, gynecologic surgeries, some antidepressants and diabetes prevents experience of orgasm by women.

Twenty percent of women experience the orgasm problem.

Sexual Pain Disorders

When fine emotions are replaced by pain, burn and ache and this condition recurs in every intercourse, woman abstains from sexuality even if she desires her partner.

Vulvodynia that causes pain during vaginal penetration, generalized vestibulodynia that results in pain in perineum and vestibule, endometriosis that leads to deep pain during intercourse or intraabdominal adhesions require different therapeutic approaches.

Vaginal atrophy and vaginal infections also cause irritation and pain.