Pain in the WHAT?

Many people are shocked to hear that our hormones have anything to do with pelvic pain while others find this to be no surprise. Let’s level the playing field. First thing’s first, understanding our anatomical landscape is helpful before diving into the nuances of how and when hormones can contribute to pelvic pain. 

There are areas of your body that are more sensitive to certain hormones than others. If we zoom out, the vulva and some of its more specific parts are highly dependent on our levels of estrogens and androgens to stay healthy and pain-free. For example, when we zoom in, the vestibule is the area right at the vaginal opening that includes the opening of the vagina and the opening of the urethra (where your urine exits your body). This is an area that is extremely rich in receptors that need hormones, like estrogen and testosterone, to stay healthy. 

Vestibulodynia is the term used when there is pain specifically in the vestibule, or vaginal opening. Entry-pain with intercourse is a common complaint of people with vestibulodynia. Pain in this area sometimes is described as raw, cutting, burning, or stinging. Vestibulodynia can also present like pain with urinating or burning pain in the urethra. These areas (the urethra and the vaginal opening) share the same type of tissue and hormone sensitivity. Sometimes, there can be visible redness in the vestibule or changes to the skin, such as thinning. Other times, everything may appear completely “normal” to the naked eye.

Pain in the vestibule can be categorized as provoked or unprovoked.

• “Provoked” means that the pain occurs when there is some sort of stimulus, such as with penetration or attempting penetration, palpating with a finger or Q-tip, inserting a tampon, etc. 

• “Unprovoked” means the pain at the vestibule occurs at rest or without any stimulus or irritant.  

Hormonally-mediated vestibulodynia is when there are hormonal contributors to pain in this area. For some people, this is solely the root cause of their pain. For others, this is a major contributor along with other factors, such as hypertonic or overactive pelvic floor muscles. There are other types of vestibulodynia as well, which we will cover in future blogs.

Talk hormones to me

When it comes to the vestibule, this area is extremely sensitive to estrogen and testosterone. You read it right – testosterone, too! Many people think that estrogen is what women have and testosterone is what men have. This is a huge societal misconception that is not backed by science. Many will be surprised to learn that the average female arguably has more testosterone than estrogen throughout her body over the course of her life. We all need estrogen and testosterone to maintain our body’s optimal functioning and health, especially when it comes to vulvovaginal health.

Speaking of estrogen, estrogen is anti-inflammatory. When we are lacking the estrogen we need, this creates the perfect storm for inflammation, which is a large contributor to pain. When it comes to testosterone, there are glands right around the urethra that rely on testosterone to do their job well. These glands are responsible for keeping this area well lubricated throughout the day and also during intimacy. 

Experts say that these vestibular glands near the urethra are also considered the prostate in females. Yes! You heard it right, women have a prostate too! When our hormone state systemically or locally to the area of the vulva or vestibule is disrupted, this can impact these glands' ability to do their job, leading to dryness and irritation. 

Why does this happen?

During phases of your life when hormones are disrupted, such as when lactating or during perimenopause or menopause, you may be more prone to pain in the vulva, vestibule, or vaginal opening. Other contributors may include current or prior use of combined hormonal birth control pills, medications like spironolactone that are often used for acne, removal of the ovaries, and breast cancer treatments. 

When someone is taking combined oral contraceptives (AKA “the pill”), they are suppressing the amount of estrogen their ovaries produce and replacing this estrogen with the often low dose provided by their birth control pill. Through a cascade of events that then unravel, testosterone is also lowered. Areas that are very estrogen and testosterone receptor-rich, like the vestibule, take the brunt of this deficiency. Many of the oral contraceptives contain a very low dose of estrogen, which while preventing pregnancies and used for other reasons, impacts the sensitive area at and around the vaginal opening. This is not a stop-using-any-birth-control-right-now plea, but it is a call to action to consider if this could be a contributing factor.

If we take breastfeeding as another example, this puts womens’ bodies into a similar state as they are in during menopause with symptoms including vaginal dryness, tissue thinning, pain with sex, etc. Through a process beginning with prolactin production, hormones such as estrogen are significantly impacted. There is far less estrogen production in both breastfeeding and menopausal life phases. During these stages, there is the potential for the perfect storm — for your body and vulva to be primed for possible painful experiences. 

Now just because you identify with one of the life phases or medication history listed does not mean you 100% have or will have pain anywhere in your vulva or vagina. However, there are a large number of people that do and will. This discrepancy may be due to other factors, such as our personal biology. We strongly believe that building an awareness of how our bodies work can help set the stage for wellness throughout the lifespan, help us with asking productive questions at doctor’s visits, and support our medical decision making throughout all of life’s transitions.

How can pelvic floor therapy help me?

When these sensitive areas are painful due to not receiving the adequate estrogen and testosterone that they need, this can cause the pelvic floor muscles to respond by guarding and tensing, which often causes penetration of any kind to be even more painful. To make matters more complicated, when the muscles are working overtime to guard and tense, then the sensitive areas like the vestibule are restricted from getting blood flow and the already minimized estrogen and testosterone needed. In other words, the hormone issue is twofold.

1. We may or may not be producing an adequate amount of hormones needed for vulvovaginal health, which can result in pain and irritation

2. Our pelvic floor muscles may be overactive and tense historically or newly tense in response to painful experiences due to the hormone issue, thus perpetuating the problem. The hormones that are circulating in the body may not be getting down to and permeating the sensitive vulvovaginal areas because the tense muscles are impeding blood flow.

What could treatment look like? 

Addressing the root cause in these cases requires collaboration with a pelvic floor therapist and gynecologist, which is most productive when they both specialize in pelvic pain or vulvovaginal pain. Treatment may include a combination of pelvic floor therapy, medication adjustments and/or topical hormone therapy if determined necessary by your gynecologist or medical team, non-hormonal options like vaginal moisturizers and lubricants,  and the list goes on. 

If you are looking for help in navigating your pelvic pain and wondering if your hormones could be playing a role, we are happy to help you navigate this process for appropriate evaluation and treatment. Relief is achievable. It starts with getting to the root of the problem to ensure you have the most optimal and effective care. 

References

Winter, A. (2024, July 13). Vulvodynia: Hormonal Considerations. Vulvodynia Symposium, Virtual. 

Goldstein, A., Pukall, C., Goldstein, I., & Krapf, J. (2023). When sex hurts: Understanding and healing pelvic pain. Hachette Books.

Perelmuter, S., Burns, R., Shearer, K., Grant, R., Soogoor, A., Jun, S., Meurer, J. A., Krapf, J., Rubin, R. (2024). Genitourinary syndrome of lactation: A new perspective on postpartum and lactation-related genitourinary symptoms. Sexual Medicine Reviews, 12, 279-287. https://doi.org/10.1093/sxmrev/qeae034