Your pleasure matters.

Why tighter may not be right-er

The pelvic floor needs a public relations campaign.

Seriously!

The pelvic floor is one of the body’s many unsung heroes, quietly humming along in the background taking care of us.  Even when something goes wrong with the pelvic floor, most people don’t know enough about it to even suspect that the pelvic floor could be the cause.

Sure, many people know that weakness in the pelvic floor can be a problem.  Maybe you’ve heard that you should do Kegels or lock your bandha (if you are into yoga) or “keep the pelvic floor lifted, ladies” during x,y, or z workout class.  

You might reasonably think that more is better when it comes to tightening the pelvic floor.  But nothing could be farther from the truth.  To see why, let’s look at that the pelvic floor is and what it does for you behind the scenes.

WHAT IS THE PELVIC FLOOR?

The pelvic floor is formed by 14 muscles, as well as nerves and connective tissue, that cover the opening of the pelvic bones, between the tailbone and the pubic bone.   

They form a hammock like support for internal organs — the bowel, bladder, uterus and vagina – keeping them lifted and in alignment so that they function properly as you move about your day.   This is the one thing most people know; the pelvic floor keeps things lifted so you are less likely to have urinary incontinence for example.  This is really important stuff!  No one likes a misaligned organ. 

The pelvic floor muscles do not act alone but are intimately interconnected with the muscles of the abdomen, back, hip and diaphragm – working together to create core strength and flexibility.  In this way, the pelvic floor is also involved in maintaining posture and allowing for easeful leg movement.  

But don’t forget that this area also includes the opening of the anus, the urethra and the vagina.  The pelvic floor muscles allow these openings to close when you need them closed and to open when you need them opened.  This is also really important stuff obviously.  No one wants an inadvertently open OR an unintentionally closed orifice at an inopportune time.

For the pelvic floor to perform all of these complex functions it must be able to be easily tighten and relax in coordinated ways.   Problems occur when these muscles are either too weak, too strong, and/or simply not functionally coordinated.  Ultimately, a nimble pelvic floor is your friend.  And crucial to being able to going to the bathroom with ease and having sex with maximal pleasure.

So, let’s give a shout out to the wonders of your pelvic floor! 

HOW DO THINGS GO WRONG IN THE PELVIC FLOOR?

To jog your muscle memory (groan, that’s a terrible joke), muscles are collections of fibers that overlap to contract and pull apart to rest and lengthen.  When these fibers are chronically pushed to overlap or to pull apart, they are prone to developing pain and dysfunction.  

One way this can manifest is as a trigger point.  You’ve probably felt a trigger point in you back, neck or shoulders after hunching over your computer or phone for hours on end.  Trigger points are areas of involuntary muscle contraction. This involuntary contraction hurts and can be released through stretching and massage.  Same thing in the pelvis, except it is more difficult to stretch these muscles and they are harder to reach to massage.

Muscles that are chronically contracted can also lead to pain because the contraction causes restricted blood flow and nerve compression.  Blood vessels and nerves flow in and around muscles as they provide blood supply and innervation to the muscle itself and to surrounding tissue.  Compression of blood vessels restricts oxygen supply to the tissue and causes pain; nerve compression also causes pain. 

Pelvic floor muscles are skeletal muscles, like the muscles in your arms or legs. Skeletal muscles contract to pull bones.  This is made possible by the fact that bones are able to move because they are connected to joints that bend.  The pelvic floor muscles are also connected to the immovable bones of the pelvis.  Which means that when they are even more prone to become chronically contracted because they can’t be released by moving the bones they are connected to.  Think of moving the bones of your vertebrae to stretch tight neck muscles or moving your leg to stretch tight hip muscles.  You simply can’t do that with the muscles of the pelvis.  

So chronic contraction or chronic lengthening of the muscles in the pelvic floor is bad.  But how does this happen?  There are many that can cause dysfunction in these muscles; here’s a few examples:

• Direct trauma to the muscle from something like falling on your tailbone or childbirth
• Intense exercise that activates the core muscles for stability 
• Injuries to the leg or hip that alter your gait; remember these muscles are all interconnected.  
• Surgery like hysterectomy or prostactectomy
• Chronic constipation and straining
• Endometriosis causes inflammation that can contribute to muscle overactivation
• Hormonal changes that cause pain in the vulva (menopause article)

The truth is that we don’t always know how or why the muscle dysfunction started.  

I think some people tend to hold their pelvic floor tighter than others.  Maybe it’s because they have always used their pelvic floor to help stabilize their core.  I always say, “no one tells you what to do with your pelvic floor when you are learning to walk.”  Maybe their go-to move was to pull up on the pelvic floor.   

Other folks may hold tension in the pelvic floor when they are stressed.  Some folks raise their shoulders to their ears, others raise their pelvic floors to their belly buttons.

The final thing to note is that anything that causes pain in the pelvis can lead to pelvic floor muscle dysfunction.  For example, let’s say it hurts when you pee.  Maybe you have recurrent UTIs.  The body wants to brace against pain, so the pelvic floor muscles will engage in an effort to protect you from pain.  

What if you have had pain with penetrative sex?  This is a major trigger for pelvic floor contraction as the body tries to prevent further pain by preventing further penetration.  This is even true when the pelvic floor contraction is the original problem.  This is how pelvic floor contraction begets pain begets more pelvic floor contraction.  

WHAT ARE THE SYMPTOMS OF PELVIC FLOOR TROUBLES?

Symptoms of weakness in the pelvic floor are fairly well know:

• Urinary incontinence is the most common
• Difficulty controlling your bowel movements or leakage
• Pelvic organ prolapse (this is about more than just muscle weakness though)

What you may not know is that pelvic floor dysfunction (tightness, contraction, uncoordinated movements) can cause a whole host of symptoms.  

Pelvic floor dysfunction causes so many types of symptoms that it should be just about the first thing you think of if you are having pain down there.  Doesn’t mean that is the problem, but it’s the first thing I would want to investigate.

Here are some symptoms that can be related to dysfunctional pelvic floor:

• Vulva owners: Pain of any kind in the vulva, vagina, clitoris, perineum or anus
• Penis owners: Pain in the penis, scrotum, perineum or anus, erectile dysfunction, post ejaculation pain
• Burning, itching, stabbing sensations in the genitals
• Pain at the opening to vagina with intercourse
• Urinary discomfort or frequency
• Pain with sitting
• Pain with orgasm or after orgasm, inability to orgasm

So, if it hurts when you pee and you don’t have a UTI, could be your pelvic floor.

If it hurts when you sit, could be your pelvic floor.

Hurt when you have sex?  Definitely could be your pelvic floor.

However, when it comes to pain it is never as straightforward as just tissue injury or muscle contraction.  Ultimately, pain does not originate in the body at all, but rather in the brain.  (link to pain article)

As a quick summary, the brain creates pain when it thinks that the body is in danger.  However, the subconscious systems that monitor for danger and create pain can get wonky.  The brain can start to perceive danger to tissue when there is none.  This can happen in all sorts of ways.  Perhaps there was an initial injury, but then the brain and the nervous system become overly sensitive, creating pain even after the initial injury has resolved.  Again, pain isn’t about tissue injury but about the brain perceiving danger.  To learn more about this process and what to do about it, check out this article.

WHAT TO DO IF YOU SUSPECT PELVIC FLOOR TROUBLE

First of all, know that you are not alone and you are not broken.  Estimates are that 20% of women will have pelvic pain at some point in their lives and an estimated 2 million men have chronic pelvic pain.  Ultimately, this problem can affect anyone with a pelvic floor, all vulva owners and penis owners regardless of their gender.

If you suspect your symptoms could be related to pelvic floor dysfunction, you will need to seek support from someone who can do a pelvic floor muscle exam.  If you normally see your primary care doctor for pelvic exams, they may be able to help you.  Your gynecologist or urologist can also do this exam.  However, your primary care doctor and even your gynecologist or urologist may not have been trained in how to examine these muscles or in all the ways they can cause problems.  It’s a problem, but it is one of the ways that the lack of good sex ed for providers can harm you. 

I may be biased ☺ but if you have access to a licensed medical provider who is a certified sex counselor, that would be an excellent place to start.  This way you can have a full exam to evaluate for all causes of your pain or other symptoms and a comprehensive plan for treatment can be created with you.

However, sex counselors like me are few and far between.  

All jokes aside, pelvic floor physical therapists are a go-to resource.  A pelvic floor physical therapist is just like any other physical therapist.  They are highly skilled and licensed providers that are specifically trained to support the musculoskeletal system, just in this case it is the musculoskeletal system of the pelvis and related tissues.  

What can you expect at a pelvic floor PT exam or treatment session?  This will vary from person to person obviously.  But examining and treating the pelvic floor will typically require that the pelvic floor be accessed internally.  Most often this means that a gloved lubricated finger will be placed in your vagina or anus to feel for and treat trigger points in the tissue of the pelvic floor.  

Internal exams and treatment sessions might seem like a lot to contemplate.  It’s not anyone’s idea of day at the park that is for sure.  Pelvic PTs are certainly aware of this and will support you to feel more comfortable throughout the session.  

If “internal work” is not something you are willing to do now, a great pelvic PT can offer other strategies for supporting pelvic floor function.

Clearly, pelvic floor PTs (and anyone who has the privilege of helping people with internal exams or treatments) have a lot of responsibility with this sensitive subject.  For this reason, I recommend that you look for a pelvic floor PT who is certified and who only does pelvic floor work if possible.

Here are some resources to help you find a qualified provider:

• International Pelvic Pain Society
• International Society for the Study of Women’s Sexual Health
• American Physical Therapy Association – Pelvic Health
• Local to Ithaca? Check out Trumble Physical Therapy

PELVIC FLOOR EXERCISE – NOT JUST ABOUT KEGELS

Hopefully you will have access to a supportive professional if you are having issues that you suspect could be related to your pelvic floor.  However, I know not everyone does or you may not feel comfortable with this yet.

What can you do?

There are some helpful exercises that you can explore along the way.  

First, Kegel exercises are probably not it, especially if you are having pain. Tightening your mula bandha during yoga may also be contraindicated (as much as I love all things yoga!).  As all of the discussion has demonstrated so far, more tightening is really gonna just make things worse.

What you can do is begin by slowing moving towards bringing your pelvic floor into awareness.  

Where is your pelvic floor in space right now?  Is it tight?  Is it relaxed?  This may seem like an odd question or even a nonsensical one.  But stick with it, and see if you can become aware of how you are holding the pelvic floor.

One good way to do this is to bear down like you are having a bowel movement.  This pressure will push the pelvic floor forward, stretching and relaxing it.   Then squeeze the pelvic floor lightly like you are trying to stop the flow of urine.   Gentle relaxation and contraction of this floor can help create greater awareness.

You can also use your breath to feel into the pelvic floor and to offer it some gentle “exercise.”  The pelvic floor moves with your diaphragm as you breath in and out. Try taking a deep breath in.  Move the breath into the belly, watching the belly rise and fall with each in and out breath.  Can you also feel how the breath expands into the pelvic floor, creating gentle downward pressure or expansion?  This belly breathing is a great exercise to do every day, not just for your pelvic floor but for your mind, your gastrointestinal system and your nervous system. 

Your pelvic floor is also connected to your throat.  Professional singers know this well.  You might notice this if you bear down like having a bowel movement.  Do you feel how you may create pressure in the throat and hold your breath to do that?  

Ultimately, the throat and the diaphragm and the pelvic floor are all one interconnected pressure system.  Bring gentle awareness to your breathing and speaking or singing to deepen your connection to your pelvic floor.

Other good exercises could include:

• Childs pose or balasana
• Squatting down or malasana

If you feel like tightness in the floor is making sex painful, you can also use these exercises to more towards relaxing the pelvic floor before you have sex. 

I also encourage you to feel empowered to explore your pelvic floor yourself.  Hold your hand against your vulva as your press into the pelvic floor and release.  Can you feel the subtle movement?  Consider inserting one finger into the vagina or anus and then contracting and releasing the pelvic floor.  Can you feel this movement?  Or do you have pain in specific areas? 

This exploration may bring up emotions.  That is not unexpected.  Just be gentle with yourself.  Offer loving-compassion as much as possible along the way.

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Ultimately the pelvic floor is an important source of physical grounding but it is also a place of deep emotions since it connects us to so many fundamental experiences of being human, not the least of which is sex.

This is your body’s core, the center of gravity, the source of movement.  Called the hara, the chi center, the seat of kundalini energy in various ancient traditions.  The chakra system seems to capture some of this when it describes this area, the root chakra, as being responsible for a sense of stability, grounding, safety and security.  It is the foundation from which all the other chakras can move and grow.

I know more, “woo!” But I do believe that this area is more than just a set of muscles and nerves; a more emotional or spiritual energy is available here, making it a place of great vulnerability.

So, give yourself and your pelvic floor some love.  You deserve it.

Perhaps the most common complaint of women* in my office is of pain with sex.  When I am meeting with a woman around the time of menopause or after, far too often the conversations goes something like this…

Me: “Did this pain start in menopause?”

Client: “Yes, I was fine before that?”

Me: “Did your doctor or nurse practitioner ever prescribe vaginal estrogen?” Client: “Oh yeah, a long time ago but I never used it.  I saw that warning about cancer in the papers that came with the prescription and it just didn’t seem like it was safe.  Do you think it is ok to use?”

And almost universally, I think, “Oh no! Another woman who didn’t get what they needed for an easily treated condition because of this black box warning!”

Could vaginal estrogen really be safe?  

Let’s see what the prescribing information that comes with all estrogen products says….

(https://www.nap.edu/read/25791/chapter/19#310)

This is some fine print for sure…here is some of the text: 

The Women’s Health Initiative (WHI) reported increased risks of myocardial infarction, stroke, invasive breast cancer, pulmonary emboli, and deep vein thrombosis in postmenopausal women during 5 years of treatment with conjugated equine estrogens (0.625 mg) combined with medroxyprogesterone acetate (2.5 mg) relative to placebo (see CLINICAL PHARMACOLOGY, Clinical Studies). Other doses of conjugated estrogens and medroxyprogesterone acetate and other combinations of estrogens and progestins were not studied in the WHI, and, in the absence of comparable data, these risks should be assumed to be similar. Because of these risks, estrogens with or without progestins should be prescribed at the lowest effective doses and for the shortest duration consistent with treatment goals and risks for the individual woman.

That is a pretty dramatic statement! MI, Stroke, PE, CANCER – Oh my!  No wonder women are so frightened!

Since 1976 the FDA has required a package insert about the potential adverse health effects of all estrogen containing products.   In fact, oral contraceptive pills were the first medication to ever have a direct to patient package insert.  

The right for patients to have direct access to information about the safety of medications, rather than relying on the good will of physicians and other health care providers, was won after a hard-fought, contentious battle. You can read more about that in the excellent book The Estrogen Elixir by Elizabeth Siegel Watkins.  To me, this is  a straightforward positive development for patient autonomy, informed consent, and a powerful blow to the patriarcho-pharmaceutical system!  Go, ladies!  

But estrogens don’t just have a package insert; they have a large black box warning.  A black box warning is reserved for the most dangerous of medications that have adverse reactions that may be life-threatening, fatal or disabling.  Since 2003, all estrogen products have required a black box warning.  

How is it that estrogen came to be thought of as a life-threatening medication?

THE WOMEN’S HEALTH INITIATIVE, ESTROGEN & THE FDA

Prior to 2001I, it was thought that estrogen had numerous health benefits and minimal risks.  For example, it was believed that estrogen had minimal to no effect on breast cancer risk.  It was also thought that estrogen protected women from cardiovascular disease.  These beliefs were based on multiple large observational trials – but no randomized control trial (the gold standard for knowledge in the science of medicine) had been done.  

Because of this high degree of safety, the numerous supposed benefits of HT, and advertising that promised that HT could keep women “forever young,” HT (in the form of Prempro) was the number one prescribed medication in America in the 1990s. I think that’s shocking! Hormone therapy was number one prescribed medication. Wow.

Enter the WHI, the first large randomized control trial to study the effect of HT on women’s health.  

The Women’s Health Initiative was a landmark study in menopausal hormone therapy (HT). Over 15,000 women were recruited to study the effects of hormone therapy on cardiovascular disease, though other health effects were also monitored including breast cancer, pulmonary embolism, and gallbladder disease.  The study was stopped early in 2001 due to the surprising finding that there seemed to be an increased risk of breast cancer and cardiovascular disease for women on HT.  

When researchers pulled the plug on the study early and announced to the world that HT could actually increase the risk of heart attacks, strokes and breast cancer, it set off a media firestorm.  It was front page news on the NY Times and the morning news.  Women all over the world stopped HT.   Doctors stopped discussing menopause with women, because there no longer was an effective treatment for the often-debilitating symptoms it could cause. 

Of course, the FDA also noted these findings and this is how a black box warning as we know it today became mandatory on all estrogen products in the US. 

SYSTEMIC HORMONE THERAPY VS LOW DOSE VAGINAL HORMONAL THERAPY

If we take it for granted that the findings from the WHI were true and indisputable (for reasons why this isn’t an easy thing to do, click here),  this research only applies to the safety of systemic hormonal therapy (HT).  Systemic HT refers to the use of hormones (applied directly to the skin in the form of a patch or taken orally) with the intention for the medication to enter the circulation and raise the overall body level of estrogen (and potentially progesterone).

What about using hormones just on the vagina and vulva to treat local symptoms there?

This is called low dose vaginal estrogen therapy.  Unlike systemic HT, the intention is to use hormones (in the form of creams, tablets, ovules, suppositories or rings) only on the tissues of the vagina and vulva (and the urinary system, but more on that later).  

Low dose vaginal hormonal therapy is therefore prescribed at much lower doses than systemic hormonal therapy – hence the name “low dose.”  After all, it’s only meant to affect the area where it is applied.

For instance, the average dose of vaginal estrogen is 10mcg of estradiol (a form of bio-identical estrogen) most often used twice per week.  This means that an entire year’s supply of local vaginal estrogen is equal to taking 1mg of estradiol per year.  This is less than half the dose of one oral contraceptive pill. One mg of estradiol  is equal to 0.01mg ethinyl estradiol found in an oral contraceptive pill.

This is low dose, real low dose.  There are even versions of estradiol that go lower – down to 4 mcg.

But, medications are absorbed through the skin of the vagina, right?  Even low doses of a medication could get into the systemic circulation, right?  

Yes, absolutely.  

But how much of the medication becomes systemic and does it matter?

As to the first question, we know that estrogen levels in the blood stream do rise transiently when local vaginal hormone therapy is applied.  Research has confirmed, however, that these levels are not sustained in a range above post-menopausal levels.    

Does this matter?  Namely, does this transient slight increase in the level of estrogen in the systemic circulation cause life-threatening disease- as the FDA’s black box warning states in such dire terms?

IS LOW DOSE VAGINAL ESTROGEN SAFE?

Fortunately, we have excellent data available to offer a begin to offer a reliable answer to this question. 

In addition to the large randomized control trial of HT described above, the WHI also had a component that was an observational trial that tracked the health outcomes for women using of systemic HT or local vaginal estrogen therapy . 

This study was a doozy.  Between 1992 and 2005, it enrolled 93,676 post-menopausal women.  Of these, about 4,200 used vaginal estrogen alone, without systemic HT.  These women were followed for on average 6-7 years. 

The study found that the use of low dose vaginal estrogens did not increase the rates of cardiovascular disease, cancer or blood clots.

In 2020, researchers tallied up all of the research about low dose vaginal estrogens is compared, the finding is the same – it is effective and it is safe.

BUT WHAT ABOUT WOMEN WHO HAVE HAD BREAST CANCER?

Women who have had breast cancer often undergo treatments that seek to decrease estrogen levels in order to reduce the risk of cancer recurrence.  These treatments can lead to profound vaginal dryness and discomfort. 

Can women with breast cancer or with a high risk of breast cancer consider low dose vaginal hormones?

The answer to this question used to be a resounding and definitive, “NO!”

However, in recent years, the medical community has begun to reconsider this.

Several studies have suggested that there is no increased risk for breast cancer for women with or at high risk for breast cancer.  The WHI Observational study found no connection.  Neither did this large Finnish study.  Neither did this small study from 2012.

There was enough data that in 2016, the American College of Obstetricians and Gynecologists (ACOG), stated that “The data do not show an increased recurrence among women currently undergoing treatment for breast cancer or those with a personal history of breast cancer who use vaginal estrogen to relieve urogenital symptoms.”  

So, ACOG says that women with or at high risk for breast cancer can consider using low dose vaginal hormones if non-hormonal options are ineffective. 

In 2020, the North American Menopause Society (NAMS) and the International Society for the Study of Women’s Sexual Health (ISSWSH) issued their updated statement.  They agree that the first line treatments for GSM are non-hormonal moisturizers, lubricants and sometimes vaginal dilators.  These treatments can be effective; but what if these treatments don’t work?  Then the use of local vaginal estrogen can be considered.

ATTEMPTS TO CHANGE THE BLACK BOX WARNING

Based on the currently available evidence about low dose vaginal estrogens, the black box warning currently required on these products not only doesn’t protect women, but it is actually a danger to them. 

Women deserve information about the safety of all medications; this is not in dispute.  The problem comes when the information provided is either misleading or downright false.

False information frightens women unnecessarily and encourages them to avoid safe and effective treatments for no reason.  

This is simply unacceptable.

For these reasons, the North American Menopause Society (NAMS), the international society specializing in menopause in America, submitted a petition to the FDA in 2008 requesting that the black box warning be removed from low-dose vaginal estrogen products.

Unfortunately, the FDA summarily rejected this petition, holding to their position that all estrogens are a danger despite the evidence to the contrary.  

The FDA is simply misreading the meaning of the literature on the subject and refusing to heed any advice from gynecologists, menopause specialists or even oncologists.  They also refuse to acknowledge the damage that their incorrect information has done to countless women’s lives.  

Why has the FDA let women down in this regard?  Well,  it cannot be argued that the FDA has a good track record with women’s health. Whether it be with medical devices.  Or excluding women from drug research trials. 

I am not a willy-nilly critique of the FDA.  They serve an important role in healthcare, I simply demand that they fulfill that role more effectively.  Help every woman have access to safe and effective treatments for debilitating medical conditions like genitourinary syndrome of menopause (GSM). 

___________________________________________________

If you are considering low dose vaginal hormones, check out this article to learn more about the type of products that are available.

But do risks associated with systemic hormonal therapy apply to low-dose vaginal creams or inserts that are used to treat GSM. 

*In this article, the term “woman” or “women” will refer to people that are born with a vulva and vagina. As we know, there are women who are not born with this genitalia and other genders who do have a vulva and vagina. Language is somewhat inept in its ability to elegantly capture this beautiful complexity. I encourage you to use the information in this article as it applies to you or your loved ones.

It turns out that sex hurts way more often than you would think.

In fact, pain is probably the single most common concern of women* who come to talk to me about their sex lives.

It may surprise you to know that menopause is the culprit for a lot of this pain (though there are many other causes). As is breastfeeding. As is anything else that decreases estrogen levels.

This pain can feel like burning, tearing, ripping, or stabbing with any attempt at vaginal penetration. One woman poetically described it as feeling, “like there are razor blades in there any time we try to have sex.”

That creates quite a mental image.

To make matters worse, the vulvovaginal tissue may not just be painful during sex, but can feel irritated and create mild misery all the time. Every time you wipe with toilet paper or a wash cloth. Every time you put on jeans or even underwear.

But wait there’s more! You can also feel have irritation or burning in the urethra that feels like a UTI. But there’s no infection. It’s just menopause.

Or maybe you are one of the unlucky women who will actually get more frequent UTIs when estrogen drops.

YOUR VULVA, CLITORIS & VAGINA AT PUBERTY

Why does not having a period any more have such a profound effect on the vulva and vagina?

To answer this, let’s first think back to what happens to vulva and vagina when they were first exposed to estrogen at puberty.

If you check out a textbook of human development, you will see the Tanner Stages described. These stages outline the stereotypical development of so-called secondary sexual characteristics in boys and girls.

As sex hormones come online, girls are described as developing breasts, pubic hairs, and periods. The observers of human development noticed that boys get pubic hairs too, but surprisingly (not surprised) their genitals are also a point of interest, as much attention is paid to the growth of the testicles and penis.

But the fine Mr. Tanner and his colleagues do not describe what happens to the vulva, clitoris and vagina at puberty. Surprised? Not surprised.

And since your textbooks and your doctors never thought about this much, you likely haven’t considered it either.

So, what does happen?

Well, it turns out that the vulva, vagina and clitoris are just as sensitive to the onset of puberty and sex steroid hormones as is the penis.

{https://www.researchgate.net/profile/Miranda-Farage/publication/7557975_Lifetime_changes_in_the_vulva_and_vagina/links/569e7ffa08ae2c638eb56d29/Lifetime-changes-in-the-vulva-and-vagina.pdf}

The lovely labia thicken and grow in length. The skin of the vulva may shift to darker shades of pink and brown.

The wondrous clitoris lengthens and expands, becoming more visible especially during arousal (for more on the real anatomy and physiology of the clitoris).

The marvelous vagina lengthens and becomes more flexible. The introitus or opening of the vagina widens. Secretions from the cervix and vagina increase, which helps with lubrication and fertility.

Inside the vagina, the friendly microbiome, which is essential to vaginal health, matures and stabilizes to fight off infection.

In short, the development of the vulva, vagina, and clitoris is a major event in puberty. It should be recognized and celebrated! So here is my belated congratulations!

PUBERTY IS DRIVEN BY ESTROGEN…MOSTLY

The changes that happen to the body at puberty are orchestrated by a wide array of hormones.

In general, we think of this being primarily about rising estrogen levels for vulva owners and dictated by testosterone for penis owners. When it comes to genital development, this is largely true as it is estrogen that turns on the cellular machinery that causes the vulva, clitoris and vagina to mature.

Other hormones are relevant, though. These hormones likely play a more subtle, but essential role. However, because researchers have seemed mentally wedded to the idea that “women = estrogen” and “men = testosterone,” our knowledge of this is limited.

But women make also make a slew of other hormones, including testosterone and progesterone.

We have rather recently discovered that testosterone is essential to vulvovaginal health. Testosterone is an important contributor to the vulvovaginal tissues ability to produce lubrication. In addition, the opening of the vagina (called the vestibule) can be very sensitive to testosterone levels. In fact, without enough testosterone, you may get the same kind of pain that you get without enough estrogen. Testosterone is also vital to clitoral health, helping to maintain good blood flow which supports pleasure and arousal. (https://pubmed.ncbi.nlm.nih.gov/27914563/).

So, vulvas, clitorises and vaginas love estrogen. No doubt about it. But they also wouldn’t mind a little testosterone, too.

Though I love progesterone for many things and think it is an underrated hormone for women’s health and wellness, it doesn’t seem to play an important role in vulvovaginal health.

Ok, so we have reviewed that estrogen is necessary to get the ball rolling “down there” at puberty. But the cellular machinery that is turned on at puberty doesn’t just need a one-time hit of estrogen. It needs at least a minimal amount of estrogen at all times to keep going. At that is just what they get as estrogen rises and falls with the menstrual cycle.

YOUR VULVA AND VAGINA OFF ESTROGEN

The vulva, clitoris and vagina are exposed to estrogen throughout the waxing and waning phases of the menstrual cycle. Estrogen levels rise and fall in relatively predictable patterns when you bleed or ovulate. When this cycle slows or stops, estrogen levels drop to nothing.

This can be a normal process of aging. This is what happens in menopause.

But it doesn’t just happen at menopause. Breastfeeding women can also lose their period for months to years.

It can happen to people born with vulvas but who are on estrogen blockers and testosterone as part of gender transition.

Women under extreme stress can stop having cycles. So can women who are enduring treatment for cancer or who are suffering from other illnesses.

If estrogen is essential to the development and health of the vulva, vagina and clitoris, what happens when it goes away?

What happens is that the same cellular machinery that was turned on at puberty when estrogen came on board, is now turned off. Every person will experience this differently but the underlying process is the same.

It is important that every woman understand what can happen so that if symptoms develop they know why and what can be done about it. What follows is a list of potential changes that can happen. This is not meant to make you worry but rather it is meant to empower! Here is general process that happens:

• Loss of cushion. The layer of tissue that provides cushioning under the skin of the vulva and vagina shrinks.
• Loss of flexibility. Before menopause there is a layer of tissue under the skin that is pleated like…well like a pleated skirt. This allows it to stretch easily. Without estrogen, this tissue becomes flat and rigid.

• Loss of lubrication. Estrogen (and testosterone) supports the cervix and the vagina to secrete lubrication. No estrogen equals a drop in lubrication.
• Changes to the microbiome and increased pH. Estrogen helps the vagina produce glycogen – the food source for your bacterial friends in the vagina – lactobacillus. Without lactobacillus, the microbiome shifts and the pH goes up. This can change the odor of the vagina – which can be really distressing.
• Decreased strength of pelvic floor muscles. Decreased strength in these muscles contributes to urinary incontinence.
• Smaller labia. Not an earth-shattering problem for most people, but interesting nonetheless.
• Smaller introitus (opening to the vagina). No, the vagina isn’t going to close up. But even subtle changes in the opening which make it smaller and less flexible can lead to significant pain.
• Urethral changes. The urethra becomes larger and more prominent. It can also undergo other benign changes that lead to pain with urination. For some women, this combined with the changes to the vaginal microbiome can lead to increased UTIs.
• Potentially smaller, less sensitive clitoris. This is can affect arousal and orgasm, obviously. Women describe feeling like it takes a really, really long time to get to orgasm or that orgasm is kind of…meh.

These changes affect every person differently. However, studies suggest up to 87% of women will have some symptoms of low estrogen after menopause.
{https://pubmed.ncbi.nlm.nih.gov/33739315/}

This is called GENITOURINARY SYNDROME OF MENOPAUSE or GSM when it happens after the permanent loss of the menstrual cycle.

Given all of these changes, it’s pretty easy to see why sex can become so painful. Less cushion, less flexibility, less lubrication, a smaller introitus? Ouch, indeed! This is why women describe burning, ripping, tearing sensations with sex.

Again, some women may have few or no symptoms; others may find sex intolerable or have other symptoms of general irritation or urethral irritation.

But every woman should know about how estrogen affects their genitals and what can happen when it goes away. This simple information is basic to women’s ability to maintain their health and advocate for themselves as needed.

But maybe this is news to you? Or maybe you knew a little something but not all the details?

Well you are not alone.

THE PATRIARCHY STRIKES AGAIN!

How is it that a syndrome that will affect every single woman who goes through menopause and countless others is not better known?

Why is it that less than half of women have ever heard of this condition and even fewer than that have tried a tried treatment for it? { https://pubmed.ncbi.nlm.nih.gov/33739315/}

How is it that the medical establishment doesn’t provide “anticipatory guidance”? You know…could you give women a heads up about what happens and let them know what they can do about it?

Well…anybody?

Clearly, the reverberations of the patriarchy still echo throughout healthcare. The most annoying thing is that this sort of treatment of women’s issues is still so common place that we aren’t even surprised any more.

In fact, I am no longer surprised when yet another woman tells me that she has never heard of this. I am not surprised when she tells me she hasn’t had sex in several years and that she has been suffering in resigned silence.

I’m not surprised, I am just straight up angry!

From a medical standpoint, this is a very well-understood part of a woman’s life. There are clearly developed and easily accessible guidelines for how to diagnose it and how to treat it. In case you are looking for them, here they are. (https://www.menopause.org/docs/default-source/default-document-library/2020-gsm-ps.pdf)

And yet women are not taught about this and are left to suffer in silence far too often. This is quite simply totally and completely unacceptable. Women deserve better.

Women deserve information about how their body works, information about what to expect as they age or have health changes that affect their hormone levels, and accurate information about SAFE, SIMPLE, AND EFFECTIVE TREATMENTS.

Yes, that’s right. Loss of estrogen is a real problem for vulvovaginal tissue, but there are SAFE, SIMPLE, and EFFECTIVE TREATMENTS!

The medical establishment has let women down when it comes to this issue. It’s a bummer. It’s unacceptable. Though, lots of work (www.menopause.org) is being done to sensitize providers to the importance of this conversation, women are still not adequately supported.

So, let’s support each other.

I encourage you to pass this information along. It’s likely that there are people in your life who know little or nothing about this issue. Please share this with a friend, a wife, a mother, a loved one.

We can close this knowledge gap! One slightly awkward conversation about vulvovaginal health at a time! ☺

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To learn more about safe treatments, check out Five Things to Know About Treating Painful Sex After Menopause.

*In this article, the term “woman” or “women” will refer to people that are born with a vulva and vagina. As we know, there are women who are not born with this genitalia and other genders who do have a vulva and vagina. Language is somewhat inept in its ability to elegantly capture this beautiful complexity. I encourage you to use the information in this article as it applies to you or your loved ones.