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A woman, seated, holds her stomach in pain

Taking the stigma out of talking about pelvic pain

Two Stanford gynecologists talk about pelvic and sexual pain, and why it's so important to empower patients to address it.

There are few things more awkward to discuss than pelvic pain, but Diana Atashroo, MD, and Leah Millheiser, MD, two clinical assistant professors of obstetrics and gynecology, are trying to change that.

Whether the pain is chronic or occurs during menstruation or sex, women tend to shy away from talking about discomfort in their lower lady zone.

And it's not that they are uncomfortable talking about a slightly embarrassing topic. Women with pelvic pain might also face psychological and physical complications, making it all the more intimidating to discuss, said Millheiser, who directs the Female Sexual Medicine Program at Stanford Hospital.

Millheiser and Atashroo want to remove the stigma and help patients find lasting solutions. They recently shared with me how they identify, manage and treat pelvic pain; disentangle its associated complications; and normalize talking about it.

Why is pelvic pain such a challenging issue to address?

Atashroo: Pelvic pain varies a lot between patients -- some experience it for short periods of time, others for years. Patients can have symptoms like pain with intercourse, pain after surgeries, pain associated with fibroids, or any other pain in the gynecologic realm.

Many of my patients have also been misdiagnosed, dismissed, or have undergone treatments that were ineffective. They come to me feeling like a broken record; they are emotionally spent, they are tired; and they already mistrust doctors because they have had so many different, inaccurate diagnoses.

Millheiser: Not all doctors are trained to properly assess pelvic pain in women. As a resident in training, I would witness doctors, on their way out of the exam room, ask, "Do you have any other questions?" If a patient had pelvic pain, she would often sheepishly say, "Well there's this one thing."

I've heard doctors tell women who asked about pain with sex or low libido to try a glass of wine, a lubricant or a psychologist. Those women would rarely come back to address the pain, and I don't think it's because their issue was resolved. It made me realize that there's this giant gap in women's sexual health care.

How are you helping women better assess and treat their pain?

Atashroo: In our clinic, we're focused on something we call a bio-psychosocial approach to pain, in which you identify the biological issue but you also incorporate and validate the social and psychological components of pelvic pain, which are equally as important. We often work with psychologists, physical therapists and other sub-specialties, so it's a multidisciplinary approach.

Our approaches could be medical, surgical, or it could just be sitting down and having an educational conversation on the effects of pain. A lot of times patients don't know what's going on with their bodies or how their bodies are reacting to something. A large portion of this care really comes down to communication.

Millheiser: I sometimes think of myself as a "gynechiatrist." So much of what I do is counseling women whose sexual health concerns have gone untreated for a very long time. Dyspareunia, which is pain during sex, or vaginismus, which causes pain as a result of hypercontractility of the pelvic floor, can often have physical and psychological causes. Sexual pain can even come from the use of birth control pills.

If patients can't find help, their sexual pain can lead to other issues, including low libido. However, we find that if you treat the sexual concern that showed up first, the others tend to improve as a result.

The other issue is a stigma around discussing pelvic pain. I've had journalists ask me not to say the word "vagina" because they can't put it on TV. We need to normalize sexual and pelvic health as part of women's health, and that starts by not being afraid to talk about it in an anatomically appropriate way.

What's your key message to patients?

Millheiser: Don't suffer in silence. There is comprehensive care available for your sexual concerns. Also, don't settle for an unsatisfactory answer -- always seek a second opinion. There are sexual health specialists in every state, and there are resources like the International Society for the Study of Women's Sexual Health where patients can find providers who specialize sexual pain disorders.

Atashroo: I want my patients to know that I believe their pain story, and I believe their pain is real. I encourage women experiencing pelvic pain to find a health care provider who is going to listen to them, validate their and offer them options for a treatment that's comprehensive. There are resources like the International Pelvic Pain Society where patients can find information and videos on pelvic pain, as well as providers that specialize in pelvic pain conditions.

Photo by Khunatorn

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