I love Sex and the City. Actually, I never wanted to watch it for years, because it seemed rough and vulgar, but once I did, I fell in love with it. And, in the end, when the series ended, with Carrie walking fresh, happy and proud, bouncing on her heels and on "You've Got the Love" by Florence + the Machine for the sidewalks of NY, I had, and I still have, the feeling that an era was over.
Sex and the City has marked a small revolution, perhaps it will have brought a watered-down feminist instance but. thanks to Sex and the City, women now have a language to talk about their sexual experiences, their friendships, their stories and idiosyncrasies.
Of course, attempts at post-feminist emancipation always remain confined to a world that is ultimately "feminine" and heterosexual, but not too much. In short, I love it. Period. It was a socio-cultural phenomenon that cannot be ignored.
And yet there is one thing I don't forgive in Sex and the City . Season XNUMX, episode XNUMX. Do you remember that certain moment when Charlotte tells her friends that she was diagnosed with vulvodynia and that her vagina is "depressed?" Depressed. The vagina is depressed. The dullest explanation I’ve ever heard . I also went to listen to the original audio, to make sure there were no "poetic licenses" in the translation. No. The vagina is depressed, both for Italians and English speakers.
Fine. My personal experience with chronic vulvar pain, because yes, I had that too, is quite descriptive of the situation. First of all, speaking so deliberately of my modesty, I am actually breaking the first taboo because yes, we don't talk about it, we don't have to talk about it. So my mother, as a good feminist, I think she did some damage, making me so shameless about it.
We live in a somewhat phallocentric society . From a quick search, I notice that the "market" of erectile dysfunction (the only male medical condition with which it seemed reasonable to create a comparison) is saturated, with new studies being published continuously: the references on PubMed are XNUMX, collapsing at XNUMX on the theme "vulvodynia". I agree if you object that, among the papers I mention, there are certainly also low quality articles, but you will agree that, even if you want to make a skim and keeping only those of high quality, there is proportionally no history.
Vagina either doesn't care (scientifically speaking) or is scary. And this complicates things. It's strange, considering that the 16% of the US female population encounters vulvodynia in their lives. If we extend statistics to the rest of the world, the problem is remarkable.
An American study of XNUMX titled "The girl who cried pain: a bias against women in the treatment of pain" showed that, despite the fact that women live pain more frequently than men in their daily lives, men receive better treatment for their painful symptoms . A chronic disease of any kind already has a stigma, but this is worsened if the condition is invisible, explains the UK Vulval Pain Society website. And pain is the only manifestation of vulvodynia.
Imagine therefore a chronic painful disease, without an apparent organic cause, applied to a woman, to the most representative anatomical part of femininity, and you will have created the perfect storm.
I know vulvodynia. It destroyed my existence, made me lose jobs, let me discover the benziodiazepines and self-harm. And, frankly, I never understood anything of it, except that the symptoms, which I had learned to control with breathing and biofeedback, are among the ones have disappeared since I started my treatment for central sensitization.
Depressed vagina, depressed vagina ... my dear Charlotte, you miss a bit of definition. Not only is our friend V. depressed because she cannot perform her sexual functions, but she is also deeply saddened. From an emotional and physical point of view. Burning pain, often constant. This is what patients who have had the misfortune of knowing vulvodynia report.
In XNUMX the Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia reported the following definition: localized pain (clitoral or labia minora) or generalized, provoked or spontaneous, with primary or secondary origin (recurrent candidiasis), constant or intermittent (menstrual cycles).
Vulvodynia impacts more or less with the normal course of patients' daily life and this depends on its characteristics and how it can be "subjectively debilitating". After all, pain is a projection of our central nervous system and it is up to the individual to determine the intensity or not.
By grace, pain remains pain and a blowtorch constantly present on our most precious treasure, and it affects our lives, of course it does . It affects the perception of our body, how we conduct our lives and how, inevitably, we live our sexual sphere.
"Come on, after all it's just a bit of inflammation, put some cream on, you will surely get irritated with those super tight jeans ... Let's use a little lube honey, you're just a little tired and stressed." Aha, yes, fairy tales.
Vulvodynia is a neuropathic pain. No one is crazy, none is hysterical. The central nervous system changes, becomes sensitive, becomes constantly touchy, that's it.
The damage can be located anywhere in the nervous system: in the peripheral system, in the spinal or supraspinal system, in the brain.
The explanation is "simple": the nervous mechanisms that modulate the sensation of pain are confused and can send the information nociception to the brain in an amplified way; in the same way the brain "can cry wolf" just because something is working too much and too often. Clinically, neuropathic pain is characterized by two abnormal sensory processes, called hyperalgesia and allodynia. In the first case we mean an amplified response to a painful stimulus which is normal in itself; in the second we mean a change in the perception of the stimulus from tactile to "painful burning". It is not a mirage, after all.
Fortunately, these mechanisms begin to be chewed by most: now we consider psychosexual factors a direct consequence of vulvodynia rather than the cause.
The interaction between biological, predisposing, precipitating and maintenance factors, which contribute to the organic and neurogenic damage of the vulva, can interact with psychogenic factors, which always have a neurochemical correlation. Neuropathic pain is basically a clinical diagnosis that needs to be confirmed by reproducible tests or diagnostic tests (to make it short: we must "see pain somewhere" in a diagnostic exam).
It often happens in the studio that patients come with a sort of personal encyclopedia. The famous "doctor shopping", but no one has managed to find something that could be the source of pain: folders on medical files, all negative. The patient is desperate, suffers, but "has nothing", according to the tests. It happens, very often. Until some time ago we were amazed, displaced and frustrated. Luckily, in the XNUMX those great geniuses of the IASP - International Association for the Study of Pain have found the need to introduce a third point of clarification for those who have "nothing" (nothing to be found or to be seen in a laboratory test ). Nociplastic pain. I quote: pain that emerges from an altered nociception without injury or threat of a tissue that may be the cause of activation of peripheral nociceptors or evident injury to the somatosensory system that may cause pain.In practice, there are people who feel "spontaneously". In this case, especially in this case, the psychosocial component plays a fundamental role as an additional activator of the algogenic process by activating the circuit of the dog chasing his own tail.
Rosemary Basano has conceptualized a model that explains, in a circular manner, the sexual functioning of a woman. The context and the mental state are the most important elements of the female sexual cycle. The interlocking rings of this chain are also sexual stimuli and finally emotional and physical satisfaction (orgasm). The mental state of a woman with persistent vulvar pain or a dyspareunia will certainly not be predisposing. Let us consider that we are facing a woman with a superfine mental strength, one of those who is not discouraged: the coital pain due to dyspareunia interferes with the various aspects of sexual function. It directly inhibits vaginal lubrication, causing excitation difficulties with vaginal dryness: orgasmic difficulty, frustration, dissatisfaction, secondary loss of sexual desire and mental excitement with consequent avoidance of relationships.
When the symptom immediately manifests itself as vulvar pain, it is associated primarily with an inflammation of the vaginal mucosa. This then determines the defensive contraction of the levator ani muscles (main components of the pelvic floor) and, finally, the proliferation of the pain fibers. When instead, on intact vaginal muscosa, the starting symptom is the pain during sexual intercourse, the first consequence is the defensive contraction of the levator ani muscles, followed by the blockage of the lubrication, microabrasions by penetration and proliferation of nerve fibers of pain with vulvodynia finally neuropathic. (Graziottin et al. 2011).
Doctor, what can I do?
Natalie O.Rosen in her review sought to investigate, basing on existing literature, what could be the best treatment for vulvodynia. Her conclusion, which among other things also supports the Fourth International Consultation on Sexual Medicine, points out that the best treatment options are: psychological interventions (no, not because someone is crazy, but to learn how to manage pain in everyday life), pelvic floor physiotherapy, vestibulectomy (for the provoked vestibulodynia).Pharmacological treatments can be beneficial and include antinociceptive agents, anti-inflammatory agents, neuromodulators, muscle relaxants.
As mentioned above, there is a clear link between vulvodynia and pelvic floor muscle dysfunctions, which can be translated into hypertonicity, lack of strength and control. The goal of pelvic floor rehabilitation is to restore functionality to muscles and tissues, lower neural tension, improve sexual function.
Manual pelvic floor therapy includes a wide variety of techniques such as stretching, massage and trigger point treatment by acting directly on the treated area and neuromodulating the information that reaches the central nervous system from the periphery. We are going to treat the central nervous system, indirectly.
Retrospective studies have reported significant improvements in referred pain, in dyspareunia, in sexual functions after the application of TENS: a current that is able to close the "gates" at the medullary level that send the altered information of pain to the central nervous system.
Rehabilitation yes, drugs perhaps, therapeutic exercise? The low-load therapeutic exercise, adapted to the individual, has basically the same effect as the neuromodulatory drugs. Exercise makes our body produce good stuff, stimulating it, keeping it alive. Among other things, let's not forget that patients suffering from vulvodynia may be subject to fibromyalgia and other pathologies that deal with chronic pain.
Rehabilitation yes, drugs perhaps, therapeutic exercise yes and a lot of awareness.
Unfortunately, scientific information, even among doctors, is struggling to spread and the lives of patients suffering from vulvodynia are often an odyssey from one specialist to another, from one therapy to another without any result. If, after treatment, as it happens, because it is not specific to the problem, the symptoms remain, the patient is told that she has nothing and often to go to the psychologist. The diagnosis, therefore, almost always becomes that of psychosomatic illness. Unfortunately it is a rather widespread situation and it often happens that patients find themselves without a cure and with the label of "imaginary invalid". However, some studies point out that the psychiatric profile of women with vulvodynia is not different from that of women with other vulvar disorders.
So we return to one of our usual discourses. There must be a greater awareness of the condition both among health professionals and the general public. Physicians should be better trained to recognize and diagnose vulvodynia to know what treatments to offer, but also how to explain patients their condition.
Perhaps the only accuracy that Sex and the City offers, is when Charlotte's friends respond to her "Vulvo-what?" while revealing her diagnosis. This reaction is too common among ordinary people and even among health professionals. As always, fortunately, there is scientific research, but there is the usual disconnect between research and practice.
Maybe Sex and the City didn't really fail miserably. It did it in trivializing the serious and complicated nature of this condition, but it had the merit, at least, of making people talk about the problem, after almost twenty years (sigh!) from that episode.
This article is not one's all me. Half of it was written by Carla Sforza, who helped me make sense of a big black hole in my life. She is one of the "beautiful discoveries" that "Le Stelline" brought, and for which I will never be grateful enough. Carla is a freelance physiotherapist, manual therapist, specializing in rehabilitation of the pelvic floor in female urinary incontinence and chronic pelvic pain. You can find her on Facebook as Fisioelle.
"The girl who cried pain: a bias against women in the treatment of pain" by Hoffmann DE, Tarzian AJ. on The Journal of Law, Medicine and Ethics 2001 Spring; 29 (1): 13-27 PubMed # 11521267
2015 ISSVD, ISSWSH and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia by Bornstein J1, Goldstein AT, Stockdale CK, Bergeron S, Pukall C, Zolnoun D, Coady D on Obstet Gynecol. 2016 Apr; 127 (4): 745-5 PubMed #27008217
Psychological characteristics and outcome of patients attending a clinic for vulval disease Fenella Wojnarowska Richard Mayou, Sue Simkin, Alex Day on Journal of the European Academy of Dermatology and Venereology, July 2006
Graziottin A, Murina F. Vulvodynia diagnosis and treatment strategies. Springer- Verlag Italy 2011
Rosen NO, Dawson SJ, Brooks M, Kellogg-Spadt S. Treatment of Vulvodynia: Pharmacological and Non-Pharmacological Approaches. Drugs. 2019 Apr; 79 (5): 483-493. doi: 10.1007 / s40265-019-01085-1. PubMed PMID: 30847806.