By Stephanie Prendergast, MPT, Cofounder, PHRC West Los Angeles
A frequent question from social media:
“I have Vestibulodynia and painful bladder syndrome. I am almost symptom free except for near or during my period. My hormone levels are fine. My urologist prescribed testosterone cream because he found atrophy. At the same time I have another doctor telling me that to reduce inflammation caused by the hormonal variations of the period I should take continuous birth control pills, which I heard can make things worse. I appreciate any insight that you can offer.”
Are oral contraceptive pills a cause of pelvic pain or are they a solution? Questions like the one above come up frequently, and part of the problem is defining ‘pelvic pain.’ By current usage, the term ‘pelvic pain ’encompasses a number of symptoms: menstrual cramps, vulvar pain, painful sex, and irritative bladder symptoms. These symptoms have different causes and different treatments, by narrowing the definitions we can better answer the above question.
Pelvic Pain: vulvar pain and irritative bladder symptoms
The vulvar vestibule and the urethra and bladder are derived from the same embryological layer: the intermediate mesoderm urogenital sinus. There are a number of reasons why people often have symptoms of both Vulvodynia/Vestibulodynia and painful bladder syndrome/Interstitial cystitis, and the fact they share an embryologic layer is one of them. A second reason is because the vestibule, urethra and bladder are hormonally sensitive structures. In order for these organs to function normally they need estrogen and testosterone, hormone insufficiency affects the bladder and the vulva. A third reason why people often feel both irritative bladder symptoms and vulvar pain is because of their close proximity to the pelvic floor muscles. Numerous research studies show that the majority of patients with Vestibulodynia/Vulvodynia and irritative bladder symptoms also have pelvic floor dysfunction.
Research has shown that some women will develop Vestibulodynia from taking oral contraceptive birth control pills. If women start birth control pills under the age of 17 there is an 11-fold risk of developing this syndrome, in women over the age of 17 there is a 4-fold risk. Certain people have a genetic polymorphism, meaning specific properties in their DNA, that are more likely to become compromised than others by reduced circulating free testosterone and elevated SHBG. These are two of the changes that occur when taking OCPs. Please note, when we are discussing hormonal deficiencies in premenopausal women we are not talking about estrogens which require testing at specific points in the menstrual cycle. These tests often return ‘normal’ or ‘fine, and not the main reason people are symptomatic. The majority of physicians do not test for SHBG and may not calculate a person’s free testosterone.
For more information about the exact mechanisms check out:
Pelvic Pain: Dysmenorrhea (menstrual cramps)
Anyone who has a period knows that oral contraceptives are offered as solutions for everything: reducing menstrual flow and length of menses, to help acne, to ‘regulate’ periods, and to reduce dysmenorrhea (painful cramps). When most general gynecologists hear ‘pelvic pain’ they usually think of Dysmenorrhea. Dysmenorrhea is a common symptom of Endometriosis, and this doctor may or may not know much about Vulvodynia or Interstitial Cystitis. Research shows that oral contraceptive pills will lessen the symptom of dysmenorrhea. These pills do not treat endometriosis but they do suppress symptoms. The majority of healthcare providers are not aware that birth control pills can cause painful sex and irritative bladder symptoms and that they are a leading cause of Vestibulodynia in premenopausal women.
When people have hormone deficiencies their symptoms feel worse prior to the start of menses. This is because of fluctuating hormones, making deficient urogenital tissues more symptomatic. When people report to a GYN that they feel worse around their period, doctors often think of Endometriosis, therefore it is very important for patients to explain exactly what feels worse or it will be assumed the patient is talking about cramps. Without careful interviewing and adequate knowledge, birth control pills may be prescribed as a solution and really they can be the cause.
Clinical observation has taught us that people with the same set of symptoms will often receive different diagnoses based on the type of physician that they see. If someone with painful sex and urinary urgency and frequency goes to a urologist they will be diagnosed with IC. If they go to a gynecologist they will be diagnosed with Vulvodynia. If they go to both then they think they have multiple diagnoses and that things are really wrong, when in fact many of these symptoms exist together and can be effectively treated by getting to the root cause!
Treatment Considerations and Solutions
We understand the confusion. In today’s world the healthcare system is not effectively taking care of people with symptoms of painful sex and irritative bladder symptoms. There are a handful of doctors in the United States who specialize in these disorders, and an equally small number of excision specialists prepared to treat women with endometriosis. All of these symptoms and diagnoses are also associated with pelvic floor dysfunction, and while the field of pelvic floor physical therapy is expanding there are certainly more patients than providers. People are misdiagnosed, underdiagnosed, over diagnosed and are suffering as a result.
The first step is identifying the underlying causes of someone’s symptoms. Most women have taken oral contraceptives at some point in their life and a certain percentage of them will have the symptoms of painful sex and irritative bladder symptoms. The urethra is part of the vestibule.
If hormonal deficiencies exist, stopping the cause of hormonal suppression is the first step. The next step is to treat the tissues with various topical hormonal therapies, sometimes systemic support is needed as well. This is true for premenopausal and menopausal women. A pelvic floor physical therapy examination is also warranted!
For the population of people suffering from severe dysmenorrhea and possibly endometriosis it is recommended to undergo surgery with an excision specialist to confirm or refute the presence of the disease, remove the impaired tissue, and then develop an interdisciplinary treatment plan to tackle co-existing impairments.
Birth control pills can cause painful sex and irritative bladder symptoms in certain women that are genetically predisposed. Birth control pills can suppress dysmenorrhea but this may not make sense if the consequences are to cause other problems. People have been forced to seek out help via social media as many doctors are not aware of these facts, this specialized care is not part of standard medical school curricula, but the landscape is improving as more doctors and physical therapists are taking an interest in pelvic health! Hopefully this sheds light onto some of the confusion and provides hope, there is always a solution for these symptoms, people simply need to find the right people to help.
Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
Melissa Patrick is a certified yoga instructor and meditation teacher and is also available virtually to help, for more information please visit our therapeutic yoga page.
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