How Clean is Too Clean?

By Riva Preil

Believe it or not, people sometimes overdo it with regards to vaginal hygiene.  This is especially true with regards to individuals with vulvar disorders (ex. eczema, lichen sclerosis, urinary tract infections, or yeast infections).  A common misconception is that the disorder is a result of inadequate cleansing of the vulva, thereby leading to itching, irritation, and pain.  However, over scrubbing of the perineum and vulva may actually exacerbate vaginal irritation.  It is important to gently cleanse the vagina without using irritating chemicals.  Most scented soaps, scrubs, powders, and detergents are detrimental to vaginal health; instead, one should opt for unscented products.  Furthermore, gentle fingertip cleansing should be performed rather than using a washcloth.

In addition, it is important to be mindful of clothing, because lower extremity garments often affect vulvar irritation. Tights pants and jeans, thongs, spandex, and pantyhose are often the culprits of triggering a flare up.  When possible, one should wear cotton underwear, loose pants (ex. sweatpants while working out instead of leggings), and thigh-highs or knee-highs to prevent pain.  Hopefully, incorporation of these minor tips can create a major improvement in one’s quality of life.



Rock Your Body Mechanics

By Riva Preil

Tis the season to be reviewing proper body mechanics, especially considering the amount of heavy lifting and transporting (ex. suitcases, gifts, decorations). Protecting your back is one of the best presents you can give yourself this holiday season, and the benefits will far outweigh that of any iPad. That being said, please pay close to attention to the following tips you can easily incorporate into your routine to promote optimal health and safety:

  1. SQUAT TO LIFT HEAVY OBJECTS- while lifting an object, step close to the object, spread your feet shoulder-width apart, and bend from the hips, knees, and ankles. Head and shoulders should remain upright, and tighten your abdominal muscles (your core) throughout the lift. Avoid bending from the back, and instead use your large, strong lower extremity muscles.
  2. USE GOLFER’S LIFT TECHNIQUE TO LIFT LIGHT OBJECTS- Choose one leg, and shift your body weight onto that leg. Put your opposite arm on a supportive surface (ex. countertop, rail, table etc.) and bend forward.  Allow the supporting knee to bend slightly and allow the unweighted leg to lift off the ground in line with your torso.
  3. PUSH RATHER THAN PULL- When moving heavy objects (ex. table, bed), pushing the item from behind while standing erect allows you to use your body weight during the move, which decreases the burden from your back.
  4. AVOID TWISTING- Trunk rotation while carrying or moving a heavy object puts severe stress on the lumbar vertebrae and the intervertebral discs. It is better to pivot and move from your feet while engaging in loaded twisting movements (ex. carrying luggage, vacuuming, etc.). As with all back protection strategies, remain as close to the item as possible throughout activity.
  5. SINK SAFETY- Most sinks are situated lower than our backs would like. Pay attention next time your brush your teeth- do you find yourself bending forward? Does this make your back feel strained? If so, try this simple trick- place one foot atop a stool while brushing your teeth or washing your face, and see how much better your back feels afterwards.
  6. LOGROLL YOUR WAY OUT OF BED- The worst thing is starting your day off on a bad foot…or a bad back for that matter! Getting out of bed in the morning could be a much more pleasant experience by avoiding awkward twists and bends as you arise. Instead, try using the logroll technique- roll onto your side, scoot close to the edge of the bed, and bend your hips and knees. Then, push up through your upper body as you drop your legs off the bed. This maneuver allows you to move your back as one unit and decreases pressure on the spine.

Good luck with these techniques! I hope they help you feel great during 2013 and beyond. Happy New Year!

Besting Bacterial Vaginosis, Part II

By Riva Preil

The diagnostic features of VBD include extreme pain upon attempted vaginal penetration, vestibular pain when touched with a cotton swab, and erythema (redness) in the vestibule.  These are called Freidrich’s criteria.  Treatment includes tricyclic medications (ex. amitriptyline) to alleviate pain, especially in cases of secondary VBD.  Also, antiseizure medications (ex. carbamazepine) and anticonvulsant drugs (ex. gabapentin) have been used to help women with VBD. One should speak with their physician regarding medications and the possible side effects if they think they may benefit from this form of treatment.

Furthermore, physical therapy is a crucial component in treating VBD.  The pain which results from VBD can be viewed as a stressor or assault to the pelvic floor muscles. In response to pain, the muscles in the pelvic floor can tighten and may even spasm as a protective mechanism to prevent further injury.  However, the tightening of the muscles themselves can cause a cascade of problems including formation of trigger points, decreased muscle flexibility, skeletal misalignments, and additional nerve compression.  Therefore, women with VBD should participate in physical therapy to help treat the secondary musculoskeletal dysfunctions.

Vestibulectomy, a surgical procedure performed to remove the irritated and vestibular tissue along with the inflamed nerve endings, should be used as a last resort and only if all the treatments have failed.  The hesitancy surrounding this surgery is due to the fact that nerves tend to have better memories than we want them to have- the brain may still continue to perceive pain even from a severed nerve!  (This is similar to the concept of phantom limb pain, and this is the reason why individuals may continue to feel the presence of a limb even after it has been amputated.)  Therefore, since the initial success rate of vestibulectomy is only 60% (approximately), it should be reserved for individuals who are completely unable to participate in intercourse due to pain (if medication and physical therapy were unsuccessful).  Fortunately, this procedure should not impair areas associated with sexual pleasure, and it has not been shown to interfere with fertility, pregnancy, and delivery.

Pilates: Spinal Rotation

By Denise Vidal

The best way to maintain a healthy spine is to move it in all possible directions everyday.  So far, in our Pilates blogs, we have focused on flexion of the spine (abdominal curl) and extension of the spine (lying prone). In this blog we are going to discuss spinal rotation. The movement of rotation is relatively simple; however, the mechanics of the spine in rotation require a little explanation. If we can do the movement of spinal rotation while visualizing the proper mechanics, we’ll get much more out of the exercise.

As you may know, there are cartilaginous disks between the vertebra of your spine which absorb the shock of your spinal movement.  As we flex, extend, or rotate the spine, the disks expand and disperse to allow the vertebra to move while still protecting the spinal cord and surrounding nerves. The disks, in return, need the movement of the vertebral column to maintain its flexibility. I like to compare the disk to a ball of silly putty. The more you play with it, the more it maintains it’s ability to stretch. Once you leave it alone, it becomes hard and stiff.

Think about the disk’s pliable quality while doing this spinal rotation movement.
You can do this either sitting or standing, just make sure that whichever position you choose your head, spine, and pelvis are aligned. That’s just a fancy way of saying, ‘sit up straight’, but without tension. Once you’re in an aligned position, take a deep breath.  As you exhale slowly rotate to look to the right. In your mind’s eye, see the disks of your spine soften and spread. You can imagine a marshmallow between your fingers as you push down on it. It stays soft and fluffy while responding to the pressure of your fingers.

Slowly go back and forth from your right to your left side, taking a deep breath before each rotation. You can do this as many times as you want throughout the day. Eventually, you can think about this idea while doing rotational movements throughout the day, like whenever you turn to reach for something at your desk.

In the next blog we’ll apply this thought to a rotation exercise in Pilates. As always, if you’re experiencing any pelvic or back pain, please consult your doctor or P.T. before attempting any exercise.

Anatomy of An Irritated Vestibule

By Riva Preil

Vestibulodynia (VBD, also called vulvar vestibulitis or vestibulitis) is a specific type of vulvodynia (refer to “Vulvo-what-ia?”, November 26 blog for details).  Both are considered chronic pain syndromes involving hypersensitivity of the central nervous system.  Whereas vulvodynia is believed to be caused by direct nerve injury, VBD is most likely due to repetitive inflammation around the nerve which interferes with the normal transmission of messages through the central nervous system.  New connections are made between receptor cells, the spinal cord, and the brain, and ordinarily non-noxious (non-painful) stimuli send messages to the brain which scream “PAIN!” loud and clear.  Therefore, tight jeans, wiping after toileting, water pressure while showering, cycling, gynecological speculum examinations, tampon usage, and intercourse may become very painful for an individual with VBD.

VBD can be sub-divided into primary VBD and secondary VBD.  Primary VBD refers to pain with the first attempt at vaginal penetration (either when first attempting to use a tampon or when an individual becomes sexually active).  Women who experience this generally suffer from other forms of painful conditions such as urinary dysfunction, constipation, irritable bowel syndrome (IBS), temporomandibular joint (TMJ) dysfunction, interstitial cystitis (IC), or fibromyalgia.  Secondary VBD refers to the development of pain with penetration after successfully tolerating pain free tampon usage or intercourse.  It is believed that certain triggers may be connected with the development of VBD, such as yeast infection, frequent urinary tract infections (UTI), human papillomavirus (HPV), or herpes, to name a few.

To be continued…

Besting Bacterial Vaginosis

By Riva Preil

The #1 cause of vaginal complaints in America is due to bacterial vaginosis (BV). BV is due to the vagina becoming less acidic than it should be which creates and imbalance in the various vaginal bacteria. This creates an unpleasant fish odor in the vagina, and it can also result in increased vaginal discharge and itching and/or burning. Pain is generally not associated with BV. BV is best diagnosed through a wet prep, as opposed to a vaginal culture (which does not help in the differential diagnosis of BV).  Doctors often perform a vaginal pH test to assess the level of acidity in the vagina. A pH of greater than 4.5 is considered abnormal. Furthermore, a microscopic analysis of vaginal wall cells can be performed to check for clue cells, bacteria filled cells which are unique to BV.

BV is not considered a sexually transmitted disease, however it is associated with sexual activity with multiple partners has been connected to BV. It is also associated with intrauterine device (IUD) implantations as well as hygienic douching (this should actually be avoided to prevent killing the vaginal lactobacilli which create the necessary acidic environment in the vagina). More than 50% of women with BV actually do not demonstrate any signs or symptoms. BV is NOT the same as a yeast infection, however many women often mistaken BV for a yeast infection, which is usually not accompanied with a foul odor. When women make this mistake and treat themselves with over the counter anti-yeast medication, they will not feel better because the underlying problem, BV, has not been treated. Therefore, it is important for an accurate diagnosis to be made in order to properly treat the problem, especially because BV tends to recur. Although there is currently no cure for BV, symptoms can be managed through medications such as Flagyl and clindamycin. Some women also find the vaginal acidifying moisturizer, Replens, helpful. BV mediation, as all medication, should be discussed with one’s primary care physician. In addition, BV is considered by the pelvic floor muscles as a “trauma”, and it may cause pelvic floor muscle tightness and trigger points. Pelvic floor physical therapy can be very beneficial for reducing the musculoskeletal dysfunctions associated with BV.

In Memory of Gretchen Molannen

By Riva Preil

On December 1, 2012, Gretchen Molannen ended her life tragically after years of suffering from Persistent Genital Arousal Disorder (PGAD). PGAD is a disorder where the individual experiences prolonged and intense periods of genital arousal. The symptoms may be relieved temporarily by stimulating an orgasm, however the symptoms usually return within several hours. Certain situations may trigger the symptoms, including riding in a car or cell phone vibration. For many, the discomfort associated with increased arousal progresses to pain, and those who suffer from PGAD often refrain from intercourse due to pain and/or shame. In addition, this condition interferes with many activities of daily living, such as attending to work related tasks and interpersonal relationships.

Unfortunately, researchers have limited information regarding the cause and treatment for PGAD. To date, it seems that there is a connection between PGAD and sensory nerve dysfunction. PGAD is also associated with pudendal nerve entrapments; nerve blocks have been used to treat PGAD with limited success. In some cases, PGAD may be related to pelvic arterial-venous malformation, in which case surgical intervention is indicated to correct the underlying issue. Antidepressants, antiandrogenic medications, and anesthetic gels have been prescribed to help alleviate the discomfort. However, “one of the problems with PGAD is a lack of knowledge. Many doctors don’t know about it and it’s not even recognized by the medical community as an official condition. Therefore any procedures that may potentially reduce the problems are not covered by insurance because there’s no code for PGAD. What’s more, it’s unknown how many women have the condition since many choose not to talk about it out of embarrassment” (quoted from the Ryan Jaslow’s article in CBS News; see link above). Furthermore, people experiencing PGAD may very likely benefit from pelvic floor physical therapy.  PGAD can increase sensory and motor nerve sensitivity, and it can create pelvic floor muscle tightness. This tightness can pull on the genital region and increase the symptoms of arousal and pain. Furthermore, the tightness can restrict and irritate the nerves in the pelvic region which results in hypersensitivity to the surrounding organs and in the general region. Pelvic floor physical therapy can help treat the musculoskeletal and nerve restrictions associate with PGAD.

Gretchen was courageous by sharing her story with the world. May her tragic story raise public awareness regarding the debilitating nature of this terrible disease thus spurring further research into appropriate treatment methods.  May she rest in peace.

Dislikin’ Lichen Sclerosus

By Riva Preil

Lichen sclerosus (LS) is an inflammatory skin disorder which can affect the vulva.  The most common symptom associated with LS is itching of the skin.  In addition, many women with LS report cracking of the vulvar skin which may lead to painful intercourse and/or pain during passing a bowel movement.  Flattening of the labia minora often occurs as well, and women often confuse LS with hemorrhoids. LS in and of itself is not an autoimmune disease, but it is often associated with autoimmune diseases such as thyroid issues. There seems to be a genetic component involved with LS, and very often women who have been diagnosed with LS discover that their mothers or grandmothers experience similar symptoms.

As with all skin disorders, LS can be managed (as opposed to cured). It is diagnosed via skin biopsy, and doctors often prescribe clobetasol (a strong steroid cream) to manage the symptoms.  Some women find that petroleum jelly application improves the tissue suppleness and decreases tearing and pain during intercourse and bowel movements. Laser and surgical treatment approaches should be avoided due to the lack of significant improvements shown by research. If you or someone you know presents with symptoms similar to LS, please speak to your health care provider to explore further medical care.

A Diaphragmatic Breath of Fresh Air

By Riva Preil

The diaphragm is a cone-shaped muscle at the base of the rib cage and it is the primary respiratory muscle.  An essential component of any relaxation program is proper performance of diaphragmatic breathing.  This is an important technique to learn because it helps relax the autonomic nervous system. Proper performance of diaphragmatic breathing can help to quiet brain activity which results in relaxation of all the organs and muscles within the body. An up-regulated nervous system is associated with muscle guarding, tension, stress, and tightness.  The muscles are shouting loudly at high volumes, and this pattern can result in pain and discomfort.  However, diaphragmatic breathing alleviates the tension by “turning down the volume” of the system thereby creating a calming, soothing affect.
The proper way to perform diaphragmatic breathing is as follows:

  1. Lie on your back or recline in a chair in a relaxed position. Place your hands atop the lower portion of your rib cage.
  2. Relax your jaw by placing your tongue on the roof of your mouth and keep your teeth slightly apart.
  3. Inhale slowly through your nose for a count of five seconds.  Allow your widening of the rib cage and expansion/rising of the abdomen.  Keep your upper chest, neck, and shoulders relaxed.
  4. Exhale slowly through your mouth for a count of five seconds.  Allow your ribs to collapse inward and your abdomen to fall (return to starting position).
  5. Repeat this 10x every night prior to going to sleep or at any time during the day when you experience stress or tension.

Now doesn’t that feel AMAZING? Enjoy your calm and relaxed state of being!

Pap Pointers Riva Preil

The Pap test is a test routinely performed by gynecologists to evaluate cervical cells in order to check for cancer or pre-cancerous conditions. In other words, it can help nip cancer in the bud by detecting abnormal growths before they develop into cancer. In fact, Pap test screening every three years is associated with decreased cervical mortality rate by 70%!  For clarification- the Pap test screens for cancer, which mean that it provides information about one’s risk for developing cancer.  It is NOT used as a diagnostic tool. The Pap test checks for changes in the cervix called cervical intraepithelial neoplasia (CIN), and these are slow growing growths which can be treated with early detection.

How can one best prepare for a Pap test to assure the most accurate results possible?  Please follow the pointers below for the best results:

  1. Avoid vaginal medications or douches for twenty four hours prior to the test .
  2. Try to avoid Pap testing during menses, because excess blood may interfere with the results.
  3. Avoid intercourse and/or contraceptive creams and jelly during the twenty four hours prior to the test.
  4. Please inform your gynecologist of any other vulvar or vaginal discomfort or symptoms you have been experiencing (ex. itching, burning during urination, or pain) so that they can determine whether the Pap test is appropriate at present.

Good luck to you on test day and may you pass with flying colors in the best of health!