chronic pelvic pain
First of all, if you are reading this blog because you’re experiencing pain, I’m so sorry. Pain can feel really frustrating, stressful, and isolating. I had chronic pelvic pain and interstitial cystitis symptoms for over a decade, and I know what it’s like to bounce around the medical system between doctors, physical therapists, and alternative treatments trying to find answers.
Pelvic pain is an umbrella term. In this blog post, I’m going to focus on female bodies, but blog post focused on male pelvic pain hopefully coming soon! If you’d like content on nervous system regulation specifically geared toward male pelvic pain, check out the work of Michael Hodges at Transform Pelvic Health. For folks with female bodies, pelvic pain diagnoses can include vaginismus, vulvodynia, vestibulodynia, pudendal neuralgia, and interstitial cystitis. Sometimes pain isn’t even the right word–people feel like they are experiencing burning, itching, irritation, or bladder urgency.
get checked out by a doctor first
It’s always important to get checked out by a doctor. Doctors can assess for autoimmune disease, acute infection, or hormone imbalances that needs to be addressed medically. Some people have pelvic floor muscle tension and respond really well to pelvic physical therapy. If you’re looking for recommendations for specialists in the Triangle area, I’d recommend Dr. Yasmin at Alray Gynecology and Grace Pelvic Health!
but if that’s not working, what next?
But if you’re reading this blog, you may have already been to several doctors or pelvic PTs. So, what does talk therapy have to do with a medical condition? And why am I, a person whose last hard science class was Biology 101, talking about medical stuff?
Because! New research is coming out that once pain becomes chronic (about 3-6 months), our brains and nervous system get caught in a predictive feedback loop. This is called neuroplastic pain.
what is neuroplastic pain?
Pain is a danger signal from the brain. Think about it like a fire alarm. Sometimes the fire alarm is going off because there is a fire, but sometimes the fire alarm is going off because you burnt your tuna melt in the toaster oven. Essentially–our brains can send pain as a danger signal even in the absence of tissue damage.
This doesn’t mean the pain is all your head! The brain and nervous system are producing real pain, and it can be 10/10. It just means there isn’t something damaged in the body.
So if the brain isn’t experiencing physical damage, why would it be sending pain? Our nervous system reacts to social threats the same way it responds to physical threats. For example, think about public speaking. A lot of people feel high stress before talking in public and will have a sensation of butterflies in their stomach, sweating, or nausea. It doesn’t mean anything physically is wrong with their body, but their nervous system is in high alert and responding with physical symptoms.
With chronic pain, we can get caught in the pain/fear cycle. Because we’re in pain, we are stressed or scared about experiencing pain. This puts our nervous system on high alert. In this hypervigilant state, our brains are more likely to interpret sensations as dangerous, so they send more pain as a danger signal.
what about symptoms?
I know I keep switching between the words pain and symptoms. A lot of the research and literature that has been published has used the word pain. But more research is coming out that chronic symptoms: like fatigue, dizziness, itching, urinary urgency, and unexplained GI issues are also neuroplastic. So if you’re reading this thinking “I have interstitial cystitis, that’s not really painful, more irritation and need to pee” PRT can still help.
How can I tell if my pain or symptoms are neuroplastic?
If you’re wondering how to assess if your pelvic pain is neuroplastic, check out the FIT criteria from Howard Schubiner. People can also experience mixed pain where it is partially structural and partially neuroplastic. In this case, PRT can still help reduce pain. Here is a podcast episode that goes into this theory for endometriosis.
what is pain reprocessing therapy?
Chronic pain and symptoms are awful. But the good news, if they’re neuroplastic, they can change. Pain Reprocessing Therapy is a newer therapy (developed in the last 10 years) targeted at treating chronic symptoms. It helps people retrain their brain and nervous system to get out of the pain/fear cycle.
How does that work? Overall, we are trying to get people’s nervous systems out of threat mode. This can be hard! Especially when someone has been in chronic pain, experienced trauma, or is experiencing a high amount of stress. Sometimes the education piece is enough. Knowing that pain doesn’t necessarily mean damage can be a huge relief, and the nervous system stops sending pain.
But often people need to experience a felt sense of safety in their body. A primary technique of PRT is somatic tracking. This is a guided meditation where people move towards the sensation of pain with curiosity. Often when we feel an unpleasant sensation we brace against it, avoid it, or want it to go away. This is totally understandable! But it continues to send the message to our brain that the sensation is dangerous. During somatic tracking, we’re gently moving towards the pain with curiosity and messages of safety. This helps our brain reappraise the sensation, and it can start to learn that this part of the body is safe. Over time, the brain and nervous system develop new neural pathways and stop producing the symptoms.
Pelvic pain is emotionally complex
I find that working with pelvic pain, as opposed to say, back pain, has its own complexity. Many people with pelvic pain experience pain during sex. This creates stress, pressure, or anxiety about sex. It can (understandably) decrease libido. If you’re experiencing painful sex, my advice is to stop “just pushing through” and white knuckling it. The goal is for sex to be a safe, positive experience.
When people starting experiencing pain with sex, they might have anxiety about how it will impact dating or their relationship. They might feel guilty that they aren’t having sex with their partner or sad that they can’t have the sex they used to have. Or they might fear that their body is broken and won’t ever get better. All of these emotions increase the pressure around sex. With the increased pressure, the nervous system gets more danger signals and is more likely to produce pain. The fear/pain loop is on.
Vaginas and vulvas are an area of our body that we have a lot of emotions around. Many people have experienced sexual trauma, relational abuse, or harassment. Many people grew up feeling shame around sex: from religious messages, family messages, or total lack of messages.
People can also experience pressure from the other direction: that they should be having all the fun sexy sex and orgasming all the time. If they aren’t having this experience (due to pain, low desire, or other reasons) they can feel like there is something wrong with their body. All of these reasons can make the vagina/vulva feel unsafe.
It’s important to give these feelings space, validate them, and move towards them with self compassion. If you choose to work with a PRT therapist, they can guide you through somatic work on the felt sense of emotions in the body. Often people will feel emotions of fear, anger, frustration, or sadness. If therapy doesn’t feel accessible and you want to explore emotions on your own, there are free guided somatic tracking for emotions on Insight Timer. Expressive journal writing is also a great tool, and Nicole Sach’s has a guide if you’d like to follow that.
graded exposure to pelvic pain
If you feel ready to move towards the physical pain, you can try gentle, graded exposure. This can help the nervous system interpret the sensations as safe. This might mean explicitly taking penetrative sex (or whatever sex causes pain) completely off the table for a while. This can help some people feel safe engaging in kissing, oral sex, or other intimacy because they aren’t worried about pain.
For other people, years of pain, medical trauma, or sexual trauma have left them feeling a lot of negative feelings around all parts of sex and physical intimacy. If that’s the case, you can continue to do emotional processing. If you’re ready for an exposure, scale it until it feels comfortable. Something like lying in bed cuddling or reading a book with a sex scene. It’s important to go at a pace that feels comfortable for you.
For graded exposure to the physical pain, pelvic pain can be tricky. If you feel pelvic pain throughout the day (like when you sit in a chair or wear tight clothes) you can do somatic tracking with the sensation. If you end up seeing a PRT therapist, you can do somatic tracking and exposure to the pain in session. But many people only feel pain during penetration. In that case, you can use your finger or a dilator (in a non-sexual context, like lying alone in bed) to stimulate the pain and do recorded somatic tracking exercises.
What else helps?
It can be helpful to listen to recovery stories of other people who experienced pelvic pain and resolved their pain using these methods. This can help people feel less isolated and build hope. Here are some podcast episodes that have recovery stories and go more into the science. The podcast Heal Your Chronic Pelvic Pain is completely devoted to giving information on nervous system regulation for pelvic pain.
Traditional therapy recommendations like slowing down, reducing screen time, engaging in physical activity, setting boundaries, and self compassion are also helpful for nervous system regulation. If you’re experiencing muscle tension, doing work with a trusted, caring pelvic PT can be helpful. Pelvic PT can create a safe graded exposure to the pain.
If you’d like to find a therapist trained in PRT, here is a directory where you can search for providers in your area.
obligatory disclaimer :)
This not a substitute for medical advice, this is for educational and informational purposes only.
