Chronic Vulvar Pain, Part 2.
However, the problem of chronic vulvar pain doesn’t persist simply because of patriarchy and historical gender bias. It is also based on a broad cultural misunderstanding about the basic nature of pain. Understanding and treating vulvar pain requires that we take a step back to reflect on the nature of pain in general. Fortunately, pain scientists and researchers have been doing just that for decades (1). What do they have to tell us?
At its essence, pain is an unpleasant but essential part of life that has evolved to protect organisms from danger. A simple example can illustrate this point. Think of burning your hand on a hot stove. The sensation of pain causes you to immediately jerk your hand away and likely to be more careful around hot burners in the future. Pain is therefore about identifying danger and causing behaviors that protect the organism from that danger.
The important point is that the brain determines whether a sensation is dangerous and, in fact, it is the brain that creates the sensation of pain.
This is counter intuitive to our common sense understanding. It certainly seems like pain is an input, i.e. nerves in the vulva, for instance, are triggered by painful stimuli that cause pain right there in the vulva instantaneously. However, hundreds of scientific experiments have shown that pain is an output and that all pain is created by the brain. Here is what really happens. Sensors, called nociceptors, in the vulva sense changes in the environment that are potentially dangerous. If the nociceptor is triggered, a signal is sent via the spinal cord to the brain where the brain considers, “Is this really dangerous?” If the brain, based on previous experience and a host of other conditions, surmises that this sensation is dangerous and that the organism needs to be motivated to avoid the sensation, then a pain signal is sent back down to the vulva. In summary, pain is an output, not an input.
The important point to note is that the brain is making this determination about the presence of “danger in me” and creating pain signals in a fraction of a second, all without our conscious awareness. This process is not about creating an accurate representation of the state of the body but is geared to motivate behavior in the face of perceived danger. This means that pain is not reflective of whether or not the tissue is injured, disabled, or broken…but only a reflection of how the brain is interpreting the signal in that moment.
This process is not infallible. All too often the brain simply gets it wrong. Pain can happen when there is no tissue damage or even when there is no tissue to be damaged. A common example is phantom limb pain. In this case, a person can experience intense pain in a part of the body that is not even there. The reverse is also true, in that people can not feel any pain even when their tissues are severely damaged. Importantly, the amount of pain experienced can have no connection whatsoever with the condition of the body tissues.
In some ways, pain is like an indicator light in your car (2). Clearly, it is important to pay attention to any blinking red exclamation point on your dashboard. The indicator light can helpfully tell you when something is wrong with your car before you end up broken down on the side of the road. However, there are times when the indicator light won’t go off, no matter how thoroughly you or your mechanic check and recheck the engine for damage. In this case, it is the indicator light, not the engine that is the problem.
Chronic pain is much like a car’s indicator light on the fritz—a screaming red exclamation mark that signifies nothing but is most certainly full of sound and fury (3).
There are many reasons why the brain and the nervous system signal incorrectly or excessively. In part, it is a matter of habit. Frequently triggered pain pathways become engrained and are just that much more likely to trigger regardless of the stimuli, even in non-threatening situations. Pain can therefore become an automatic response much like any other habit. It is also a matter of volume. As pain persists, the entire system becomes more sensitive - nerves become more sensitive, the pathways that bring the signals in from the body to the brain become more sensitive, and the network of brain cells that produce the pain sensation become more sensitive. This process turns up the volume on pain and can amplify even the smallest whisper into a wailing siren. Ultimately, a body that has been in pain is primed and ready to experience more pain.
Pain is not just the brain’s way of alerting the body to danger, but it is also about motivating protective behaviors to avoid further danger. However, the very behaviors designed to protect us can actually perpetuate chronic pain. A common response to pain is to avoid doing anything that provokes that pain. When we do this, we change our behaviors and we protect the area that is perceived as injured or in danger. This often causes reciprocal pain in other parts of the body that are working overtime to protect us. As pain spreads, we withdraw more and more from activities that bring us joy and pain becomes ever present and all-encompassing. In addition, by not engaging the part of the body where pain is felt, in measured and safe ways, we are not allowing the brain to adapt and re-wire the pain circuits to shut off the unnecessary alarm system. These examples describe just a few ways in which chronic pain is created and perpetuated.
However, in truth, the entire human experience shapes the way the brain reacts to and interacts with its environment and therefore how and when pain is created.
This holistic model of pain is called a biopsychosocial model because biological, psychological, relational, emotional, behavioral and social factors affect the brain’s propensity to interpret sensations as dangerous and create chronic pain. The model looks something like this:
This model shows the intricate ways in which these complex factors interact to keep the chronic vulvar pain cycle intact. The complexity of this process may make it seem like there is no way out of chronic pain. However, understanding this process is the first step in unraveling the knot of chronic vulvar pain.
1 For an excellent summary of the science, check out: Moseley GL, Butler DS. Explain Pain Supercharged. Noigroup Publications: Adelaide City West, Australia, 2017.
2 Thanks again, Lorimer. Moseley GL. Painful Yarns: Metaphors and Stories to Help Understand the Biology of Pain. OPTP, Minneapolis, MN. 2015
3 As we shall see, chronic pain always signifies something, just not always what we think.