An Interview with Dr. Jill Krapf Board Certified OBGYN
Hypotonic pelvic floor muscles are a common theme in today’s world, encouraging and educating on the benefits of muscle tone, strength, and kegels. With a strong pelvic floor being all the rage, what happens when your pelvic floor is actually too tight and tense? Hypertonic pelvic floor muscles are less talked about, but are fairly common for many women. We invited Dr. Jill Krapf, board certified OB/GYN for an interview on the ins and outs of hypertonic PFM, vulvodynia, and her essential work in women’s sexual health.
Jill, it’s great to have you on! Tell us about yourself and how you found your mission in this space.
I ama board-certified OB/GYN specializing in female sexual pain disorders. I have dedicated my clinical practice, research, and education to sexual pain conditions in women. I specialize in provoked vestibulodynia (pain at the vaginal entrance with insertion) and vulvar skin conditions (including lichen sclerosus and chronic vulvovaginitis). I am passionate about education in the field of female sexual health. I am on the Education Committee for the International Society for the Study of Women’s Sexual Health (ISSWSH). My Instagram account @jillkrapfmd promotes evidence-based education, awareness, and support around these important conditions and topics.
I have always been interested in women’s sexual health. In my final year of residency training to become an Obstetrician Gynecologist (OB/GYN), I had the good fortune of being assigned to one of Dr. Andrew Goldstein’s vulvar vestibulectomy surgeries. At that time in residency training (over 10 years ago), we had limited exposure to vulvar pain conditions. I was so interested that I spent a year learning from him and other leaders in the field.
With my additional training in vulvovaginal conditions, I started a clinic for female sexual health as a junior faculty member at my academic institution. After practicing general OB/GYN for many years with clinics devoted to sexual pain, I decided to transition my practice to treating women with vulvovaginal conditions full-time. I joined my mentor, Dr. Goldstein, at the Center for Vulvovaginal Disorders (CVVD) in Washington DC in the Summer of 2019. I love being able to provide a true diagnosis, basing the cause of the pain on how the body works.
What exactly are tight pelvic floor muscles (provoked vestibulodynia due to hypertonic pelvic floor muscle dysfunction) for those who may be unaware?
Vestibulodynia (pain at the vaginal entrance) may be due to hormones, nerves, inflammation, or muscles. Many women with vulvar burning have hypertonic (overactive) pelvic floor muscles that may be causing or contributing to their symptoms.
The muscles that make up the “floor of the pelvis” (the iliococcygeus, pubococcygeus, and puborectalis muscles) come together (with the transverse perinei muscles) at the bottom of the vulvar vestibule (4 to 8 o’clock on the vaginal opening). These muscles surrounding the entrance to the vagina can become tight and tender. This can affect the overlying tissue at the vaginal opening, leading to pain with sex and daily burning symptoms.
Pelvic and/or vulvar pain leads to tightening of the pelvic floor muscles through involuntary guarding. This reduces blood flow to the muscles and tissue leading to a buildup of lactic acid and other metabolites, which affect nerve impulses leading to the perception of burning and discomfort. This also affects the tissue where the muscles “attach,” namely the bottom of the vaginal opening. This burning sensation leads to further muscle tightening (guarding), and around and around it goes. Anxiety contributes to this burn-clench-burn cycle, adding fuel to the fire.
What are the most common reasons you see this happen?
The pelvic floor muscles may be constantly tense on their own (women tend to hold tension in their pelvic floor) or may be related to other vulvovaginal or pelvic pain conditions. These pain conditions include endometriosis, effects of pregnancy or childbirth, nerve-related conditions that affect the pudendal nerves or nerve endings of the vaginal opening, skin conditions of the vulva and/or vagina, and hormonally-associated causes of vulvovaginal pain due to menopause, perimenopause, or certain medications that decrease estrogens and androgens. In order to have complete treatment, it is essential to determine and address all the causes of the pain. A vulvar pain specialist can be very helpful in diagnosis and treatment.
When working with a patient, what methods do you use to soothe and treat this condition?
The key to evaluating vulvodynia is to determine the specific location and cause(s) of the vulvar pain. In general, causes are related to hormones, muscles, nerves, or inflammation. Through a focused history and physical examination, I can localize the pain and determine the cause of the pain. Treatment is based on the specific cause of the pain. For example, for women who have pain with sex due to vulvovaginal atrophy, treatment involves application of a local low-dose hormone topically to the area. For women with hypertonic or overactive pelvic floor muscles leading to pain, themainstay of treatment is to “release” these tense pelvic floor muscles, restoring blood flow and oxygen.
Then, it’s important to keep these muscles in a functional state, where they can contract and relax. This is typically done with myofascial release and pelvic floor physical therapy. Sometimes, local muscle relaxing medication or injections to help release the muscles can be helpful when used in conjunction with pelvic floor physical therapy.It is essential to determine all of the contributing causes of pain to create a comprehensive and effective treatment plan.
Women are often pushed to do kegels, it's the fad. Is this harmful or helpful to those with tight pelvic floor muscles?
Women with hypertonic pelvic floor muscles have muscles that are tight, short in length, and weak. Many women initially think that tight muscles are too “strong,” but actually, tight muscles are like a stiff rubber band, they do not contract and release very well, giving them less function, and therefore making them weak. Kegels done properly, meaning pelvic floor exercises that target the muscles that need strengthened and (most essentially) exercises done with an appropriate muscle release component, have utility in treatment. However, coaching and education is often needed to ensure proper training of these muscles. That is why the off-hand advice of “just do kegels” may be harmful. For folks with tight pelvic floor muscles, down-regulation and release of the muscles are very important components to treatment. This is often best guided in pelvic floor physical therapy.
Can using products like serum, dilators, or sex toys help with the discomfort caused by this condition?
There are a number of great products that can help with the treatment of sexual pain. Vaginal trainers, including dilators and pelvic wands, can be very helpful in the treatment of certain vulvovaginal pain conditions. It is essential that vaginal trainers and toys are used with a personal lubricant for ease of insertion and to decrease pain at the vaginal opening. Different personal lubricants have pros and cons (I have a few great posts on this on my Instagram @jillkrapfmd!). Water-basedserums for moisturizing the skin is often a great place to start. It is important to make sure that the serum is free from irritating chemicals and additives. In addition, CBD is a promising natural substance that may extend additional benefits.