Michael Krychman, MD

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Angie DeRosa, Senior Editor at Contemporary OB/GYN®, interviewed Michael Krychman, MD, about the importance of creating an affirming environment in medical facilities for the LGBTQ+ community. He is the executive director of the Southern California Center for Sexual Health and Survivorship in Newport Beach, Calif. 

Building and Sustaining a Gender-Affirming Medical Care Environment

Vaginal dilators are an effective medical treatment for women experiencing pelvic pain and pain during intercourse and have demonstrated clinical success for over 75 years. 

These devices (alternately known as vaginal trainers) are inserts of progressive diameter used to stretch the vagina, decrease pain, and reduce anxiety related to intercourse (Table 1). 

Dilators are prescribed by a diversity of medical health care professionals, including ob/gyns, pain specialists, pelvic floor physical therapists, nurse practitioners, counselors, and psychologists. Vaginal dilation also is standard of care for treatment of postoperative male-to-female transgender patients who wish to maintain the patency of the neovagina. 

Proper usage is thought to recondition and facilitate an adaptive body/brain connection to eliminate anticipatory anxiety and pelvic discomfort or pain that women often experience in anticipation of intercourse.

According to a survey of 239 dilator users, 56.8% of women had suffered for more than 2 years, and 52% had seen more than 3 clinicians before they began dilator therapy

 A major hindrance to timely care is patient apprehension about discussing intimate issues with anyone, including their medical professional. 

Health care professionals are often remiss in discussing sexual pain syndromes, and such problems often go unaddressed at the clinical visit. 

Additional barriers to effective assessment include poor communication skills, time constraints, and reimbursement considerations. Many women being treated with vaginal dilators have self-diagnosed their condition and sought over-the-counter treatments. 

Watch: Vaginal dilators with Michael Krychman, MD

Liu et al published a survey by one manufacturer showing that 70% of women who purchased their dilation device used it without direct guidance from a clinician.

 Some information on self-directed treatment of pelvic pain conditions is available directly to consumers in online blogs, message boards, and video-sharing sites. 

In addition, dilators may play a role in sexual pleasure, and some women report improved sensuality and sexuality after use. Minimal published scientific data are available concerning dilator use. Studies are lacking on evaluation of optimal treatment protocols, but a brief report about current dilator usage is appropriate for ob/gyns.

 summarized recently published dilator research in a review article, “

 and noted that the most frequently published data describe treatment of postmenopausal women who also have a diagnosis of genitourinary syndrome of menopause and or dyspareunia. 

Several studies also show high rates of dyspareunia in breast, gynecological, and colorectal cancer survivors, especially among those who have received brachytherapy in the pelvic region. These studies show that many of these patients can benefit from dilator use in sexual rehabilitation. However,optimal protocols for dilator use frequency and duration of dilator sessions remain to be determined and confirmed inscientific literature.

Vaginal dilators have historically been cylindrical medical devices that sequentially increase in diameter and or length. They are placed within the vagina to help expand vaginal tissues that may be contracted due to vaginal atrophy, increased pelvic muscular spasm, or exogenous fibrotic damage due to chemotherapy or brachytherapy. 

By therapeutically stretching tight fibrotic tissues, these devices facilitate relaxation of the vaginal lining.

Ultimately, consistent use of dilators may help a patient reclaim pelvic floor relaxation and provide a method of behavioral modification.

 Often referred to as vaginal trainers, dilators remain an integral part of the overall medical treatment plan for a wide variety of genito-pelvic medical conditions. 

They may be made from materials including but not limited to medical grade plastic, latex, glass, and silicone. They may also have special additive features (Table 2). Head-to-head clinical studies comparing different types of dilators have not been completed. 

Factors that influence health care professional dilator choice include ease of patient use, affordability, material, and durability.

Incorporating dilators into the treatment paradigm

Compliance with dilator use remains low, and some studies report adherence rates below 25%.3 Poorly defined intervals, limited dilator sizes, and difficulty with progressing from one size to another remain challenging obstacles.

 discussed vaginal dilator therapy in patients with vaginal agenesis and reported a comprehensive treatment paradigm. 

Patient readiness for dilation and high patient motivation for dilation are predictive of compliance and success. In addition, the authors outlined a comprehensive plan for patient education and instruction concerning dilators: Patients should be advised to void before dilating, lay in a semi-recumbent position and use the devices with lubricant and/or topical lidocaine ointment if they experience pain. 

Health care professionals should confirm that patients have an awareness and understanding of their own pelvic and vaginal anatomy. More frequent dilation (2 to 4 times per day) was reported as a variable linked to a higher rate of anatomic success compared to dilation only once daily. Henceforth, the authors encourage patients to dilate as frequently as possible. 

Alternately, in the launch data from the 

 dilator survey, patients who dilated between 15 to 20 minutes reported the greatest reductions in anxiety and pain. It appeared that 15 to 20 minutes was the optimal dilation duration for success. 

In addition, activities that seemed to distract the patient, including television watching, deep breathing, or relaxation techniques, were associated with large reductions in pain and anxiety.

Patients who were encouraged to use their dilators before coitus had reduction in pain and anxiety. 

Although there is no current consensus in the field, many sexual medicine experts recommend that their patients dilate at minimum 3 times a week for no longer than 10 to 15 minutes per session to prevent patient/dilator burnout. Best practices include provision of detailed dilator instructions regarding position, interval, and duration of use, followed by close surveillance and frequent follow-up visits with the health care professional. 

A multidisciplinary approach to the management of these complex gynecological problems is often best served with a multimodal treatment paradigm, including cognitive behavioral therapy, mindfulness, biofeedback, rhythmic breathing, vaginal and systemic medications, and training to decrease anticipatory anxiety. Genito-pelvic floor physical therapists are an important and integral component of the treatment schema and should be actively involved in the treatment plan.

Dilators are an important, adjunctive mode of treatment for women with pelvic or sexual pain syndromes. They continue to be underutilized and under-prescribed. 

Future research should focus on optimal frequency and duration of dilation sessions needed to achieve the desired clinical outcome, while minimizing patient noncompliance. Comparative studies with validated outcome measures comparing dilators of varying materials should be conducted. 

Such research will help physicians guide their patients toward effective, evidence-based dilator therapy to help mitigate anticipatory anxiety with painful intercourse and accelerate return to coitus. 

is a gynecologist who specializes in sexual health and survivorship medicine. He is executive director of the Southern California Center for Sexual Health and Survivorship Medicine Inc. in Newport Beach, Calif.

is a gynecologist at the University of California, Irvine.

is a fourth-year medical student at the University of California, Irvine.

Liu M, Juravic M, Mazza G, Krychman ML. Vaginal Dilators: Issues and Answers 

. 2020;S2050-0521(19)30125-8. doi:10.1016/j.sxmr.2019.11.005

Melnik T, Hawton K, McGuire H. Interventions for vaginismus. 

Lee Y. Patients' perception and adherence to vaginal dilator therapy: a systematic review and synthesis employing symbolic interactionism. 

Idama O, Pring T DW. Vaginal dilator therapy: an outpatient gynaecological option in the management of dyspareunia. 

Macey K, Gregory A, Nunns D, et al. Women's experiences of using vaginal trainers (dilators) to treat vaginal penetration difficulties diagnosed as vaginismus: a qualitative interview study. BMC Womens Health. 2015;15:49.

Oelschlager A, Debiec K. Vaginal dilator therapy: a guide for providers for assessing

readiness and supporting patients through the process. 

Conforti C., Genitopelvic pain penetration disorder (gppd) an overview of current terminology, etiology and treatment. 

Articles

These therapeutic medical devices can be used by patients to effectively treat pelvic pain and anxiety related to intercourse.

Vaginal Dilators: A guide for health care professionals

Forty-three percent of American women aged 18 to 85 report experiencing some form of sexual complaint; however, the actual incidence of self-reported significant distress from these issues is closer to 12%.

Defined as distress due to lack of desire, impaired arousal, inability to achieve orgasm, pain with sex, or a combination of the above, sexual dysfunction is a commonly ignored topic given the societal stigma surrounding open discussion of female sexuality.

Unfortunately, this bias toward under reportingextends to health care providers, who also report being less comfortable bringing up female sexuality.

While in part, this is due to the perception that there is inadequate time in clinic to address sexuality issues, some providers do not feel proficient in sexual dysfunction knowledge or management.

Although over the last 10 years there has been a cultural shift toward acknowledging the spectrum of sexual relationships and conditions, several recent studies on training received in sexual medicine have not found increased attention on education in this area.

Discomfort among practitioners who are managing sexual dysfunction remains high.

 In addition, while the Internet has made it easier for patients to find information about their symptoms, they remain less likely to bring up intimate issues with their healthcare providers unless directly asked.

Despite this hesitancy from patients and practitioners to delve into sexual health, many studies support the idea that regular sexual expression is associated with improved psychological well-being and reduction in physical problems.

Intimacy has been found to be vital to overall well-being.

The aim of this article is to briefly review how to incorporate sexual dysfunction evaluation and simple treatments into current practice.

As health care practitioners, we effectively diagnose and treat disorders within our specialty. The challenge of sexual dysfunction is that the etiology may be complex, which can make starting the conversation about sexual function daunting. 

However, the American College of Obstetricians and Gynecologists (ACOG) recommends that all obstetrician and gynecologists should be initiating “clinical discussion of sexual function during routine care visits to identify issues that may require further exploration and to helpdestigmatize discussion.”

Although medical education regarding sexual medicine remains lacking, an advanced understanding is not needed to help patients feel comfortable. 

Start by normalizing the topic, ensuring patients that sexual problems are common and that the first step in improvement is being willing to talk about it. It can be effective to start the conversation with a simple open-ended question, for example: “Many women have concerns about sex. I wanted to check in and see how you’re doing.”

Allowing the patient to speak freely, followed by empathetic listening and asking pointed, detailed clarifying questions gives the patient space to express herself.

If short appointment times are the primary barrier to discussing sexual health, there are validated sexual function checklists, such as the Patient-Reported Outcomes Measurement System or Female Sexual Function Index (FSFI), that can be incorporated into the intake process; however, the onus is then on the provider to acknowledge aberrant answers and schedule follow-up appointments.

If a patient raises specific issues, begin by validating her concerns. If you are under time constraints, it’s acceptable toschedule a future focused sexual health follow-up appointment.

During that visit, take a detailed sexual history that includes: the patient’s sexual/gender identities, nature/duration/chronology and onset of symptoms, severity of distress caused by symptoms, patients’ personal attempts to alleviate symptoms, relationship quality, past/current abuse history (sexual, verbal, emotional or physical), and Internet/social media usage.

Assess hygiene, sleep quality, and body changes/image concerns.

 In addition, as part of obtaining a history, discussing the female sexual response cycle can be helpful to evaluate where in the cycle the breakdown is occurring: desire, arousal, orgasm, or resolution. 

It is useful to review that in women, the sexual response is not always linear and that a satisfying sexual encounter (SSE) does not always require moving through all phases, nor is an orgasm always necessary for a SSE.

A discussion focused on one area of concern of the cycle may shed light on underlying causes related to another problem. 

For example, a patient with pain with sex may think that her decreased ability to become aroused is due to other factors (relationship issues, age, lack of foreplay, etc.), when in actuality it is underlying vulvar vestibulitis and vulvar pathology that needs to be addressed. 

As part of this appointment, screen all patients for intimate partner violence because sexual dysfunction may be the primary and only manifestation. It is important to acknowledge that even after an initial intake appointment, the patient may not reveal the extent of her sexuality concern and that multiple appointments may be necessary for full disclosure.

Finally, assumptions in sexual medicine can be detrimental. Do not assume that all patients are heterosexual and engaging in monogamous relationships. Multiple relationship paradigms exist, and clinicians should be familiar with these sexual variations. 

Most importantly, try to create a welcoming, non-judgmental environment. Ensure that medical intake forms use inclusive language and pay attention to the descriptors a patient uses during her visit (for example, partner versus husband). You may never get a second chance to make a first impression. 

Comprehensive diagnosis, patience, and empathetic listening are the cornerstones for building a therapeutic alliance with your patient and facilitating a joint partnership in development of a treatment paradigm.

Although the etiology of female sexual dysfunction is often multifactorial, do not forget that the problem may actually be due to an underlying preexisting medical condition.

For example, changes in levels of thyroid hormone lead to alterations in circulating sex hormones. This can lead to autonomic dysregulation, causing sexual dysfunction.

In women, both hypothyroidism and hyperthyroidism have been associated with altered desire, arousal, orgasm, and satisfaction with intercourse.

 If the patient has a male partner, thyroid disease can be associated with erectile and ejaculatory disfunction.

Other chronic conditions may also impact sexual functioning. The role of diabetes in male sexual dysfunction is well established because erectile function can be severely diminished due to vascular complications of diabetes.

The impact of diabetes on female sexual functioning is less clear; however, some studies confirm that it can diminish genital sensation.

Similarly, neurologic diseases, such as Parkinson’s, multiple sclerosis, or sequalae of a cerebrovascular accident, can impact sexual function as mobility and sensation is often compromised.

Transient changes in health status should not be ignored. With all the focus on the arrival of a new baby, it can be easy for providers to forget to address sexual functioning with pregnant and postpartum women. 

Research has shown that hypoactive sexual desire disorder and painful intercourse/dyspareunia are common in postpartum women due to the interplay of low estrogen levels, mood changes, and fatigue.

Remember to ask about sexual function at postpartum appointments, even if it is not a patient’s chief concern.

Medication use may also be the cause of sexual problems. It is not uncommon for changes in sexual functioning to be associated with the start of a new medication. For example, some psychiatric medications have a reputation for causing sexual dysfunction; however, the true incidence is difficult to assess as sexual dysfunction can also be independently associated with psychiatric disorders such as depression, anxiety, and psychosis.

Most commonly, selective serotonin receptor inhibitors (SSRIs),

 benzodiazepines, and first-generation antipsychotics impact the sexual response cycle.

Maintaining a patient’s mental health is the main priority and if she feels that her medication is to blame for a decreased libido, consider recommending that she discuss a medication switch with her psychiatrist. 

Aside from psychiatric medications, antiepileptics may be associated with sexual dysfunction,

 as have hormonal contraceptives, although the data are conflicting and many confounding factors may be present.

Above all, optimization of general medical health conditions and well-being will allow you to provide the best care, treating the whole person rather than just her sexual considerations. Treatment of female sexual complaints should start by stabilizing any preexisting medical conditions and monitoring polypharmacy/ excessive medication use. 

Medications can directly and indirectly impact sexual function and care should be taken to assess and evaluate the impact of prescriptions, herbs, supplements, and over-the-counter (OTC) formulations on sexual responsivity.

Sexual dysfunction rarely exists in a vacuum. Ensure that you take a thorough medical history prior to assuming intercourse is the real problem.

Aside from addressing underlying medical issues, providing patients with simple behavioral modifications or interventions has been shown to improve or enhance sexual well-being. When men and women are satisfied with their sex lives, their overall health improves.

Therefore, talking with patients about prioritizing time for intimacy and sex, as well as planning intimate activities with their partners, such as regular date nights, can help reset relationships. 

In a world where distractions and technology overload are commonplace, effort needs to be made to shift the focus back toward enhancing connections and fortifying bonds.

Aside from encouraging couples time, you may also want to suggest novel sexual adventures. Many patients may never have explored sex toys/aids, accessories, or the use of supplemental lubricating products. Patient education and support can be therapeutic as well. Patients may not be aware that multiple medical conditions and medications can impact arousal and sexual lubrication. 

For example, during menopause, vaginal tissue becomes pale, frail, and inelastic due to a hypoestrogenic state.

 As a result, the vagina produces less physiologic lubrication. Given that genitourinary syndrome of menopause (GSM) and vaginal dryness is a common etiology of painful intercourse, having frank conversations about vaginal moisturizers and lubricants is a solution that is easy to implement.

Water-based lubricants are commonly used in most situations (sensitive skin, condoms, sex toys); however, they are stickier and shorter-lasting than the alternative silicone- or oil-based lubricants. 

Silicone-based lubricants will feel slicker and last longer than water-based lubricants. In addition, silicone-based lubricants are safe for use during water-based sexual activity (pools, hot tubs, showers, lakes) and also can be used with sex toys. Caution is advised if using with other silicone-based toys as it can impact the integrity of rubber products.

It’salso very important to instruct your patients to read labels and understand ingredients as some additives can be caustic to the sensitive vaginal mucosal lining.

Educate patients that some of the OTC options, whether lubricants or herbal concoctions, are not based in science and can be damaging. For example, vaginal tighteninggelsare not approved by the US Food and Drug Administration and many may negatively impact the healthy vaginal biome.

Many OTC supplements promise results but often fail on performance and scientific support.30 Nevertheless, in general, lubrication and sex aids are easy recommendations that any provider can safely make.

Understand the context of the relationship

Aside from treating the patient in your office, counsel her that the health of a relationship (or relationships) can significantly impact sexual functioning. 

Assessing the dysfunction in the context of a partnership can help shed light on the etiology of the issue. An understanding of relationship dynamics, communication styles, and emotional interactions is important when formulating a comprehensive treatment plan.If the patient is willing, an open discussion with her partner can be beneficial and therapeutic. 

During this appointment, address factors in the relationship that directly relate to sexual dysfunction (unrealistic expectations, different fetishes, etc.), but also lifestyle challenges (shift work, work travel, body changes, etc.).

There is evidence that exercises aimed at improving and enhancing partner communication about sexual wants, needs, and preferences can help alleviate a portion of sexual discomfort.

Furthermore, group-based or couples-based cognitive-behavioral therapy can be useful for improving low sexual interest.

As women’s health care professionals, we are often the only providers who may discuss sexual health concerns. Few residencies offer in-depth, formalized training about normal and abnormal sexual functioning. 

While we may want to tackle all issues related to women’s health, appropriate referral to specialists specifically trained in sexual medicine should not be seen as a clinical failure, but rather as a cornerstone of improving a patient’s sexual health.

ACOG recommends connecting patients with health professionals with expertisein sexual dysfunction, such as sex therapists and marriage/relationship counselors, as well as mental health specialists, such as psychiatrists and psychologists.

Couples counseling is often a good fit for patients looking to spend time addressing broad relationship issues. A sex therapist may offer help but mainly focuses on sexual concerns, such as negotiating discordant sexual desires and assigning exercises to help overcome dysfunction. 

There is emergingscientific data on the efficacy of sex therapy, and the general consensus of sexual medicine experts is that therapy and counseling can significantly improve sexual functioning, relationships, and quality of life.

Genital pelvic floor physical therapists may also play a critical role in the treatment of pelvic pain syndromes.

American Association of Sex Educators Counselors and Therapist (AASECT)

The International Society for the Study of Women’s Sexual Health (ISSWSH)

American College of Obstetricians and Gynecologists (ACOG) 

With the emergence of telehealth and Internet connectivity, even for practices in remote areas, telemedicine can help connect providers to patients. 

There is less information regarding distance counseling as it pertains to sexual health; however, it is effective for gynecologic care.

 For male health, tele-sexual health has been used to address concerns such as erectile dysfunction treatment and testosterone replacement, but its role for women and hormonal therapy is currently still being explored.

Out-of-pocket cost, fee-for-service models and reimbursement for telemedicine vary, by insurance company and geographic distribution.

Patients should be encouraged to investigate their coverage.

Just as the etiology of many sexual dysfunctions is complex, the treatment also requires a multi-faceted, team-based approach. Seeking help from experts is not a clinical failure on the provider’s part. 

Instead, it should be viewed as an opportunity for medical collaboration that can maximize a patient’s chance to recover and thrive.

Sexual dysfunction is an underdiscussed, though prevalent, issue. The aim of this article is to illustrate that there are many ways to help patients struggling with sexual dysfunction. 

Given the paucity of formal training on sexual health that many ob/gyns receive in residency, understanding the basic options that are available and creating safe, open spaces in which patients feel secure enough about to express their concerns is paramount to starting the process of healing.

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Patients and practitioners may be hesitant to delve into sexual health, but talking about it is one way to normalize it.

Michael Krychman, MD

Articles

Building and Sustaining a Gender-Affirming Medical Care Environment

Vaginal Dilators: A guide for health care professionals

Discussing patients' sexual concerns