Jill Krapf, MD on painful sex, vulvovaginal disorders and mast cells with Dr. Tania Dempsey on Mast Cell Matters
This episode explores vulvar and vestibular pain (vulvodynia/vestibulodynia) and how hormones, pelvic floor muscles, nerves, inflammation, and mast cells can all contribute. Dr. Krapf explains that most patients present with burning or pain "down there," often at the vaginal entrance (the vestibule). She organizes causes into four overlapping "buckets": hormonal (low or poorly delivered estrogen/testosterone at the tissue, including menopause, postpartum, certain meds, or reduced blood flow from tight pelvic floor muscles), muscle (pelvic floor over‑tightening restricting blood flow), nerve (irritated pudendal or spinal nerves and local overgrowth of pain fibers), and inflammation (including autoimmune skin diseases, infections, abnormal vaginal discharge, and likely mast-cell–driven processes). A severe subtype, neuroproliferative vestibulodynia, shows dense nerve and mast cell clusters on biopsy; surgery (vestibulectomy) is often used but access is limited, and small studies suggest mast-cell stabilizers like ketotifen or agents like topical gabapentin, capsaicin, or luteolin might help, especially if used early. Dr. Krapf notes strong overlap between vulvar pain, hypermobility/EDS, severe pelvic floor dysfunction, early spine degeneration, POTS, Sjögren’s, and mast-cell–type symptoms, emphasizing that these women often go unheard because genital pain is hard to talk about. She stresses that there is always a cause, that patients often need a "medical detective" who looks beyond gynecology, and that informed patients do better. Local vaginal/vestibular hormones (estrogen, DHEA, and sometimes testosterone) can be key, particularly because the vestibule is rich in androgen receptors and is developmentally analogous to the prostate. She encourages clinicians in all specialties who see women with complex chronic illness to ask about genital symptoms, and recommends her book "When Sex Hurts" as a practical, referenced guide for both patients and providers.
