What do you do when you finally get the treatment you fought for, and your physio tells you the best next step is to slow down?
In this solo update, Mathilde Olstad, host of The World's Tightest Community, shares where she is with her own treatment for vulvodynia and pelvic floor tension after trying pelvic floor Botox for the first time. She talks through what the procedure was like, why her new physio asked her to go much slower than she expected, the tibial nerve stimulation device she is trialling, and how she thinks about speaking openly about vulvovaginal pain.
Pelvic floor Botox for pelvic pain: what the procedure is really like
Mathilde's pain started several years ago as stinging during and after sex. She was eventually diagnosed with vulvodynia and went through years of physio, medication and different treatments. The localised pain around the vestibule is now pretty much gone. What remains seems mainly muscular: pain with insertion and penetration, and a pelvic floor that has been very hard to get to let go, particularly on the left side. That is what the Botox was meant to address. She had it done at a specialist vulvar clinic in Oslo, and arrived ready to argue her case, only for the gynaecologist to offer it on the same day.
The numbing spray was the most painful part, stinging for maybe 20 to 30 seconds. The Botox was then injected at four points, with some pressure and a strange sensation but very little pain. There was a small amount of bleeding, and Mathilde was told to avoid working out for a few days. The effect lasts around three to six months, and she says it is too early to tell whether it has changed her pain with insertion. What stayed with her most was the relief of being examined, believed and offered another way forward after years of pelvic floor physio and home exercises.
I didn't have to persuade her that I was trying hard enough. She could see there was something we could work on and she had something to offer.
Pelvic floor physiotherapy after Botox: why going slower can be the right plan
Mathilde assumed the months after Botox were the time to do more: touch, insertion, building up positive experiences while the muscles were quieter. Her new pelvic floor physio told her to go in the opposite direction. In the first session she touched Mathilde's skin and moved up towards the inner thighs until Mathilde noticed herself tensing in anticipation. That was the starting point. Her homework for the summer was to touch and massage her thighs lovingly, with nothing near the vulva or vagina.
She found it frustrating, and then noticed she had turned the exercise into something to achieve. Many people with chronic pelvic pain will recognise this: the diligent patient who researches everything and pushes through discomfort. Her physio's argument is that the anticipation of pain matters regardless of what the muscle is doing, so treatment has to begin where the bracing begins. Mathilde is still finding it annoying, but says it has also been a relief to have someone outside her say that this is enough for now, and to work with a clinician who is confident that progress will come.
I thought I should have put my hand up later. I should have let her go further before saying that I felt uncomfortable because now I'd set the bar too low.
Talking openly about vulvodynia and painful sex: shame, embarrassment and community
Someone recently asked Mathilde how she deals with the embarrassment of talking publicly about vulvodynia, vaginismus and painful sex. She did not start out comfortable with it. Until about a year ago she worked in finance, and before launching the podcast she asked a close friend whether it was embarrassing. The friend told her she admired her for saying it out loud. There are still flickers of embarrassment, but mostly she now finds it empowering, because her anger grew bigger than her shame.
That anger comes from the gap between what clinicians and researchers know and what a person in pain is actually told. The podcast now reaches over 10,000 listeners a month, and listener messages shape what gets covered, including a recent episode on supporting a partner that began with one email. Mathilde invites listeners to send in ideas for what the community should do next. Being more open about your own experience can be as small as telling one person.
I think what changed for me was partly that my anger became bigger than my embarrassment.
Tibial nerve stimulation (TTNS) for pelvic pain: what it is and how to trial it
Alongside Botox and physio, Mathilde is trying transcutaneous tibial nerve stimulation, or TTNS. Electrode pads go near the ankle and on the foot, and a small machine sends electrical pulses through the skin. The tibial nerve connects back to the lower spinal cord, with some overlap with the nerve roots involved in pelvic function. One proposed mechanism is that stimulation activates pathways that inhibit pain, essentially turning the volume down. Mathilde is clear that she is not the expert on this.
The research is more established for bladder symptoms, and there are still open questions about who it helps for pelvic pain and by how much. Mathilde uses it for 20 minutes a day for an initial three months, then will assess whether anything has changed. She finds it easy to fit into the day. If you are curious, ask a pelvic health clinician whether TTNS suits your symptoms, and expect it to be one part of a wider plan with pelvic floor therapy rather than a stand-alone fix.
