What does a conference room full of the world's leading researchers in women's sexual pain reveal about how far the field has come - and how far it still has to go?
Mathilde has just returned from the ISSWSH (International Society for the Study of Women's Sexual Health) annual meeting in Long Beach. This solo episode is part conference recap, part deep dive into the research she encountered there, and part personal reflection on what it means to cover this field from the inside of living with the conditions it studies. It covers new research, new treatment categories, and a disparity in access to care that should not be possible - and is.
What sexual medicine is - and why a whole field exists around it
Sexual medicine is a subspeciality that sits at the intersection of gynaecology, urology, psychology, endocrinology, and neuroscience. ISSWSH is the primary academic society for practitioners in this field, and its annual meeting is where the research that will shape clinical practice in the next five to ten years gets presented and debated. Mathilde explains why this field exists separately from mainstream gynaecology - the answer is essentially that mainstream gynaecology has historically been unable or unwilling to address the full complexity of women's sexual health and pain.
For people with vulvodynia, vaginismus, or other pelvic pain conditions, understanding that there is a specialised field with its own evidence base, its own journals, and its own clinical standards matters practically. It means there are clinicians who operate at a higher level of knowledge than the standard gynaecology referral - and knowing what to ask for, and where to look, changes what treatment is accessible.
Vulvodynia subtypes and treatment matching: why the wrong treatment won't work
One of the most significant research themes at ISSWSH is the movement toward subtype-specific treatment. Hormonally-driven vulvodynia - where the primary driver is hormonal insufficiency at the vestibular epithelium - shows a 70% response rate to topical oestrogen and testosterone therapy when correctly identified. But that 70% response rate is only achieved in the right patients; applying the same treatment to patients with different primary drivers produces much lower rates.
This is why treatment failure is often not a statement about the treatment - it is a statement about the match between treatment and subtype. Mathilde covers this directly and clearly: if you have tried treatment after treatment and nothing has worked, it may not be that treatment doesn't work for you. It may be that you have been treated for the wrong subtype.
"If you've tried treatment after treatment and nothing has worked, it may not be that treatment doesn't work for you. It may be that you've been treated for the wrong subtype."
New research: neuroproliferative dyspareunia, PEVD, and the vaginal oestrogen update
The conference also featured research on newly validated pain subtypes and updated clinical guidance. Neuroproliferative dyspareunia - a nerve-driven form of dyspareunia involving abnormal proliferation of nerve fibres in the vestibular tissue - was presented as a subtype requiring different treatment from the standard hormonal approaches. Pelvic venous disorder (PEVD) - essentially varicose veins inside the pelvis - was discussed in the context of its associations with POTS, MCAS, and hypermobility, a cluster of conditions that many people with chronic pelvic pain will recognise.
The removal of the black box warning from vaginal oestrogen - a regulatory update with major clinical implications - is also covered. The black box warning had been causing practitioners to avoid prescribing vaginal oestrogen for menopausal and post-menopausal patients, despite strong evidence for its safety and its role in treating genitourinary syndrome of menopause. The update removes a significant barrier to appropriate prescribing.
Why women's pain is still being dismissed - and the access gap that shouldn't exist
Mathilde closes with two things she found hard to leave behind after the conference: the persistent evidence that women's pain is still being dismissed and underfunded, and the access and equity data that makes that injustice concrete. Manhattan has 60 times more pelvic floor physiotherapists per capita than the Bronx. Only 21% of practices accept Medicaid. The research frontier is advancing, but the gap between what is possible for someone with access to a specialist and what is possible for most patients is not closing at the same rate.
She also shares something personal about privilege - about what it means to have been able to attend this conference, to access the information in it, and to carry the knowledge of what is possible for people who are nowhere near this level of care. It is a note that the episode ends on honestly, without resolution.
