One of the most frequently asked questions we get as pelvic floor specialists from our female patients is “is it normal that I have pain with sex?” While it is common, it is not and does not have to be accepted as “normal.” According to statistics from the American College of Gynecology (ACOG), 75% of women will experience painful sex (also called dyspareunia) at some point in their lifetime. The underlying conditions can often be difficult to diagnose and therefore go un- or underdiagnosed and perpetuate a cycle of patient distress due to bad management (yes, we still hear patients being told “it’s all in your head,” or “just relax and have a glass of wine before sex.” Argh!).
There are multiple physical reasons for pain with sex that can be addressed by a physical therapist that specializes in pelvic health and your gynecologist. In pelvic floor physical therapy, we start with a conversation about the pain during sex – typically “what, when, and where?” What is the pain characteristic? When does it happen? Where is the pain? These questions help guide our assessment and diagnose the particular tissue that is contributing to the pain.
If the answers to the above questions are “burning or friction-like pain at the vaginal opening during initial penetration” these can be conditions related to the superficial pelvic floor muscles and tissue. Conditions that affect the vulva or vestibule (primary vulvar or vestibular pain, primary clitoral pain) often cause lack of blood flow and lubrication to the tissues contributing to pain with penetration. Reducing tension and improving the length of the pelvic floor muscles via manual therapy techniques can improve blood flow, lubrication, and allow for pain-free penetration. Further, if your body is lacking self-lubrication, use a water-based lubricant. If there is a lack of estrogen (immediately following ovulation, when breastfeeding, or peri- and post-manopause), combining a topical estrogen cream (prescribed by your doctor) with pelvic floor physical physical therapy can improve tissue extensibility, blood flow, and lubrication. In conditions such as vaginisimus, the superficial pelvic floor muscles involuntarily contract, not allowing for penetration. Learning how to voluntarily relax those muscles in physical therapy can provide full resolution to conditions such as vaginisimus allowing for pain-free penetrative sex.
When pain is felt deep within the vagina or pelvis, the deep pelvic floor muscles can be the contributing factors. Often, we see women with tight pelvic floor muscles causing pain during penetration and even orgasm. Again, reducing the tension and learning how to properly coordinate the muscles into relaxation via manual techniques in physical therapy and with a pelvic wand can improve tolerance to sex and restore normal orgasm. Other causes of deep pain can relate to conditions such as endometriosis, PCOS, pelvic inflammatory disease, ovarian cysts, uterine fibroids, and IBS/constipation which can upregulate the body’s “fight or flight” reflex and lead to tightness in the pelvic floor muscles and pudendal nerve irritation. In combination with other treatments, pelvic floor physical therapy can address these secondary impairments and provide relief for dyspareunia.
Now we cannot forget there are other conditions that can lead to painful sex which can be diagnosed with the help of your PT or your gynecologist. Conditions such as lichen’s sclerosis may require a topical steroid along with physical therapy. STI/STDs can contribute to painful sex and need to be treated by your physician. Other simple factors include irritation caused by an allergy to your laundry detergent or soap; a quick fix is to change to a gentler detergent and only use water when washing yourself. Regardless of the cause, if you are having painful sex, there is something you can do about it! Use this blog to help guide your conversation with a pelvic health specialist to determine the cause and start the right form of treatment. Click here to schedule with our pelvic floor specialists in Boulder or Lafayette today!
References:
Mitchell KR, Geary R, Graham CA, et al. Painful sex (dyspareunia) in women: prevalence and associated factors in a British population probability survey. BJOG. 2017;124(11):1689-1697. doi:10.1111/1471-0528.14518
Sorensen J, Bautista KE, Lamvu G, Feranec J. Evaluation and Treatment of Female Sexual Pain: A Clinical Review. Cureus. 2018;10(3).
American College of Obstetricians and Gynecologists, 2022.