Help. It hurts when I have sex. – For women.

We are sorry. No matter what you might have been told, sex is not supposed to hurt.

Yet, in the Marriage Intimacy Project study, 19% of women said they experienced pain with sex at least half (50%) of the time and 18% saidthe pain interfered with sexual pleasure at least 50% of the time. That’s a lot of pain.

Unfortunately, an accurate diagnosis and effective treatment can be elusive for many. Finding out what is really wrong can take multiple visits to different specialists. Embarrassment, shame, fear, and an appropriate desire for privacy around our sexuality can make pushing forward difficult. We’d like to encourage you to keep moving forward.

What’s wrong?

Because of the complexity of sex and the complexity of female anatomy, there are a LOT of things that can go wrong. (The article “The Complexity of Sexual Pain” further explains the complexity involved.)

Technically, painful sex is called “dyspareunia”, but that diagnosis is as helpful as telling you it’s a “headache” when your head hurts. You still don’t know what’s causing the pain.

The International Society for the Study of Women’s Sexual Health (ISSWSH) lists multiple types of sexual pain caused by a host of issues. As a sample, external pain may be in the general vulva region (vulvodynia), the vestibule (the soft tissue right around the vaginal opening –vestibulodynia), or the clitoris (clitorodynia). This pain may be caused by hormonal changes, infection, inflammation, skin conditions (i.e., lichen sclerosis), nerve issues (i.e., nerve injury), physical trauma, changes and/or trauma during pregnancy/delivery, the effects of other diseases, or a host of other problems.

Deeper in, the pain may be caused by structural abnormalities (i.e., the shape of your cervix or position of your uterus), musculoskeletal (i.e., overactive pelvic muscles, vaginismis), cysts, inflammation, infection, neurologic issues, hormonal factors, psychosocial factors, or even a fit problem to name a few.

Figuring out the cause requires a systematic and detailed exam. ISSWSH has several steps they recommend in evaluating the source of vulvar pain (genital pain). Most gynecologists have not been trained in how to walk through these steps. A sex therapist or pelvic floor physical therapist often can each do only one or two of them.

A multi-disciplinary treatment team is the treatment of choice.

Because of its complexity, experts in sexual pain believe a team of people is typically required for accurate diagnosis and treatment.

Sexual Medicine Specialist

A critical part of your team is a sexual medicine specialist. (Begin your search in the “Find a Provider” section of https://ISSWSH.org.) Unfortunately, there aren’t enough sexual medicine specialists. When you do find one, he or she may not be a part of your insurance plan, or you may have to travel a distance to see them. That said, many of my clients find that traveling to see a true specialist is well worth the energy and expense.

If you can’t find a sexual medicine specialist, do some deep digging for a gynecologist or urologist who has training, experience, and success in working with sexual pain. You are the consumer. Ask the tough questions to find someone good. I hear too many sad stories of people who have been depending on well-meaning doctors/providers who do not have the proper training and experience to address sexual pain issues.

As a starting point for addressing this complex issue, it is common for a physician/provider to immediately recommend changes that have previously worked for similar patients. For example, I have found that some physicians/providers switch the patient from oral birth control to another form of birth control because of how frequently oral birth control is a cause of vulvar pain. Another physician I work with looks for interstitial cystitis because pain radiates, and it isn’t always easy to locate the actual source of the pain. For menopausal women, GSM (genitourinary syndrome of menopause) is a common culprit of pain and decreased sensation. Effective treatment is almost miraculous in some of these cases.

Don’t be discouraged if the first interventions don’t work, however. We learn as much from what doesn’t work as what does. Keep following up. If your doctor can’t help, ask them who they think could and keep seeking help.

Pelvic Floor Specialist

The second person you want on your team is a physical therapist specializing in pelvic floor issues. (Begin your search at aptapelvichealth.org or pelvicguru.com). Even if the root of your pain isn’t your pelvic floor, this is still a valuable professional on your team for two reasons. One, in some cases, developing a healthy pelvic floor has been shown to resolve enigmatic pain (pain that is difficult to understand, diagnose, or identify the cause of). Getting that part of your body healthier can only be good for you. Right? And a healthy pelvic floor has been shown to increase the pleasure of sex. Added bonus.

Two, when touch to the vulva causes pain, your body instinctively goes into self-protect mode. One factor in self-protect mode is that your muscles tighten. Let’s say, for example, the root of your pain is vulvar vestibulitis caused by your oral birth control. Touch to your vestibule (the opening of your vagina) is going to hurt. Stretching it for a penis is definitely going to hurt.

When you experience intense vulvar pain, often described as burning, tearing, stretching, or rubbing, your pelvic floor clenches. It doesn’t take long for your pelvic floor to learn to automatically clench when a penis gets close. Trying to push a penis through a clenched pelvic floor hurts even more. So, the muscles tighten more. This results in a pain cycle that is unconscious and difficult to stop.

A pelvic floor specialist can help you learn how to voluntarily control these muscles. You can learn to relax them, counteracting the cycle that intensifies the pain.

Female Genital-Pelvic Pain Dysfunction, sometimes called vaginismus or hypertonic pelvic muscle dysfunction, can be the root of the pain, but often it is secondary to another cause of the pain. I have worked with many women who have been diagnosed with “vaginismus” by a therapist and treated by a pelvic floor specialist without resolution of the pain. Typically, it’s because she wasn’t properly examined, so the root cause of the muscle dysfunction was missed. The root cause needed to be discovered and treated before the “vaginismus” could be resolved.

Sex Therapist

Finally, I highly recommend a sex therapist trained in working with sexual pain be the cornerstone of this team. (Begin your search at ABCST.org.) The sexual pain journey can be overwhelming, confusing, and discouraging. Having a coach who can help you stay hopeful, problem-solve, and stay on track without the journey becoming all-consuming can be vital.

A sex therapist can also help in those times where the root cause of the pain is relational or historical. Trauma, whether in history or current, can prompt your body to go into protect mode and “lock down” sexually as the pelvic floor clamps shut. Trying to force through the lock can be very painful, verifying to the unconscious mind that you are not safe, so the pelvic floor feels even more of a need to lock down. We see correlations to sexual pain in women raised in chaotic or highly restrictive environments (i.e., alcoholic homes, strict religious families, sexually repressive families, etc.). As one example, I was talking recently with a gynecologist who works with women in a conservative Muslim community and was overwhelmed with severe sexual pain cases. We also see an increase in auto-protect reactions and sexual pain when someone has experienced rape, molestation, incest, and other acts of sexual violence.

I have also worked with wives experiencing sexual pain in a marriage where they experienced strong sexual pressure from a husband who was not honoring to her. In one case, the wife divorced that husband, and married a man who was sexually disciplined and deeply honored her. Her pain miraculously disappeared. I believe her body was clearly trying to protect herself in her first marriage. While this isn’t an endorsement for finding a different spouse as a treatment method, it does illustrate the complexity of sexual pain.

A trained, experienced sex therapist can be key to solving your pain issue.

Bonus

Last, if you can find one, join a therapy group or a support group for women experiencing sexual pain. Humans often heal in profound ways when in community. While these can be difficult to find, women helping women is a powerful force.

One possible group for those with unconsummated marriages (including those due to pain) is the new UPWARD group (Unconsummated People Working Actively to Rediscover Dreams).

Closing comments

Finally, a word of caution: Consumer beware. Anyone who provides a simplistic answer to your pain is likely not trained to recognize the complexity of the problem and may do more harm than good. Be a good customer and seek qualified care and support.

 

 

Educate Yourself:

Prosayla is a great place to start educating yourself on sexual pain for women. Sponsored by ISSWSH, it contains articles and information you can rely on.  https://www.prosayla.com

The National Vulvodynia Association has also put together a booklet called Vulvodynia: A Self-Help Guide available for free online.  https://www.isswsh.org/images/PDF/NVA.Self-help.guide.pdf

The National Vulvodynia Association also has a booklet for partners of women with vulvodynia (My Partner Has Vulvodynia – What Do I Need to Know?).  https://www.nva.org/publications/self-help-guides/

 

 

Special thanks to the following awesome clinicians for their help in ensuring the accuracy of this article:

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