When people think physical therapy they most often think of athletes and exercise. While this is partly true, as a physical therapist, my education and training was all about function.
Your knee hurts and now you have difficulty walking? That’s a problem.
You have carpal tunnel syndrome and need to be able to type for your job? That’s a problem.
You try to have penetrative sex but it hurts so you can’t have sex? You guessed it, that’s a problem.
Pain with sex is common, but it should not be considered normal. In fact The American College of Obstetricians and Gynecologists report 3 out of 4 women will experience dyspareunia (pain with sex) at some point in their life! That is basically the cast of Sex and The City! So if you think you are the only one suffering in silence, chances are that someone you know is in the same boat. As a pelvic floor physical therapist, I treat people of all genders with sexual dysfunction. For the purpose of this post, I will focus on individuals with vaginas and vulvas.
What constitutes pain with sex?
If you experience pain or any form of discomfort with sexual activity, that is considered pain with sex. So not just talking P in the V here. People can have pain with oral or finger stimulation. Some people may report pain when inserting a sex toy, with arousal and/or orgasm. I have patients that report the act of sex is great, but afterwards they have pain or bleeding. The pain doesn’t have to be in the vagina; it can be anywhere including the rectum, perineum, vulva or clitoris. This may explain why people aren’t openly talking about this common issue. Discussing the rectal pain you experience after masturbation or how your clitoris aches if your partner touches it isn’t something we discuss at the average cocktail party. Unless you invite a physical therapist like me, which may be why so many people avoid eye contact with me at social functions.
Now what can make you go from saying “Oh yes!” to “Ow” during sex? There are many factors that can lead to pain with sex or sexual dysfunction, including but not limited to:
- Polycystic Ovarian Syndrome (PCOS)
- An infection (yeast, bacterial, an STI etc)
- Hormonal imbalance
- Certain surgeries or medical treatment (radiation, chemotherapy)
- Pelvic floor dysfunction
That last one is where someone like a pelvic floor physical therapist would play a big role. It may come as a surprise, but there are muscles in your pelvis (aka the pelvic floor). They are small but they pack a punch and they are less of a floor and more of a muscular bowl. They support your pelvic organs: the bladder, uterus and colon, and make sure that you pee and poop when you want. So, if these muscles become dysfunctional, which can occur due to some of the factors listed above, it can lead to things like urinary incontinence, constipation or pain with sex! How? These muscles can get restricted, spasmodic or hypertonic (tight) like any other muscle of the body, which can irritate nerves and limit blood flow to the area, which is a physiological recipe for pain. So if these muscles are not feeling good to begin with they will not be stoked to hang out with a finger, dildo or penis. When they heard Netflix and chill, they were really excited for the chill part.
Sometimes the pelvic floor muscles involuntarily contract and make it so that nothing is able to enter the vagina, including tampons or a speculum. This is called vaginismus. If someone experienced this with the first attempt at having penetrative sex or when trying to use a tampon it would be considered primary vaginismus. Whereas, if someone was able to have pain-free penetrative sex, use tampons and see the gynecologist no problem, but then suddenly it felt like their vagina had a mind of it’s own and said Nope, this would be considered secondary vaginismus.
Pelvic floor dysfunction and some of the other factors listed above can cause vaginismus. Other things like anxiety, stress or history of sexual abuse/assault can be a cause as well. Having negative feelings or being fearful about sexual activity can also play a role. Therefore, people with vaginismus, or pain with sex in general, often benefit from working with a therapist in addition to other healthcare providers, such as a PT.
Other treatment may include medication to treat an underlying infection, improve a hormone imbalance or to help with pain management. Dietary changes may help decrease overall inflammation as gastrointestinal issues can irritate the pelvic floor. Engaging in meditation can help address any anxiety or stress that may be contributing to sexual dysfunction.
Other lifestyle changes may include not using fragrant soaps or lotions on the vulva as this can lead to irritation or an allergic reaction. The vagina is like a self-cleaning oven and doesn’t need much to stay healthy. Over-washing the vulvovaginal area can actually mess with the naturally occurring vaginal flora and increase the risk of infection. For similar reasons, it is important to use a good quality lubricant during sex. Look for a lube that is free of unnecessary chemicals, and water-based if you are planning on using condoms, since silicone-based lubes can deteriorate the latex in condoms.
Long story short, pain with sex is a common issue. It can be caused by many factors, and while it may seem like there is nothing to do about it, there are plenty of providers out there who are ready to help you.
If you aren’t sure where to find a clinician or want more resources feel free to check out The International Pelvic Pain Society or The Pelvic Health and Rehabilitation Center.