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When It Doesn’t “Hurt so Good”

By Dr. Pisaster | Pajiba Dirty Talk | January 4, 2011 |

By Dr. Pisaster | Pajiba Dirty Talk | January 4, 2011 |

A lot of sites have picked up on the fact that in the National Sex Survey that came out a few months ago, about a third of women reported pain during sex. As I noted at the time, only a very small percentage reported severe pain — for most the pain was mild to moderate, and probably wasn’t as big a deal to the women reporting it as it was to bloggers, but there is a small number of women for whom sex is so painful it’s virtually impossible. I don’t just mean during transient yeast infections or during an STI outbreak, but chronically. There are a number of possible causes for such pain, and in some cases no cause is known, but there are treatment options depending on the type of pain.

There are three main types of sexual pain for women, pain during sex only, vulvodynia, which is a fancy name for chronic vulvular pain, and vaginismus, which involves involuntary spasm of the muscles surrounding the vaginal walls. These are not by any means mutually exclusive - clenching of the vaginal muscles before penetration, for instance, is a common response to other types of pain. I am going to assume that anyone reading who’s dealing with this type of pain has already ruled out the obvious possibilities like STIs and chronic yeast infections (and lubrication - people love to suggest that one like women somehow don’t notice when they aren’t wet). The other possible causes are less common, and unfortunately often trickier to treat. Vulvodynia can be caused in some cases by a localized allergic reaction or sensitivity to something, such as bath soap or clothing detergent. The first step in looking for a cause is to eliminate this possibility. It can also be caused by injury or irritation of the vulvular nerves. There are medications that can be used to treat nerve pain (some antidepressants for example). In some cases this type of pain can also be caused by a disease called lichen schlerosus, which is thought to be an autoimmune disorder that most commonly affects the vulva. It is sometimes visible as patchy white skin in the affected area. This disease can be detected with a tissue biopsy, and treatment involves the use of cortical steroid creams. There are also some medications that can help.

Pain during sex (usually penetrative) that is not related to inflammation or pain in the vulva has numerous possible causes. Endometriosis, a condition in which uterine tissue grows in other parts of the body, can cause pain during sex. This condition can sometimes be detected via pelvic ultrasound, but the most definitive diagnostic tool is surgical biopsy. Endometriosis cannot be cured, but again there are medications to help mitigate its symptoms. Hysterectomy is also an option if you aren’t planning on having children (or more children). Another possible cause is ovarian cysts. Cysts can be removed surgically, although other treatment may be needed as well if the cysts are caused by an underlying condition such as polycystic ovary syndrome. Pain during sex can also be caused by chronic inflammation of the urethra or bladder. Again, these can be hard to treat, but medication to reduce the frequency of urination and relieve pain (certain antidepressants seem to work well to do both these things) can help. In cases where the cause remains unknown, medications such as hormone therapy, anti-inflammatories, and tricyclic antidepressants may be tried. (Antidepressants can be effective, by the way, not because the problem is all in your head, but because they affect other parts of the body besides the brain. They’re actually commonly used to treat a number of physical disorders.)

Unlike the other two, vaginismus doesn’t really have any known causes. In some cases it may be a response to past trauma or a reaction to pain, but it frequently occurs without these factors. If trauma is a factor, then seeing a mental health professional may help, but the most effective treatment is physical therapy (yes they have physical therapists for that). In fact, physical therapy can be effective in treating the other types of sexual pain as well. If nothing else has helped to relieve your pain or you are reluctant to try medication, I strongly urge you to consider physical therapy. A physical therapist will conduct a physical examination to determine the condition of you muscles, skin, and mucosa and locate tender areas. Depending on your condition, they may try a variety of approaches, including exercises to strengthen or relax the muscles surrounding the vagina, massage and manual manipulation of tissues, biofeedback, and electrical stimulation. In the case of vaginismus, dilators to accustom the vagina the entry are often used. Letting a stranger work around in your business may seem uncomfortable, but it really is an effective treatment for many women with vulvular or vaginal pain. This site has information on how to find a pelvic floor physical therapist in your area.

As a final note, if you are dealing with chronic pain during sexual activity and are in a relationship, obviously it can have a huge impact on your partner as well. It’s important to try to maintain physical intimacy, even if this doesn’t involve penetrative sex. Any sexual activity that doesn’t hurt and doesn’t leave you and your partner frustrated is a good idea. Even if you can’t handle any genital contact, there are still other ways to stay close. Maybe you could give them oral or manual sex in exchange for a really great backrub, for example. The important thing is to try to make sure your partner is a sexually satisfied as possible (opening up the relationship may also be an option for some couples) and that you two are maintaining at least some sort of physical interaction, sexual or otherwise. Seeing a therapist (the mental kind) separately or together may also be a good idea, since the mental strain of dealing with chronic sexual pain is difficult for both those suffering from it and their partners.

Dr. Pisaster has a doctorate in biophysics, not actually anything sexy. She does however enjoy having sex, reading about sex, and talking about sex. Especially when she’s had a little whiskey.

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