Does sex hurt?
Lets begin with: it is not all in your head.
It is reported that 7.5% of women will report painful intercourse to their primary caregiver across their lifespan. This condition is a set of symptoms (that penetrative intercourse is painful) that have been traditionally under-reported as women do not feel they can report it, or when it is reported, women are not listened to. It is often linked to other symptoms such as vaginal dryness, depression, relationship challenges, previous non-volitional experiences, vulvodynia, vulvar vestbulitis, vulvar skin conditions (eg. lichens schlerosis). It is often years between onset of symptoms to actual diagnosis. With all this complicated structure, women can feel like maybe it’s not real. But it is. And it is treatable.
Treatment occurs best in a a Whole Person framework where all contributing factors or influences may be considered and addressed. This is often supported by multiple disciplines.
If you have painful sex physiotherapy is a treatment option because, while there are many factors that must all come together to allow for a positive sexual experience, one of those factors is physical. Muscles, nerves and connective tissues need to be able to stretch and accomodate to the size of whatever is going inside a vagina. These tissues need to be strong enough to provide support for erectile tissues like the clitoris for optimal excitation and climax. They need to be considered without fear or negative thoughts for their performance to be truly optimized.
Treatment of painful sex conditions always begins with a detailed conversation about your health, surgical, movement and applicable sexual history. Your goals are clearly defined and regularly referred to throughout the process.
Have you considered that sex is executed via dynamic whole body movements? No matter your partner or position, your body needs to be able to move in specific ways to allow for successful intercourse, including penetration. That is why we will assess your whole body first, so that I may learn your Driver Profile (See What to Expect). Only then will we entertain the idea of an internal vaginal or rectal assessment to learn what your pelvic floor muscles and tissues are doing during penetration/intercourse related activities.
Usually, women who have pain with intercourse also have pain with insertions of tampons or with having their annual pelvic exam, especially when a speculum is involved. This means when they hear that I will attempt an internal exam they are justifiably concerned, even scared, of this idea. Often the pain has been intense, and they know that going inside will hurt again. Not going to want to do this.
This concern is something I take very seriously. I do not want to activate your pain pathways. To place your experiences of penetration in their proper light I cannot activate those pathways. I have rules about this. It’s simple. And allows you as the patient and me as the therapist to move safely through a process that is potentially aggravating, scary and challenging.
The rule is: you are not to feel pain that is greater than a 4/10.
This means: if 0/10 is no pain and 10/10 is the worst pain you can imagine you are never to feel something that you would interpret as 4/10 or more.
If you do feel something that rates as greater than a 4/10 then you will let me know, I will stop whatever I am doing (which usually involves holding stil)l and we will troubleshoot to attempt to decrease this discomfort, learn where/what it comes from, and decide what we will do next. That decision might be that I stop the assessment altogether. It usually does not require that step.
The reason I don’t say “I never want you to feel anything remotely uncomfortable”, aka 0/10, is that sometimes intercourse is not comfortable for a moment or two. And that discomfort is normal and informative. Discomfort is different than pain. Having an internal evaluation in my office, even if as safe and clean and comfortable as possible is still likely to be uncomfortable on some level. But it shouldn’t be painful. That is all I can promise to try to achieve.
Once the Whole-Body and internal Pelvic Floor assessments have been completed, we can discuss your individual treatment plan. If I think you need to be referred to other practitioners to support your process (such as a clinical counsellor that works in this area) I will provide recommendations.
Treatment often involves relearning to use your pelvic floor muscles to allow for things to go inside in whatever body position you might choose. This can be accomplished with clinical visits where I use manual techniques and biofeedback to release and train your pelvic floor muscles, and homework with vaginal dilators. Not all women need to use dilators so if you don’t have them, or are not sure, don’t purchase any until after our assessments are complete. I will advise you about this.
A positive sexual experience often involves more than one person. If you are involved in a relationship and wish to allow that person to be with you on this journey you are welcome to bring them to any of your appointments. I do not need to know in advance, if they are with you in the waiting room, I’ll make room for them. These people often want to be involved, often have suffered with you and as such want to find solutions with you. Most importantly, if you do need to use vaginal dilators for homework, they can be an invaluable partner in that particular homework task. I welcome partners!
If you suffer from painful sex, book an appointment today to get on the path to wellness.