Is Sex Painful for You? Here's How to Change Your Symptoms.
Authored by Dr. Maryssa Steffen, PT, DPT, Board-Certified Women’s Health Clinical Specialist.
Do you feel pain during initial vaginal penetrative sex or deeper penetration?
Do your vulvar or pelvic symptoms depend on your body position during sex?
The medical term for sexual discomfort or intercourse pain is dyspareunia.
Your vulvar pain may occur during different parts of sexual experience.
You may feel vulvar or pelvic burning, stabbing, spasming, or tightness.
“Dyspareunia is defined as the occurrence of pain during or after sexual intercourse, which directly affects physical, sexual, and mental health. This condition can lead to depression, anxiety, and low self-esteem in [people] who experience it.”
Classifications of dyspareunia:
Pain in the vulva and vaginal entrance is “superficial dyspareunia.”
If the painful area is the cervix, bladder, and/or lower pelvis, then it is “deep dyspareunia.”
Primary dyspareunia is associated with pain at the beginning of sexual life.
Secondary dyspareunia is when it appears at a later time.
Do any of these apply to you?
Pain with sex is complex and challenging to find a single cause. This is because pelvic health includes “structural, inflammatory, infectious, traumatic, hormonal, and psychosocial conditions.” You may experience a cycle of symptoms that come and go, depending on emotional intimacy, sexual stimuli, arousal, and physical and emotional satisfaction.
If you are experiencing pain with sex, it is important to work with an evidence based, multi-disciplinary team to address all aspects. This team may include gynecologists, physical therapists, sex therapists, and pain psychologists, psychotherapists or psychiatrists.
If you have pain with sex, a pelvic physical therapist can diagnose the structural components and will consider your medical history and other symptoms to individualize your treatments and work with your healthcare team.
Physical therapy interventions may include education about sustainable habits, improving motivation and individually guiding an active lifestyle, supporting a healthy self-image and embracing your body, and enhancing the mobility and function of the pelvic floor and neighboring tissues and systems.
What about sex pain treatment?
From a 2023 meta-analysis published by the Women’s Health Group at Boston Medical Center, “the combination of pelvic floor muscle training with other treatment strategies in a multimodal intervention has been shown to yield the best results for improving sexual function.”
What can a multimodal intervention be like?
Generally speaking, most clients with dyspareunia benefit from the following:
Relaxation techniques
Diaphragmatic breathing
Exploring sexual interest, desire, and arousal quality
Pain education
The above approaches improve relaxation capacity, restore your ability to rest your pelvic floor muscles, increases vaginal elasticity, and enhances muscle awareness and pelvic floor awareness during movement.
As a result, you may experience significant reductions in pain intensity during sex, decreased severity of painful sex, and less sexual distress.
You may experience significant improvements in sexual quality of life, sexual desire, arousal, lubrication, orgasms, and sexual satisfaction. Studies show these benefits can still be present at least 6 months after a completed course of interventions.
Electrotherapy in combination with other therapeutic modalities, can significantly help painful intercourse.
What is TENS?
High-frequency TENS is strictly pain relieving.
It activates how your sensory nerves are receiving information and inhibits the response of sensory fibers that interpret pain by activating communicating nerves in your spinal cord posterior horn before the signal reaches your brain.
Ask your doctor or your pelvic physical therapist about the TENS unit with a vaginal probe.
Pelvic physical therapy may also include manual therapy as part of a multimodal approach to your care
To improve blood flow, vulvar and visceral mobility, relieve nerve compression and pain.
Myofascial release is used to bring the muscle to its optimal length, decrease pain, and improve function.
To change pelvic floor muscle trigger points, which represent one of the causes of dyspareunia.
What body areas would benefit from manual therapy to treat painful sex?
Release of trigger points of the abdomen, diaphragm, piriformis, iliopsoas, and vaginal pelvic floor muscles.
Studies show that release to the superficial pelvic floor muscles, for just four weekly sessions, each lasting five minutes, achieved greater improvements compared to other studies that used more complex and prolonged treatment.
What about pelvic floor strengthening or Kegels?
There were no significant differences in improvements in sexual function when pelvic floor muscle training was applied in isolation. In other words, you need more than a “strong” pelvic floor to improve sexual pleasure and decrease pain.
The most reductions in pain with sex occurred with the groups who combined electrotherapy (TENS or electrical stimulation) with pelvic floor muscle training.
The meta-analysis also concludes that supervised and progressive exercises, combined with manual therapy techniques, electrotherapy, and patient education yields the best results across a population of hundreds of people with dyspareunia.
Therefore, it is important to have professional supervision to ensure proper technique and appropriate progressions in your exercises.
Additionally, combining the training program with other complementary techniques can enhance its effectiveness.
You should have clear instructions for performing exercises at home because it is crucial for maintaining continuity and achieving optimal results.
What is a Kegel?
You need to be critical when you hear about “Kegels.” Like any other exercise and any other muscle group in your body, the specificity of the movement, how you load your muscles with weight, how you reverse the contraction with relaxation, and your endurance should all be considered when designing an exercise program. This is also true for your pelvic floor muscles.
If you experience pain with sex, your pelvic floor training should be specific to you.
Just like if you have shoulder pain and you want to lift heavy weights, your medical and injury history, your body awareness, your postural strength, your flexibility, and how heavy you can lift now, are some of the important factors to consider when starting an exercise program that improves your shoulder pain.
Your pelvic floor muscles deserve the same attention and nuance because you have a body that is different from everyone else.
Also, you need to be clear about your physical therapy program and understand that it should be continued for as long as necessary to bring about functional and lasting changes.
Rather than solely focusing on strength gain, “just Kegel,” your program to treat painful sex will likely include:
Pelvic floor muscle coordination and relaxation capacity.
Breathing normalization and correct posture.
Pelvic floor stretching exercises, alone or with a PT, with or without a dilator.
Pelvic floor muscle training, by contracting and relaxing the muscles, with or without biofeedback.
Biofeedback is a device you can use with a vaginal probe that measures the electrical activity of your pelvic floor muscles and gives you visual feedback about when you contract and when you relax your muscles. It can be a helpful modality if you are a visual learner or if you have trouble isolating your pelvic floor muscles.
Biofeedback training can enhance and train your pelvic floor awareness.
Be careful about expensive and trendy biofeedback devices because they often cue you to squeeze, with little or no cues to relax. Training means you can do BOTH.
Do you have difficulty with achieving orgasm, you are unable to experience orgasm, or orgasm happens infrequently?
Studies show that pelvic floor muscle weakness contributes to a person’s inability to reach orgasm, which is often observed in cases of dyspareunia.
Also, having good resting tone in the muscles attached to the clitoral corpus cavernosum, such as the ischiocavernosus and bulbospongiosus muscles, can enhance the involuntary contraction of the perineal musculature, thereby improving arousal and orgasmic response.
Ischiocavernosus and bulbocavernosus muscles supporting the clitoris in yellow.
If you experience pain with sex or difficulty with orgasm, a program with complementary modalities may be the most beneficial.
If you do not have access to a pelvic floor PT in your area, you can start with a consistent movement practice that includes relaxation, breathing, and posture. For example, a daily or weekly online or in-person restorative yoga class, Qigong, or Tai Chi are great options to start with.
If you are interested in biofeedback, there are affordable units online. However, you will get the best results if you can find a PT for a Telehealth visit in your state. Your PT can guide how you are using the biofeedback. You may experience significant progress within a few visits!
If you are working with a pelvic floor therapist in person, they may combine perineal muscle strengthening with biofeedback training, and the application of TENS at a high frequency and intensity below the pain threshold. These modalities are known to interact with your neurophysiology to change your brain’s response to pain and your muscle’s adaptations.
Your therapist will likely also use manual therapy trigger point release because it is proven to effectively reduce pain intensity during sex.
It is important to note that dyspareunia is not solely a physical disorder, but it also has significant psychological implications. Therefore, having a trusted mental health professional on your team in the treatment process is vital to enhance the overall quality of life for you.
If you are in the state of California, book a discovery call to learn more about sex pain treatment. We offer Telehealth and in person visits. Our office is located in Oakland, CA.
Reference
Fernández-Pérez P, Leirós-Rodríguez R, Marqués-Sánchez MP, Martínez-Fernández MC, de Carvalho FO, Maciel LYS. Effectiveness of physical therapy interventions in women with dyspareunia: a systematic review and meta-analysis. BMC Womens Health. 2023 Jul 24;23(1):387. doi: 10.1186/s12905-023-02532-8. PMID: 37482613; PMCID: PMC10364425.
