Access to sex education is notoriously inadequate. Even if we disregard the limited scope and availability already present, there’s one element that, while seemingly simple, rarely gets any airtime in the sex ed conversations we are having. It’s a topic that can affect people of all ages, genders, and sexual orientations. It’s a topic that can significantly affect quality of life and relationships. However, it’s a topic that we tend to skip.
The topic: Sex should not hurt.
We call pain with sex dyspareunia and it is absolutely a topic worth discussing. While any person can unfortunately experience pain with sex, for today’s discussion, we are going to focus on those experiencing pain in and around the vagina and vulva with any form of penetration. (Don’t worry! We are going to cover dyspareunia experienced by males in a later post!). Conservative research shows that 10-30% of women will experience dyspareunia in their lifetime and seeking care is key.
There are many reasons why you may be experiencing dyspareunia and it will take a bit of detective work to identify the driver of your pain. Your healthcare provider will ask questions prior to an exam to help with this process. Has the pain always been present (what we call primary dyspareunia) or did it start later after sex was previously pain-free (secondary dyspareunia). Does the pain feel more superficial near the entry or does it feel deep inside the vagina, hips, or even abdomen. What adjectives would you use to describe your pain: sharp, shooting, throbbing, tugging, dull, aching? Does it happen every time you have sex or just at certain times, in certain positions, or with thrusting? It can sometimes be difficult to talk about your own experience with sex, but the more information you can give your provider the better the two of you can work as a team to find answers.
Common drivers of dyspareunia include vaginal dryness, hormonal changes, infections, injury from childbirth or prior surgeries, bowel or bladder concerns, prolapses, or issues with the branches of nerves that enter the pelvis. In addition to this list is, you guessed it, issues with the pelvic floor muscles. These issues are rarely seen in isolation. Pelvic floor dysfunction often goes hand and hand with any of the above. Moreover, if you have experienced dyspareunia from any issue, pelvic floor dysfunction will commonly result secondarily and make your symptoms more intense and harder to treat if left unaddressed.
Your pelvic floor wants to protect you. Even without you realizing it, if your body has experienced pain, it will often contract to try and keep things safe. This includes closing the muscles around the vagina. While an endearing act of our bodies trying to protect us, this only ends up making matters worse when we are trying to have pain-free sex. Often, this tightening pattern will continue even after the original source of pain has resolved (rude, I know!). All this to say, anyone who is experiencing dyspareunia should see a Pelvic Floor PT as addressing the pelvic floor is going to be a critical step.
So how do we teach the pelvic floor the right way to respond during sex?? A Pelvic Health PT will help identify which muscles are involved, stretch these areas and teach you ways of stretching these muscles yourself at home. Tools such as dilators and pelvic wands can be incredibly helpful for this purpose. They will also teach you ways to stabilize throughout your core appropriately to decrease the chance of your pelvic floor spasming and becoming too tight. They will teach you stretches to elongate the pelvic floor and reduce any pull they may be under from tight muscles externally. They can teach breathing techniques, lubricant options, and positions to try that can be key, especially in those early days of your journey.
One other factor to consider is the affects of stress. The body is really good at healing injuries like open wounds and breaks. It knows what to do when there is an obvious source of the injury – close it down and protect! With stress however, that guarding response isn’t so helpful. The body knows something is wrong and decides the best strategy is to go to an area that is already under strain, the pelvic floor, and close it down. To put it mildly, this isn’t a helpful response.
If you’ve ever received the advise to “just relax”, you know how frustrating trying to “just relax” can be. It’s a bit of a “don’t think of an elephant” situation. If pain with sex is a source of stress and if your body really wants to clinch when it gets worried, guess what it’s going to do – get stressed and worried and clinch stronger than ever. I would absolutely love it if we could simply rationalize with the pelvic floor and tell it that clinching is making everything worse, but the body doesn’t work that way. It’s going to take practice and repeat stretching. Don’t get frustrated with yourself or your body if progress is slow. You’ll get there! Thankfully we have lots of tools in our toolbox to reach your goals.
There’s one last thing I want to make sure we touch on before we wrap up this discussion. Sex being pain-free is a LOW bar. Wanting sex to be not only something that you don’t dread but actually enjoy is more than valid. We will be doing more posts about pelvic floor and pleasure during sex, but please, please, please, talk with your Pelvic Floor PT if you find yourself no longer experiencing pelvic pain but wishing sex was more enjoyable.
As always, reach out with any questions or if you need help finding a provider who is right for you!