Why Sex Can (but shouldn't) Hurt

20% of women are having pain with sex – here’s what you can do about it.

Data on the subject of pain in the vulvar region, or with intercourse is hard to gather, as many women are not reporting this accurately to their doctors. According to the 2018 Jean Hailes’ Women’s Health Week Survey:

• 1/5 younger women (aged 18-35) have discussed or need to discuss with their doctor pain when having sex

• 1/4 have discussed or need to discuss a lack of interest in sex

• 1/5 women younger than 66 reported that they have not but need to discuss with their doctor a lack of interest in sex; this is higher than any other topic that women identified as an issue.

Somehow this doesn’t fit with on – screen steamy sex scenes where most women seem to be at peak arousal within minutes.

The difficulty in addressing the cause of pain arises from confusion over the definition of the conditions. Some conditions may be temporary or activity – specific (i.e. postnatal, position – related), while others are chronic and may require more than physiotherapy alone (endometriosis, fistulas, etc).

Vaginismus & Dyspareunia - Old Definitions for the Most Common Pain Disorder in Women

Dyspareunia & vaginismus were commonly thought of as separate conditions, however they have now been merged with 4 symptoms dimensions under the term Genito – pelvic pain / penetration disorder. According to the DSM – 5, diagnosis of GPPD can be made if only 1 of the following symptoms is present:

1. Difficulty with intercourse / penetration

(comparable to old definition of vaginismus)

2. Vulvovaginal or pelvic pain before / during / after vaginal

intercourse / penetration attempts,

not caused by vaginismus or inadequate lubrication

(comparable to old definition of dyspareunia)

3. Fear or anxiety about vulvovaginal or pelvic pain or vaginal

penetration

4. Tensing or tightening of the PFM during attempted vaginal

penetration

(considered to be emotional & behavioural consequences of

sexual pain)

To make a diagnosis, symptoms will persist for a minimum of 6 months, & cause “clinically significant distress” in the individual. Subtypes can be further refined into early onset or late onset, generalized or situational.

Other Causes of Pain With Intercourse:

• Vulvar disorders (candidiasis, herpes, dermatitis, lichens sclerosis, trauma)

• Atrophy & hypo - oestrogenization

• Inadequate lubrication

• Interstitial cystitis (IC)

• Prolapse

• Endometriosis

• Regional pain syndromes

• Fistulas

• Dermatitis

• Systemic diseases, i.e. Crohn’s

• Leaky gut

• Congenital abnormalities

• Psychosexual issues

• Vulval varicosities / pelvic congestion

Vulvodynia is vulval pain of at least 3 months duration, “without clear identifiable cause,” which may have potential associated factors. This is considered by some as a diagnosis of exclusion. It can be localized (cliterodynia, vestibulodynia or mixed) or generalized. It can be provoked (insertional, contact), spontaneous (replaces the word unprovoked) or mixed. It can also be primary (PVD1) or secondary onset (PVD2). Generalized vulvodynia is on the rise in young women – studies have linked the increase in more sex, partners, hair removal, & going on the OCP earlier as potential causes.

Which Part is Causing My Pain?

The “parts” or anatomy of pain drivers for most women is the same – muscles, skin, fascia, nerves, & ligaments do not range hugely in anatomical variability. Internal & external drivers on these tissues, however, can vary for each woman depending on her age, time in her life, etc.

Potential drivers for pain can include:

• Physical inflammation caused by eating sugar, processed grains, processed fats, or other inflammatory foods

• Over-exercising

• Not exercising at all

• Lack of sleep

• Chronic stress

• Low vitamin D or other nutrient deficiencies

• Digestive issues - bloating, chronic constipation, diarrhea, abdominal discomfort

• History of surgery, injury or severe illness

• Chronic infections

• Environmental toxic chemical, heavy metal or mold exposures

• Fear

• Lack of feeling safe in an intimate relationship

• Lack of understanding about the condition

• Lack of strategies to address the pain & promote healing

Treatment for pain with sex

Do you know if your pelvic floor is over – active?

Is it hard to relax your pelvic floor?

Is your pain present before, during, or after intercourse?

Managing pain with intercourse requires a team which may include your doctor, gastroenterologist, pelvic floor physiotherapist, nutritionist & a sexual psychotherapist.

Book in for an assessment today – pelvic floor physiotherapists are trained to assess and treat over – activity of the pelvic floor, scar tissue management, fecal urgency, straining and dyssyneric defecation, pelvic organ prolapse (POP), fascial release work for endometriosis and more.