(Making) love hurts

So many women out there suffer from pain with intercourse…and most of them suffer in silence. The few that are brave enough to speak up and visit a doctor are often greeted with statements like “It’s all in your head” or worse, they are confronted with a physician that is just uncomfortable with the subject so they avoid it. Thus, the suffering goes on. Sex becomes something to dread, not something to enjoy, something to get through rather than something to look forward to. Relationships waiver and relations become strained. As much as we like to think that sex should not be the most important thing in a relationship, it is actually important. We cannot deny it. It is the most personal, intimate act that we can share with another person. At it’s finest, it is imbued with love and trust as well as physical satisfaction. It is the ultimate release. It is an essential part of a healthy relationship. Even the best-matched couples on the planet begin to suffer somewhat when sex becomes unpleasant or taken off the table all together.

So let’s talk about painful sex and what we can do about it. I am proud to say that I am one of the Ob Gyn physicians that is not uncomfortable with the subject. Treating pain with intercourse is a large part of my practice. I devote entire office visits just to this. Most of the patients that I see have been suffering for years and seen several doctors only to be dismissed. For whatever reason, they decide to give me a try and then are pleasantly surprised and grateful that i am wiling to embrace the subject. Some of them even bring me flowers or cards when everything goes well. That is just an added perk, but not the point of course.

What are the causes of painful intercourse? There are more than you think. Let’s break them down and what we can do about them. One of the most common causes of pain with intercourse is psychogenic pain. This occurs when the woman has real pain with intercourse but no physical cause can be found. I know what I said before about women being told that it is all in their head and how terrible that was, but let me explain. Women with psychogenic pain often have a history of trauma such as rape or rough sex or an abusive relationship. Most of the time they have never told a soul about it and have never had the opportunity to have any closure about the incident. On top of that, the trauma from those incidents was so devastating that it left a psychological scar that never healed. In their minds, even the thought of sex takes them to a dark place with pain and fear, not pleasure. Until that is addressed, some of them will never be able to have a healthy intimate relationship. Sometimes a psychogenic pain response can be triggered by a lack of trust in the relationship. They are fearful of adultery and possible exposure to sexually transmitted infections. To make matters worse, these women begin losing their sense of self worth, wondering why they are no longer good enough to satisfy their partner. Again, unless these issues are addressed, no amount of treatment will help them have a satisfying and painless sexual relationship. These are some of the first things that I privately ask about in our first interview. I get them help and counselling. We work on empowerment strategies, anything they need to process their traumas and either mend or leave their toxic relationships.

Another cause of painful sex is endometriosis. Endometriosis is a disease in which retrograde menstrual flow goes backwards up through the fallopian tubes and back out into the pelvis. In the right woman with the right environment and genetics, those implants of endometrial tissue set up shop all over the pelvis and cause pain and inflammation. The best way to diagnosis endometriosis is with a laparoscopy and actual visualization and biopsy of the implants in the pelvis. The trick is, that if you were to biopsy normal appearing peritoneum in the pelvis, up to 20% of the time you could find endometriosis. The other tricky part, is that some patients can have incredible pain with just one visible implant while others can have a pelvis full and have no symptoms whatsoever. We are ever striving for better, quality of life enhancing treatments for endometriosis. Most of them involve hormone modulation or shut down with the thought being that shutting down hormones will shut down growth of the implants and “starve them.” However, a lot of the treatments can only be continued for so long because of side effects. The only permanent treatment for endometriosis is hysterectomy with removal of both ovaries. We try to save that for the most drastic cases that have completed childbearing already.

Another cause of painful sex is pelvic inflammatory disease. Pelvic inflammatory disease usually occurs as a result of the spread of sexually transmitted bacteria from the vagina, through the cervix, into the uterus and then through the tubes and ovaries. The bacteria can spread to the rest of the pelvis and cause inflammation, abscess and scar tissue. All of these things can cause painful intercourse with cervical motion tenderness and pain with deep penetration. Once the infection is treated, there is an 88 percent+ chance that the pain will go away. Antibiotics are the way to go.

Yet another cause of painful sex is simple vaginitis or vulvitis. These occur when there is inflammation or discharge which can cause itching or pain and thus, pain with intercourse. This pain and inflammation can be caused from reactions to household things like detergent, soaps or personal cleansers or an actual bacterial infection like bacterial vaginosis or yeast. Treat the infection and the pain usually goes away. Figure out which things around the house is irritating( Tide, Summer’s Eve, Vagisil, scented soaps are common offenders for example), and get rid of it and substitute it with Cetaphil or All Free and Clear, and usually the inflammation goes away in about two weeks and so does the pain. I have made up a hand dandy “be kind to your vulva” tip sheet that helps patients get this under control faster and keep them from getting irritated again.

Another cause of painful sex is something called vulvodynia. This condition is the result of localized intense inflammation around the peri-urethral and vestibule areas of the vulva and causes intense pain with initial penetration during intercourse. This condition can be easily diagnosed with something called a q tip test. The q tip is used to touch certain points around the vulva. If a patient has this condition, they will perceive the q tip as a razor blade scratching them during the examination. Knowing this ahead of time, I always make sure to show the patient the q tip before i conduct the test, because most of them are sure that i secretly pulled out something sharp instead. That is how intense the pain can be. The pain that the patients get with vulvodynia often leads to a condition called vaginismus on top of it. Vaginismus is involuntary intense tightening and contraction of the vaginal muscles in response to penetration, which then causes a lot of deep pain with penetration. The key in these patients is to treat the vulvodynia first. We have had all kinds of theories about the cause of vulvodynia over the years, none of which have really panned out. At first we thought it was related to chronic yeast. Then we thought it was related to a high oxalate diet. The list goes on. The bottom line is that we really don’t know. I have found that a short course of a tiny amount of estrogen cream goes a long way at first. I do not use it for any longer than a month to avoid any possible unopposed estrogen effects. Then i transition the patient to any one of a number of compounded ointments that i have developed over the years. Usually these contain a small amount of an anti spasmodic, something non-narcotic for chronic pain, and a bit of lidocaine. The patients can easily use a tiny amount of this ointment up to three times a day to keep their pain and inflammation at bay. I make sure to educate them that this condition is considered chronic and we need to focus on control not cure. Most patients are so happy to not be in pain that they are happy to use a tiny bit of ointment every day. I think it is also important in these patients to remove any possibility of external irritants as well, like with the vulvitis patients so I give them the ” be kind to your vulva” tip sheet also. The vaginismus is a tougher nut to crack. Even when the vulvodynia is improved, the vaginismus sometimes still remains. I think that in these cases, the brain is so used to intercourse being painful, that it cannot allow the patient to enjoy intercouse even when the primary cause of pain is gone. That is just how our brains work. In these cases, we still have options. I like to start with vibrator therapy for example. I have the patient purchase a set of medical dilators that start all the way down to pinky size and gradually increase up to the size of an average penis. The patient starts with the pinky size dilator and coats it with a small amount of steroid cream and inserts it for twenty minutes. The goal to achieve with each size is to be able to tolerate insertion for 20 minutes twice a day before the patient can increase to the next size. After several weeks, most patients can usually increase up to the final size and then can begin enjoying sex again. For some patients, we need to incorporate biofeedback therapy in addition. Biofeedback therapy uses sensors with a biofeedback monitor. In can be used for a variety of purposes. In this case, a patient is hooked up to the biofeedback monitor and then various dilators are introduced in a sequential monitor. When a dilator is introduced, the patient is instructed to look at the biofeedback monitor. They are educated about what a relaxed muscle looks like versus a contracted muscle on the monitor. They then work to achieve a relaxed muscle every time a dilator is inserted. Over time, they learn to consciously relax their pelvic muscles with insertion. These sessions are variable in price and are sometimes covered by insurance. The number of sessions that each patient requires varies.

Last but not least, another cause of painful sex is good old menopausal vaginal dryness. We can’t forget that one. This is usually caused by something called atrophic vaginitis. Atrophic vaginitis occurs when the vaginal mucosa folds straighten out from lack of estrogen causing thinning, drying, and inflammation of the vaginal walls. We can treat this with a course of vaginal estrogen in pill or cream form. I limit this to three months if they have an intact uterus or add progesterone too if they need it for longer. We now also have medications like Osphena, which is a selective estrogen receptor modulator. It is a cousin to medicines like Evista or Tamoxifen. Osphena can be taken orally. For patients that cannot take hormones I treat their vaginal dryness with water based lubricants like astro glide. You can also use extra virgin olive oil vaginally or even vitamin e gel caps as a suppository. All of these are potential alternatives for vaginal dryness. There are others, but these are the first lines in my office. For the patients that do not respond to any of the above, we can always use small amount of topical lidocaine about ten minutes before intercourse. I have the patient apply a small amount to their vulva and that way we can at least decrease the pain, even if we cannot address the dryness.

Long story short, there are a lot of different causes of painful sex and there are options for all of them. I urge all you ladies out there to stop suffering in silence. It is not all in your head. There is something that we can do for you! All you have to do is find a physician and ask! Have a fantastic day folks!

Dr. Katz