Sexual Pain

Sexual dysfunction is a broad term that is used to describe problems with sexual activity. An important consideration is that sexual dysfunction can lead to personal distress, which is highly dependent on a person’s goals, relationship status, partner expectations, and cultural factors.

There are four categories of sexual dysfunction: desire disorders, arousal disorders, orgasms disorders, and pain disorders. Many people with sexual dysfunction experience problems in several of these areas.

Sexual dysfunction can occur in all people, but is more common in women. Prevalence of female sexual dysfunction varies widely across age groups and cultures but affects at least 20-40% of women at some point during their lives. Sexual function can change over time. While some people report more persistent issues with sexual function, others report that sexual dysfunction seems to resolve over time or occurs in intermittent episodes over their lifetime. For example, sexual dysfunction seems to be more common around the transition to menopause.

Female sexual dysfunction is multifactorial and is rarely due to one issue alone. While medical conditions can contribute to sexual dysfunction, factors such as relationship conflict, poor communication, or untreated depression or anxiety can also play a role. Likewise, sexual dysfunction may also contribute to relationship conflict.

Women who have chronic pelvic pain seem to be at least twice as likely to experience sexual dysfunction related to pain, and are also at higher risk for sexual dysfunction related to desire, arousal, or orgasm. Experiencing chronic pain impacts sexual health in many ways. Even if sex itself is not painful, chronic pain can affect self-image and relationship dynamics, which can impact sexual function.

In this module, we will focus on primarily on sexual dysfunction related to pain. While sexual pain is very common, affecting at least 20% of women, it is important to note that pain with sexual activity is not normal or expected.

Sexual pain can range from mild to severe in intensity. Pain can be quite localized to a specific area or can be more generalized across the pelvis. Some people have pain with every episode of sexual activity, whereas others only occasionally experience pain. Pain may be present during sexual activity, linger after sexual activity, or both. In short, symptoms vary quite a bit from person to person, so it is very important to be open and honest with your health care provider when discussing your symptoms as this information can help them determine what factors are contributing to your individual situation.

Female sexual pain can involve pain with vaginal penetration (dyspareunia), pain with external genital or vulvar touch (genital sexual pain), painful involuntary contraction of pelvic floor muscles (vaginismus), or significant anxiety about sexual pain before, during, or after sexual contact. This module focuses mostly on dyspareunia and genital sexual pain as these are the most common factors in women who experience sexual pain.

Genital sexual pain may involve the clitoris, vulva, or labia.  This may occur with touching or with initial vaginal entry during penetration. This has also been called superficial dyspareunia. Description of pain can vary, but is often described as stinging, burning, raw, or sharp.

Dyspareunia is pain with vaginal penetration. This has also been called deep dyspareunia to differentiate from genital sexual pain. This is mostly commonly felt deep in the pelvis, but some people feel it in the back, hips, or more on one side of the pelvis than another. Pain description can vary, but is often described as stabbing, sharp, cramping, aching, or throbbing. Pain may be associated with depth of vaginal penetration or may be positional, meaning that certain sexual positions may cause more pain that others. Some people find that all vaginal penetration is equally painful regardless of position. Many people with dyspareunia find that pain lingers for hours or even days after vaginal penetration.

Of note, many people with dyspareunia say that it feels like their pain coming from their uterus or ovaries because they feel pain deep in the pelvis and because location feels similar to menstrual pain. Keep in mind that there are a lot of structures and organs within the pelvis and it can be very difficult for anyone to precisely localize the source of pain, even for people who are very in tune with their body. For example, the pelvic floor muscles form a sling or web that wraps around the uterus and sits right next to the ovaries. When you experience cramping during a menstrual period, both the uterine muscle and pelvic floor muscles contribute to this cramping or contraction sensation. Furthermore, there is significant overlap in the sensory nerve pathways that carry pain signals from pelvic structures, which makes precise localization of pain more challenging. This is not to say that the uterus or ovaries can’t contribute to dyspareunia, but it is important to keep an open mind and assess for all contributions factors so that you can get to the treatment plan that is most effective for you.

There are many conditions that can contribute to sexual pain, and many people have more than one contributing factor. Conditions that may contribute to genital sexual pain include vulvodynia, genitourinary syndrome of menopause or vaginal atrophy related to medications, dermatologic conditions such as lichen sclerosis, or vulvovaginal infections. Conditions that may contribute to dyspareunia include pelvic myofascial pain, endometriosis, pelvic mass such as large fibroids or ovarian cysts, adenomyosis, pelvic organ prolapse, or other pelvic pain conditions such as bladder pain syndrome/interstitial cystitis or irritable bowel syndrome/chronic constipation. This is certainly not a comprehensive list of possible conditions, and your health care provider should perform a thorough assessment to identify all contributing factors.

• Painful periods and Endometriosis
• Myofascial pain
• Vulvodynia

Evaluation of sexual pain or sexual dysfunction should be comprehensive and should consider many possible contributing factors. Your physician is likely to ask a number of questions related to sexual health and pain symptoms. It is very helpful for your physician to understand somewhat intimate details about your sexual experience in order to perform a thorough assessment of the possible causes.

Your physician will also likely perform a physical examination, including a pelvic examination. They should inspect the vaginal and vulvar tissues, which may involve use of a speculum. They should also gently palpate the pelvic floor muscles and pelvic organs, including uterus, ovaries, bladder/urethra, and rectum. The goal of this examination is to try to determine which of the organs or tissues are contributing to pain symptoms. It is normal to feel pressure during this examination, but pain is not normal and may indicate that a particular structure is contributing to your pain with sexual activity. They may recommend pelvic imaging or lab tests in some cases.

There is no standard treatment for all people with sexual pain because there are so many different factors that can contribute. Treatment of your symptoms needs to address the specific conditions or factors present in your case. Remember that sexual dysfunction may involve more than pain, and evaluation and treatment should also consider issues with desire, arousal, and orgasm.

It is important to use a comprehensive, holistic approach to treatment of sexual pain and sexual dysfunction. Because many people have several contributing conditions, your health care provider should help you make a plan to manage each of these factors.

For example, even if you identify a specific condition, such as endometriosis, contributing to dyspareunia, it may also be necessary to address additional contributing factors such as pelvic floor myofascial pain or relationship stress that can occur in response to having chronic pain from endometriosis.

We have organized treatment strategies into options you do on your own (self-care) and options you can consider in collaboration with your health care provider (professional care).

Self-Care

• Take your time – Female sexual arousal causes the muscles around the vagina to relax in order to make the vaginal canal longer and wider, and even moves the uterus upwards slightly. Many people can experience vaginal or pelvic pain if the muscles are not able to complete this part of the arousal process, whether that is due to pelvic myofascial pain (overly contracted muscles that are not able to relax fully) or because of inadequate time spent in the arousal phase before attempting vaginal penetration.
• Lubricants – Vaginal tissues naturally produce a fluid, called vaginal lubrication, as part of the female sexual arousal process. The overwhelming majority of this lubrication is produces by the vaginal epithelium (skin) rather than by the cervix or vaginal glands. Adequate vaginal lubrication is extremely important for comfortable and enjoyable vaginal penetration. The vaginal epithelial tissue is quite sensitive and friction from vaginal penetration with inadequate lubrication causes discomfort for most women. When women sense pain at the vaginal epithelium, the pelvic floor muscles naturally contract or tighten in response. This can prevent the natural vaginal relaxation, lengthening, and widening process discussed above from occurring. The release of vaginal lubrication also requires adequate time in the sexual arousal process. However, some women may be assistance with vaginal lubrication, which could be related to menopause, medications, or stress. Use of a over the counter lubricant can be extremely helpful. Silicone-based lubricants have a more slippery texture and last a long time. Water-soluble lubricants are great for people with vaginal sensitivity, but don’t last as long. Some people find that coconut oil to be helpful for vaginal lubrication or moisturization. However, oil-based lubricants and petroleum jelly typically should be avoided when using condoms as they can cause the latex to dissolve and increase the chances that the condom will break.
• Penetration bumpers – Bumper rings can be placed at the base of a penis (or other penetration object just as a dilator or sex toy) and act as a buffer in order to decrease depth of penetration, which can be extremely helpful for many patients with dyspareunia. Many of our patients have used Ohnut rings, which can be ordered online (www.ohnut.co/). Rings are soft and stretchy and you can use between one and four rings at a time to customize depth of penetration. These rings can be used with lubricants and condoms. Male partners report that these are comfortable to use and may actually increase their pleasure with intercourse because they do not worry as much as about causing their partner discomfort.
• Vaginal dilators – Vaginal dilators can help gently stretch the skin and muscles near the opening of the vagina. Regular, frequent use can be helpful for some people who have significant pelvic myofascial pain, vaginismus, or significant anxiety around vaginal penetration. Vaginal dilators typically come in a set so that people can start with smaller sizes and slowly increase to larger sizes as the tissues become more flexible. It is very important to use lubricants with dilators to maximize comfort and tolerance. Many people find it more helpful to use dilators in conjunction with pelvic physical therapy or with the advice of a pelvic physical therapist, as they can offer more individualized recommendations and detailed guidance. Vaginal dilators do not work for everyone or for every condition that causes sexual pain, and they are not a replacement for evaluation and treatment with a pelvic physical therapist. But they may be a helpful tool for many people as part of their management strategy.
• Communication – All of the strategies discussed above require open and honest communication with your sexual partner. Many people find this to be one of the hardest parts of managing sexual pain. Even in relationships that are supportive and healthy, it can feel awkward or embarrassing to discuss sexual dysfunction or negotiate for a change in your sexual interaction. Sexual dysfunction and sexual pain can impact romantic relationships in a unique way and may contribute to relationship conflict, particularly when if it feels that your goals for intimacy don’t align with those of your partner. You can use strategies like assertive communication style, talking about pain, and organizing thoughts for more effective communication found in the Communication module.
• Relaxation and Mindfulness – Female sexual arousal is not limited to your vaginal lubrication and pelvic floor muscle processes. Sexual arousal and desire also involve your mind, including thoughts and emotions. It is extremely common to experience anxiety in response to sexual dysfunction, particularly when it contributes to conflict in romantic relationships or interferes with goals such as becoming pregnant and building a family. However, anxiety may be negatively impacting sexual arousal and desire, thus creating a difficult cycle. The Relaxation and Mindfulness module contains strategies to help you acknowledge and manage anxious thoughts and emotions in a productive way, which may help you focus your thoughts and emotions on sexual arousal or desire. This is not to say that sexual dysfunction is all in your head or that you can just “relax” your way out of sexual pain or sexual dysfunction. But acknowledging and processing your normal emotional response to a distressing situation is one critical step to addressing it.
• Physical activity and exercise – Several small studies have shown that some women experience improved sexual function with regular physical activity, specifically in areas of sexual desire, sexual arousal, and lubrication. More data is needed to confirm these findings and to clarify what type, intensity, frequency of physical activity is helpful for women with sexual dysfunction. However, physical activity can be beneficial for other pelvic pain symptoms, sleep, and overall health. Increasing your physical activity is low risk and has high likelihood of benefit for your quality of life. See the Physical Activity and Exercise module for more details.

Professional Care

• Pelvic floor physical therapy - Pelvic myofascial pain is one of the most common conditions that contributes to pain with sexual activity. However, it is also one of the most overlooked factors. Fortunately, there are effective treatments to manage pelvic myofascial pain. See Myofascial Pain and Physical Therapy for more details. Also, pelvic physical therapists can often given you individualized tips of how to make vaginal penetration more comfortable, whether that be sexual positions that minimize discomfort or exercises and massages you (and your partner!) can do to help relax the pelvic muscles to optimize arousal and comfort.
• Certified sex therapist - Experiencing pain during sexual activity can be very distressing. Sexual pain and sexual dysfunction can strain intimate or romantic relationships, even when your partner is supportive and understanding. Many of the tools to manage sexual dysfunction necessitate clear, open, and honest communication with your partner.  A certified sex therapist is a mental health professional with additional training in treatment of sexual dysfunction. In addition to providing education and recommendations, they can also help you better communicate about your concerns and needs with your partner and can help you advocate for yourself with your health care team. Certified sex therapists do not perform examinations or prescribe medications, and no sexual activity is practiced in their office. You can ask your gynecologist or primary care provider for a referral to a certified sex therapist.

Initial evaluation of sexual pain and sexual dysfunction is usually performed by a gynecologist. Depending on their assessment of which conditions may be contributing, they may recommend that you see a pelvic floor physical therapist, a certified sex therapist, or another medical professional such as a urogynecologist or gastroenterologist.

American College of Obstetricians and Gynecologists
When Sex Is Painful | ACOG

American Association of Sexuality Educators, Counselors, and Therapists
https://www.aasect.org/

Center for Sexual Health – Michigan Medicine 
https://www.uofmhealth.org/conditions-treatments/sexual-health