Pelvic pain during sex: answers with a DPT

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Pelvic pain during sex feels like an intensely private and personal topic. But, if you’re experiencing it, you also want to know why, where to go, and what can help. Read on for answers and advice, with help from pelvic floor expert Dr. Sara Smith, DPT, CHC, RYT-200.

How common is it for women to have pain during sex?

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Experiencing some pain during vaginal sex is incredibly common. According to the American College of Obstetricians and Gynecologists, about 75% of women will have pain during sex at least one time in their lives. But even though pain during sex is common—there are times when it’s simply not normal and needs addressing. If your pain and/or pelvic pain during sex can’t be solved with changes in position or by finding the right lubricants, it’s time to think about reaching out for care.

9 causes of chronic pelvic pain during sex

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Pelvic pain during sex can be short-lived and passing. It can come from something as simple as straining or too-tight pelvic muscles. Other times, pelvic pain can become long-term, or chronic. Chronic pelvic pain during sex is defined as pain lasting 6 months or longer, and there are many possible causes to look into.

Vaginal infections

No one likes to hear that they have an infection—especially “down there.” But vaginal infections do happen, and they can be behind pain during intercourse. Both bacterial vaginosis and yeast infections can cause pain with sex. Yeast infections happen to more than 1 million women in the U.S. each year. Sometimes, though, they can become an ongoing issue. With infections, it’s important to see your ob-gyn for an exam and testing. Getting yeast infections again and again? Here’s what’s too much. If you suspect you’re getting 3 or 4 (or more!) per year, bring up hormone testing with your doc. High levels of estrogen can lead to repeat yeast infections.

Pelvic inflammatory disease (PID)

If you have pelvic inflammatory disease, you might have quite a few symptoms. So what are some common ones? Pelvic floor expert and physical therapist Dr. Sara Smith, DPT, CHC, RYT-200 says, “Symptoms of PID can include lower abdominal pain, burning sensation with urination, painful intercourse and/or bleeding with intercourse. Foul-smelling vaginal discharge, fever, and irregular menstrual bleeding can also be common,” she adds. “It is important to note, though, that not everyone experiences intense symptoms. Some experience very mild symptoms, which can be tricky.”

Some people think PID is the result of a sexually transmitted disease. But the reality is: STDs are not the only cause. It’s super important to have your PID treated because complications can occur now and down the road. “If left untreated, scar tissue can become problematic later, as well as continued abdominal and pelvic pain,” Dr. Sara advises. “Pelvic floor therapy can work specifically to reduce the effects of scar tissue, and you can utilize other techniques to help reduce pain that interferes with your personal life.”

Ulcerative colitis

When you hear about pain during intercourse, ulcerative colitis doesn’t always make the list—but it absolutely belongs on it. Ulcerative colitis is an inflammatory bowel disease (IBD). As a result of inflammation in the colon, it causes a variety of symptoms that affect quality of life. That includes a woman’s sex life. The primary way that ulcerative colitis physically impacts sexual health is through extensive inflammation. If high inflammation is present, women may have pain during vaginal intercourse.

Interstitial cystitis (IC)

Another condition that can be behind pain during intercourse is interstitial cystitis. Those with interstitial cystitis experience bladder pain and inflammation, as well as pain throughout the pelvis. So, does pelvic floor therapy help with interstitial cystitis—and therefore pain during sex? “Absolutely!” Dr. Sara answers. “I recall learning about IC in my training courses and it being presented as a very “bleak” condition to have. Yet, when I started working with clients, I quickly realized our bodies want to heal and be soothed. IC is no different.”

“With careful investigation, we can uncover the main triggers and create a lifestyle plan, in addition to hands-on modalities, to reduce pain points related to IC. For example, because of the chronic pain associated with it, the pelvic musculature is often in a state of over-activity. Through stretches, mind-body connection, breath, and relaxation techniques, pain with intercourse can be lessened—meaning more enjoyment!” Dr. Sara adds.

Endometriosis

Endometriosis is a condition where the uterine lining grows outside of your uterus. Most commonly, the tissue growth occurs in the pelvic area and abdomen, but it also can grow on the outside of organs as well. (Read up on a personal story with endometriosis here.) The result is inflammation, pain, fatigue, difficulty conceiving, scar tissue and adhesions, heavy periods or bleeding in-between periods too. Sometimes, these adhesions can fuse the wall of the rectum to the wall of the vagina. When this happens, the vagina can’t expand during sex like it ordinarily would. This can create intense pain and pressure during intercourse.

Pelvic congestion syndrome

Sometimes, pelvic pain during sex can be the result of a vascular disorder. With pelvic congestion syndrome, you might feel intense pain during or after intercourse or around your menstrual cycle. Think a vascular condition is for older women? Actually, with pelvic congestion syndrome, most women are young-ish (under age 50) and have had more than one baby.

What causes pelvic congestion syndrome—and what does it feel like? The pain is ongoing, or chronic. A lack of drainage of blood can cause blood to pool in your pelvis. “You might feel pain, pressure or a dull aching discomfort in the lower abdomen, pelvis, groin, or genitalia,” Dr. Sara explains. “Nerve impingement and other symptoms can also occur. There also can be swelling and pain during sexual arousal—and during or after intercourse.”

“Other symptoms can include fatigue, depression, lumbosacral neuropathy, rectal pain, and urgency of urination. As you can see, it can present differently for each person. Pregnancy, as well as estrogen levels, can affect the vein walls and contribute to the severity of pain and discomfort,” Dr. Sara says.

Symptoms tend to get worse throughout the day, as you are standing or sitting. Elevating your legs usually helps make the pain feel better. This condition is usually diagnosed only after lots of other potential causes for your pelvic pain have been eliminated and imaging confirms it. Treatment involves a stent, which can make you feel a lot more like yourself. “Pelvic floor physical therapy can also be a great adjunctive option and many find relief through a variety of modalities, supports, and treatments,” Dr. Sara adds.

Physical and/or emotional trauma

Traumas—whether physical injury or emotional—can cause pelvic pain during sex. The pain is the body’s physiological response to that trauma being triggered emotionally. “When we hear the word trauma, many immediately do not think it applies to them. But I like to think of the word on a scale from 0 to 10—even a fall you barely recall long ago onto your tailbone/pubic bone, chronic childhood constipation, or a one-night stand that left you feeling embarrassed or that you questioned later can be considered a lesser-recalled or -known trauma,” Dr. Sara explains.

So, is childbirth considered a trauma? “Even birth, while beautiful in some cases and difficult in others, is considered a traumatic event. Think of lesser traumas as stressful events,” says Dr. Sara. “With pain likely caused by trauma, a variety of measures can be incredibly helpful.”

Vaginismus

Vaginismus, which is a spasm of the pelvic floor muscles on penetration (of a partner, toy, or tampon), causes pain during intercourse too—to the point where it might feel impossible. This condition can arise from trauma, but that is not always its only cause.

“Because of the intimate connection between the brain and the pelvic floor, muscle spasms and tension can become inherent long after any threat, concern, or stressor is present,” Dr. Sara shares. “Research from a variety of studies is now showing that anxiety and other emotional responses trigger pelvic floor tension. (Read Dr. Sara’s article on hormonely.com about how emotional stress can cause pelvic pain.) The deep brain, linked for survival, can get stuck on a loop. Someone may want to experience pleasure; yet, the deeper brain unleashes behind-the-scenes emotional stressors that create unwanted muscles spasms and pain. In addition to traditional pelvic floor therapy and lifestyle shifts, coaching and emotional-release techniques have proven highly beneficial. This is because a new neural pathway and habit need to be formed in ways that reach far beyond just physical techniques and mobilization.”

Menopause


As you transition into menopause, your progesterone and estrogen levels decline dramatically. These hormones aren’t just responsible for reproduction. They have a multitude of functions in the body, so, when they are low, a variety of symptoms can pop up. One of those symptoms is a lack of hydration throughout the tissues of the body. The vagina is included—you may notice more dryness. Also, your vaginal tissue becomes thinner and more susceptible to micro-tears and abrasions. The combination of these two things can leave intercourse being anything but enjoyable.

“Menopause and perimenopause after too often looked at as negatives. The truth is, though, it is a time of deep reflection to rediscover what you value and what you stand for. It is an invitation to come home to your authentic self. Coaching, in addition to pelvic floor physical therapy, can discover your most optimal lifestyle shifts. That way, you aren’t wasting time trying it all and diluting your progress. From simple nutritional, movement, stress management and lubricant changes—it is possible to reclaim a new way to experience pleasure (both sexual and otherwise).”

Can pelvic floor therapy really help?

Pelvic floor therapy can absolutely reduce the pain you feel with sexual intercourse. Some women even find complete relief. Quality, knowledgeable pelvic floor therapists can formulate a treatment plan and goals and work with you on relaxing tense or overly tight pelvic muscles, so that you can enjoy being intimate again.

Want to work with or connect with Dr. Sara and feel better physically and emotionally? Reach out to her at drsarasmith.com.