When Sex Gives More Pain than Pleasure

Dyspareunia is a common problem for many postmenopausal women.

By Harvard Health Publications

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Diagnosing dyspareunia

Few physicians specialize in vulvar problems, and few medical schools provide much training in this area. But your primary care provider or gynecologist may be able to refer you to someone with experience in treating dyspareunia. You can also search online or contact the gynecology department of the nearest medical center or teaching hospital.

Your clinician will ask about your pain—when it began, where and when it hurts, how it feels, and what you've done to relieve it—and may have questions about your relationship with your partner. She or he will also want to know about your gynecologic history (e.g., surgeries and childbirths) and any medical conditions or concerns.

The evaluation usually involves a thorough medical history and pelvic exam, and sometimes procedures or tests (such as laboratory tests for infections). The clinician will examine your vulva, vagina, and rectal area for redness, scarring, dryness, discharge, sores, growths, and other physical signs that might help explain your dyspareunia. She or he will probably use a cotton swab (to test for sensitivity to touch), a speculum, and gloved fingers during the exam. Understandably, women with sexual pain often worry about having a pelvic exam. Talk to your clinician about your concerns before the exam begins.

Lifestyle and self-care

Here are some ways to manage vulvar discomfort and increase sexual pleasure.

Lubricants - Nonhormonal vaginal lubricants and moisturizers may help reduce friction and pain during intercourse. (Lubricants are applied just before sex; moisturizers are applied more regularly, for longer-term relief.) There are many brands with different ingredients, and finding the products that work for you can take time. Vegetable oil is an inexpensive option; however, like other oil-based lubricants, it can weaken latex and shouldn't be used with condoms.

Sexual techniques - Extend foreplay to increase moisture in the vaginal tissues before intercourse. Try switching positions. Experiment with different ways of being intimate. And communicate with your partner; speak up about what does and doesn't feel good.

"Use it or lose it" - Frequent sexual activity can help stretch and strengthen muscles and increase blood flow and lubrication. But if intercourse hurts, practice masturbation or different ways of being sexually intimate that don't involve penetration.

Gentle vulvar care - Wash with mild soap or plain water, and pat dry. Avoid perfumed, multi-ingredient products such as bubble bath, douches, and some panty liners. Wear loose clothing and choose cotton underwear. Rinse the area with cool water after urinating.

Treating dyspareunia

Treatment often requires a multifaceted approach that includes medications, other therapies, and self-care (see "Lifestyle and self-care"). If your clinician identifies any vaginal infections, skin ailments, or other treatable conditions, she or he will prescribe the appropriate antibiotics, topical corticosteroids, or other medications. Frequently prescribed strategies for managing dyspareunia include the following:

Vaginal estrogen

Local low-dose estrogen helps most women with vaginal atrophy; it's also recommended in some cases of vestibulodynia and vulvar skin problems. It comes in a cream (applied to the vulva or in the vagina), a small tablet inserted in the vagina (Vagifem), and a flexible vaginal ring worn continuously and replaced every three months (Estring).

In treating vaginal atrophy, vaginal estrogen is preferred to systemic hormone therapy, which is taken in pill and other forms, with or without a progestin. Systemic hormone therapy has been associated with an increased risk for heart attacks in older women, stroke, blood clots, and some cancers. Vaginal application releases little estrogen into the bloodstream, so it carries less risk of side effects than systemic estrogen. But discuss the pros and cons of vaginal estrogen treatment with your physician—especially if you have a history of breast cancer, since its safety in this population isn't yet clear.

Lidocaine

This numbing agent may help ease sexual discomfort when applied as an ointment to the vestibule before and after sex. (If it's used before sex, it may affect the male.)

Surgery

Women with stubborn and severe vestibulodynia may want to consider an outpatient procedure called vulvar vestibulectomy, which removes some vestibular tissue. This surgery is usually offered only after other medical approaches have failed.

Counseling

Emotional and psychological issues, from anxiety to poor communication in a relationship, can contribute to painful sex, and painful sex can put stress on a relationship. Talking with a professional counselor or sex therapist may help.

Anatomy of the vulva

The vulva consists of several layers that cover and protect the sexual organs and urinary opening. The outer lips of the vulva—the labia majora—contain fat that helps cushion the area. Inside the labia majora are the thinner flaps of skin called the labia minora, which join at the top to enclose the clitoris. The area between the labia minora, the vestibule, contains the openings to the urethra and the vagina.

Pelvic floor physical therapy

Pelvic floor physical therapy is relatively new, and there aren't much hard data on it yet, but experts consider it safe and effective. Many women with vulvar pain have tight or weakened vaginal and pelvic floor muscles. These muscles can weaken as a result of aging, childbirth, excess weight, hormonal changes, and certain physical strains. They can also tighten in response to genital pain. Physical therapy can help reduce tightness and improve muscle function.

Your physical therapist will use hands-on techniques such as massage and gentle pressure to relax and stretch your tissues and promote blood flow, including (when you're ready) the interior of the vagina. You'll also learn exercises to help strengthen pelvic floor muscles and ease tightness in the hips. A biofeedback machine may be used to monitor your progress on a computer screen linked to a small sensor in your vagina. Therapy may take eight to 12 sessions before results are noticeable.

"Pelvic floor physical therapy works, but it's not a magic wand; the patient has to do her homework during and after treatment," says Raquel Perlis of Wellesley, Mass., a registered physical therapist who specializes in treating pelvic floor dysfunction and dyspareunia. Homework may include self-massage, hip stretches, and the use of vaginal dilators to help penetration feel more comfortable.

Selected resources

National Vulvodynia Association: www.nva.org

North American Menopause Society's Sexual Health & Menopause page:

www.menopause.org/sex.aspx

The V Book: A Doctor's Guide to Complete Vulvovaginal Health, by Elizabeth G. Stewart, M.D., and Paula Spencer (Bantam Books, 2002).

When Sex Hurts: A Woman's Guide to Banishing Sexual Pain, by Andrew Goldstein, M.D., Caroline Pukall, Ph.D., and Irwin Goldstein, M.D. (Da Capo Lifelong Books, 2011).