Thursday, September 18, 2014

What to do when sex gives more pain than pleasure?

About one-third of women say they have pain during sex, according to a comprehensive new series of reports on the sexual lives of Americans published this week in the Journal of Sexual Medicine.
Debby Herbenick, one of the study’s authors, acknowledged that number “surprised” her — she didn’t think so many women would report that kind of pain. The sad truth is that these numbers might be even higher, taking in an account that women do not feel comfortable admitting the lack of pleasure from sexual intercourse as it goes against the sexual stereotypes accepted in our society. We have to admit that Dyspareunia is a common problem for many postmenopausal women.

Millions of women experience pain before, during, or after sexual intercourse—a condition called dyspareunia (from the Greek dyspareunos, meaning "badly mated"). This condition not only saps sexual desire and enjoyment, it can also strain relationships and erode quality of life in general. For postmenopausal women, dyspareunia may also raise concerns about aging and body image.

Many women suffer in silence and don't seek the help they need, or they have trouble finding a clinician who can diagnose and treat the causes of their pain. That is unfortunate, because treatments are available for many of the problems that underlie this vexing condition.

What is it?

Dyspareunia may strike you at any age, but it's particularly common among women who've reached menopause. Studies and surveys suggest that one-quarter to one-half of postmenopausal women experience some pain during sex. The pain can range from mild to excruciating; sufferers describe it as burning, stinging, sharpness, or extreme tenderness. Depending on its cause, pain may be located in the outer genitals (vulva), within the vagina, or deep in the pelvis. Many women feel discomfort mainly in the vestibule, the nerve-rich area surrounding the vaginal opening. Dyspareunia can start suddenly or develop gradually. Pain may occur every time with sex, or only occasionally. For some women, simply thinking about intercourse can start a cycle of tightness, pain, and avoidance of sex.

What causes it?

Possible causes include hormonal changes, various medical or nerve conditions, and emotional problems such as anxiety or depression. Often, that is a combination of multiple contributing factors. "One thing can easily trigger a cascade of problems," says Dr. Elizabeth G. Stewart, a vulvovaginal specialist at Harvard Vanguard Medical Associates in Burlington, Mass. and Harvard-affiliated Beth Israel Deaconess Medical Center in Boston.

The major causes for the pain with sexual penetration may be defined as follows:

1. Vaginal Atrophy

Vaginal atrophy, the deterioration of vaginal tissue caused by estrogen loss, is a major source of painful intercourse for women at midlife. When ovarian production of estrogen declines at menopause, vaginal tissue may become thinner, less lubricated, and less elastic. Eventually these changes can result in vaginal dryness, burning, itching, and pain. Reduced sexual activity as well as medications such as antihistamines can contribute to vaginal dryness.

2. Vestibulodynia

Another potential cause is vestibulodynia (also known as localized provoked vulvodynia), a chronic pain syndrome affecting the vestibule. Any kind of touch or pressure—not only from penetration but even from a tampon, cotton swab, tight jeans, or toilet tissue—can trigger discomfort. Vestibulodynia is a type of vulvodynia, or unexplained and persistent pain in the vulvar area. The condition appears to have several different causes.

Vestibulodynia is the most common cause of sexual pain in women under age 50, and it may be more common among postmenopausal women than previously recognized, according to a recent study by investigators at McGill University in Montreal. Researchers analyzed data from 182 postmenopausal women with dyspareunia and found that almost all (98%) felt pain when touched on the vestibule with a cotton swab during an exam; 64% had both vestibulodynia and vaginal atrophy, 14% had vestibulodynia alone, and 9% had atrophy alone.

3. Other medical causes

Other causes of pain with intercourse include skin diseases in the genital area, such as eczema and psoriasis; conditions such as endometriosis, pelvic inflammatory disease, bladder prolapse, and infections of the urinary tract, vagina, or reproductive organs; certain cancer treatments; injury to the pelvic area from childbirth; reconstructive surgery; damage to the pudendal nerve, which supplies the vaginal area; musculoskeletal complaints, such as arthritis or tight hip or pelvic muscles; and some kinds of male sexual dysfunction (prolonged intercourse may increase vaginal friction and pain).

4. Psychological and emotional causes

Psychological or emotional factors may be involved. Stress, anxiety, depression, guilt, a history of sexual abuse, an upsetting pelvic exam in the past, or relationship troubles can also be at the root of sexual pain. Some women experience vaginismus—involuntary clenching of vaginal muscles to prevent penetration. Vaginismus is especially common among women who associate the vaginal area with fear or physical trauma. "If you've had a painful early experience, like a horrible episiotomy repair, the pelvic floor muscles seem to remember and make the vagina say, ‘Nothing comes in here,' " says Dr. Stewart.

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.
Treating dyspareunia

Currently, there is no cure for vulvodynia, but it is important for women to seek medical attention because the pain can be managed and treated. Treatment is directed at symptom relief and includes drug therapy to ‘block’ pain signals.

Treatment often requires a multifaceted approach that includes medications, other therapies, 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.

In women who have associated pelvic floor muscle spasm or weakness, physical therapy, biofeedback and/or Botox injections may be incorporated into the treatment plan. Because each case is different, treatment tends to be tailored based on individual needs and responses.

Frequently prescribed strategies for managing dyspareunia include the following:

1. 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.

2. 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 partner.

3. 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.

4. 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.
5. 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.

6. Self-care

Here are recommendations on the self-care. Some of them are easy to arrange, others are more complicated. However, it is always better not to get to the medical condition, when the surgery becomes inevitable, if that is possible.

* Treat vulvar skin gently. Wash with mild soap or plain water and pat dry.
* Use a lubricant. Water-soluble lubricants are a good choice if you experience vaginal irritation or sensitivity. Silicone-based lubricants last longer and tend to be more slippery than water-soluble lubricants. Do not use petroleum jelly, baby oil, or mineral oil with condoms. They can dissolve the latex and cause the condom to break.
* Avoid perfumed products such as bubble bath and douches.
* Choose cotton underwear, and avoid tight clothing.
* Make time for sex. Set aside a time when neither you nor your partner is tired or anxious.
* Talk to your partner. Tell your partner where and when you feel pain, as well as what activities you find pleasurable.
* Try sexual activities that do not cause pain. For example, if intercourse is painful, you and your partner may want to focus on oral sex or mutual masturbation.
* Try nonsexual, but sensual, activities like massage.
* Given the often unpredictable course of the pain outbursts, try to be more flexible about when sex occurs and what positions and activities are involved. You may experiment with timing (time of the day or night), position, and type of lubricants.
* Take pain-relieving steps before sex: empty your bladder, take a warm bath, or take an over-the-counter pain reliever before intercourse.
* To relieve burning after intercourse, apply ice or a frozen gel pack wrapped in a small towel to the vulva.

* Self-abdominal massage

In some cases, especially at the very early stages of the problem appearance, self massage can do amazingly to prevent a simple problem from becoming a chronic disease. So, learn the following massage techniques in order to use it every time and any time you need it.

1. The massage session is best done in an incline bed or board or put some pillows under your hips and lower-back. Before you start scooping up your abdomen, relax it first by rubbing as you apply the oil.
2. Form a heart shape or v-shaped with your fingers where the forefinger tips are touching each other.
3. Put fingers above the pubic bone (touch the pubic bone as a guide) and dig your fingers in as you move them back and forth without lifting off from your skin.
4. When you feel you are about an inch to two inches deep pull your hands by scooping it upward towards your navel. To ease any pain give a slow shaking motion as you pull up your hands. You will feel pain during the process but that is normal. Try to ease the pain by moving your hands slowly and stop as you breathe, but without releasing the hands until you reach the navel area.
5. Repeat the procedure to the whole abdomen.

Note: The following day, if you are having the treatment for the first time, you will feel cramps on your abdomen (feels like you did sit-ups for the first time) but that is normal at first; however, you can ease the pain by massaging it. The pain will go away in a week or less, but expect to have it occasionally during treatment, especially when there are weak muscles that are work on.

Sources and Additional Information:

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