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.
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