There are a number of things that can lead to painful sex, but know that it's never normal to experience pain with intercourse. There are a lot of myths out there - things like "it hurts because you are getting older" or "it's probably just because you need to keep trying" or "you aren't relaxed enough, have some wine."
I'm just going to throw this out there: those are bullshit things to say to a woman who hurts with sex. If you have pain with sex, you've not experienced good sex, normal sex, certainly not "fireworks." None of those myths make sense to a woman with pelvic pain.
Here's the thing: It's never normal to have pain with sex. Common, yes, normal, no.
One obstacle women often encounter is that upon GYN exam, everything may look okay. GYNs are typically trained to look for the scary stuff, things like cancer or major prolapse, anatomical abnormalities... big picture stuff. What they sometimes don't get a chance to assess is the muscles, tendons, movement patterns, sensation... things that PTs are experts in looking at. That's the beauty of my job. I get to look at all of that and try and get to the bottom of the issue, often after a woman has been through tests to rule out the "scary stuff."
Pelvic pain during sex can come from a number of issues. There are too many to get into in one blog, but let's talk about some of the biggies.
1. Spasms or tension in muscles: This is one of the most common causes of pain that I treat as a PT. The pelvic floor is made of muscles and the vagina is supported and surrounded by these muscles. If the muscles are tight, stretching them can be painful. If you attempt vaginal penetration, it's going to hurt. Sometimes penetration isn't even possible because the muscles are so tight or spasmed. So many patients ask "Why." Really, it's hard to say. Neurologic issues, anxiety/depression, trauma, adverse childhood experiences, or even something like injury to a seemingly unrelated area can lead to pelvic floor tension. Unfortunately, this tension can lead to plenty of other issues besides pain with sex. Leaking, constipation, pain with sitting/tampons/GYN exams, etc. The good news is that there are lots of tools in our toolbox to work on this. Typically we discuss the big picture - diet, exercise, mental health, breathing... It needs to be a holistic approach.
2. Nerves: You have a lot of nerves running through your pelvis. Sometimes there are issues with the nerves coming from your spine or sacrum. Sometimes the nerves within the pelvis can have issues (getting pinched or irritated). This often involves muscle tension as well, so treatment for this is not remarkably different than muscle tension. It's still a big picture look at everything going on so that we can improve movement and reduce tension and irritation of the nerves.
3. Inflammation: Some women feel pain ONLY on the outside. For me, it was right at the vaginal opening. Sometimes it's the entire vulva. This can lead to muscle tension and further pain, leading to a cycle of pain and more inflammation. This can sometimes keep women from not only being able to have sex, but even from wearing underwear or tight pants. Again, this is something that we address holistically, looking at the whole system and working with physicians to help calm down the inflammation and get things working better.
4. Endometriosis/IBS/other medical issues: Sometimes pain with intercourse may be a result of issues that aren't directly muscle related. Conditions like endometriosis, IBS, even dysfunction in the low back can refer pain to the pelvis and make sex difficult due to pain. These are not treated solely by PTs but instead require lots of communication between PT, GYN, urogyn, neuro, GI, etc. As PTs, we can contribute a good bit to the treatment of these conditions through extensive education, improving things like pelvic floor motion, abdominal strength, motion, etc. Very often muscle tension can be a factor associated with these conditions as well.
This is certainly a much oversimplified version of pelvic pain. Things like vaginal dryness, hormones, positioning, emotional wellbeing, orthopedic concerns can all play a role in pelvic pain. It's almost never simple. The pelvis is complex. There are a lot of muscles that attach the pelvis and a lot of systems that sit within it. It is often called the "root" or center of our energy in the body. It's hugely important, so when things are a little off, it's not usually just a quick fix. However, as a PT my job is to take a step back and assess the entire picture. Looking at the pelvic floor muscles, nerves, the low back, the muscles surrounding the pelvis is just the start. Looking at how a person breaths, moves, bends, lifts, sits, stands, sqauts is just another step in putting together the puzzle. It's complex, but it's essential to get to the bottom of things. Get it, bottom??
When a woman has pain with sex, it's awful. It's an emotional nightmare, a physical nightmare. It burdens the woman with guilt, shame, fear, worry. It burdens a relationship with the same issues. I have known women who have had relationships end because of this. It's ugly and awful to carry. No one talks about it, no one knows what to say, and often "everything looks okay."
We can do better than this. We can give women hope. If you, a loved one, your spouse, your friend, anyone you know has pain with intercourse, please tell them there's hope. Tell them about physical therapy. Tell them to find someone to look further. Tell them to speak up, demand to be heard, demand better for themselves. Pain with sex is never normal. Get the help you deserve. Bring the fireworks back to your sex life y'all. It may not be an easy journey, but it will be very worth it.
Lacy Kells PT, DPT
Owner of Fayetteville Pelvic Health & Wellness
lacykells@fayettevillepelvichealth.com
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