dyspareunia

Why Does It Hurt When I Have Sex? An Overview of Possibilities

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sexual pain

The Mayo Clinic terms pain associated with sexual stimulation or vaginal contact as “sexual pain disorder,” and categorizes this as a type of female sexual dysfunction.  More commonly we speak of “dyspareunia” to refer to pain with sex. It can present in a number of different ways; it may be internal or external, it may or may not prevent orgasm, and it may even occur after sexual activity.

Unfortunately, pain with sexual activity is rarely discussed or considered seriously.  I’ve sat face to face with health care professionals who tell me that the primary cause of pain is that the women’s partner is too large for her.  Sexual dysfunction in women is typically treated as either an inevitable “female problem” or an emotional disorder requiring antidepressants or anti-anxiety medications.

Pain is not uncommon, and it is treatable. Consider how many people suffer low back pain, headaches, or stomachaches.  Imagine how much effort goes into diagnosing and treating these issues. Why then would we not be just as open about discussing and treating female sexual pain?  Given the complexity of the anatomy, which I outline below, and the intersections of hormones, pregnancy and childbirth, postural habits, and the possibility of infection and trauma, it should be no surprise that many women experience pain or other dysfunction.

In my experience as a physical therapist, I find that while some women seek treatment, most either presume it is normal or don’t realize that there are treatment options. I can’t tell you how many times a woman will report “no” to sexual pain on my intake forms, then later during the evaluation report with surprise “I have had that pain my whole life, I thought it was normal!”

I will say now what I always tell these women: with the possible exception of disruption of a hymen or a significant size difference between partners, discomfort during sexual stimulation is never considered normal. And even in these situations pain is not inevitable, and should never be allowed to continue as this can result in further trauma and future discomfort.

First, an overview of the anatomy.  The external female genital area is composed of muscles known as the pelvic floor, as well as extensive nerves, glands, and other soft tissue.  The muscles work to support of organs against gravity, for control of urination and bowel movements, and for sexual function. In the pelvic floor, there are three separate openings:  the urethra, the vagina, and the anus.  The clitoris, which is composed of highly sensitive erectile tissue, functions solely for sexual stimulation.  It is covered by a “hood” of soft tissue externally, but also extends internally.  The entirety of the labia, external clitoris, and vaginal opening are known as the vulva. Internally, the vagina extends to the uterus.

Female anatomy
Painting by: Meryl Ranzer

Clearly, this is a complex area, with many functions, and it makes sense that there might be many possible locations and causes for discomfort.  Pain may be experienced with initial penetration or superficial stimulation, with deep penetration, with orgasm, or after orgasm.  I will briefly overview some of the possible causes of each.  In a subsequent article, I will address strategies for dealing with some of these causes, from the perspective of a physical therapist specializing in women’s health and pelvic rehabilitation.

A thorough examination by a gynecologist is always the first step in assessing pelvic pain, as not all causes of pain can be treated with physical therapy.

Superficial Sexual Pain

Sexual pain may be experienced with initial (shallow) penetration or with light touch to the vulva, perineum, or anus.  It may feel like burning, stretching, or sharp stabbing discomfort.  It may increase or dissipate if sexual activity continues.  It may even be intense enough to prohibit all touch.

Decreased lubrication, related to hormone changes or lack of physiologic arousal, may cause pain with initial penetration (arousal includes increased blood flow to the genital area as well as increased lubrication). Thinning of vaginal tissues, known as atrophy, often occurs with hormone shifts associated with menopause, and may result in discomfort and light bleeding with penetration if adequate lubrication is not present.

Active infections can cause sensitivity and irritation of the vulva and vagina. These infections may be acute, or low-level and chronic. Even after infection has resolved, residual irritation or fascial restrictions within the tissues can cause pain.

Sensitivity to perfumes and dyes, such as in laundry detergent, pads, or tampons, can cause irritation and sensitivity.  There are also skin conditions that may cause unusually fragile skin and pain to touch. Swelling of glands at the opening of the vagina may also occur and is frequently found in women with vulvar vestibulitis (pain and irritation at the opening of the vagina).

An intact hymen may be the cause of pain with initial penetration. However, given the variety of shape and thickness of the hymen, and the many activities that can change it over the course of a woman’s life from childhood to adulthood, pain with penetration during a woman’s first sexual encounter should not be presumed to be inevitable.

There may be atypical anatomy, such as thickened hymenal remnants or fascial bands that restrict the vaginal opening. There may also be scar tissue that is restricting the vaginal opening, due to trauma, tearing during childbirth or episiotomy.

Tightness of the muscles of the pelvic floor can cause pain with initial penetration. This pain may be right at the opening of the vagina or referred to other areas.  In severe cases, this is known as vaginismus, which is an involuntary spasming of the muscles that prevent penetration. It can be associated with hypersensitivity of the skin and muscles so that even light touch in the genital area causes pain. Vulvodynia refers to chronic pain of the vulvar area without a known cause. It is often accompanied by tight pelvic floor muscles.

Deep Pain with Sex

Pain is often reported with deep penetration, and may be described as a deep ache, cramping, or as if a woman’s partner is “hitting something” in her pelvis.

The sensation of something being bumped or hit with penetration is often related to uterine positioning. The uterus may be tilted (which in some women is their normal anatomy, or in other women may be related to tight ligaments, scar tissue, or fascial structures). The uterus may also not be mobile enough to shift comfortably during sex.  There may be scar tissue deep in the vagina that restricts vaginal or uterine mobility. Fibroids at the uterus may make it larger, asymmetrical, or less mobile and more prone to discomfort. Finally, the cervix may be sensitive due to fascial restrictions, surgical interventions such as colposcopy for abnormal cells, or irritation from IUD placement. In these cases changing sexual position or angle of penetration sometimes improves the discomfort, although in severe cases there may be no position of comfort.

Due to the proximity of the bowels to the vaginal canal, constipation or bowel irritation may result in pain with deep penetration. A sensitive or infected bladder may also be irritated for the same reason. Bowel pain may feel like cramping or a deep ache. Bladder pain may feel like a deep ache above the pubic bone, burning, or a painful bladder pressure.

Finally, active infections in the abdomen and pelvis may also cause pain with deep penetration. Acutely, infections and accompanying irritation can cause direct sensitivity and pain.  In addition, chronic processes can cause pain due to adhesions that are formed with chronic inflammation. Endometriosis is an example of this.  Adhesions restrict the movement of tissues and can put pressure on pain-sensitive structures.  Unfortunately, adhesions are challenging to see on imaging, but they are palpable to trained therapists and physicians and are often visible when investigated surgically.

Pain with Orgasm

This type of pain is less common, but from my experience, it may indicate decreased mobility of pelvic structures, spasm or trigger points in pelvic floor muscles, or inflammation and irritation of pelvic structures.

Pain after Sexual Activity

Pain after sexual activity is often a response to irritation and trauma caused by the activity itself.  In these cases, patients may experience pain or discomfort during activity and have it continue or worsen afterward.

In the case of a deep, heavy aching discomfort after sexual activity, pain may be related to venous congestion in the pelvis. During activity, blood flow into the pelvis increases, but for these women, the blood flow out cannot keep up just like swelling or varicosities commonly found in the legs. This may be directly related to inefficiencies of the veins themselves, but in many cases is related to scar tissue and fascial restrictions that restrict blood flow.

Clearly, there are many causes of discomfort with sexual activity, but for each cause, there are treatment strategies!  There is no reason to accept discomfort as normal or inevitable. The first step in addressing pain is to visit a gynecologist well versed in sexual pain to rule out infection, fibroids, cysts, hormonal shifts, or other issues and to discuss treatment strategies. One strategy may be physical therapy, as specialized women’s health PT has excellent results in treating pelvic and sexual pain. In my next article, I will discuss which types of sexual pain can be treated with physical therapy, and what treatment may entail.

We Need Your Help

More people than ever are reading Hormones Matter, a testament to the need for independent voices in health and medicine. We are not funded and accept limited advertising. Unlike many health sites, we don’t force you to purchase a subscription. We believe health information should be open to all. If you read Hormones Matter, and like it, please help support it. Contribute now.

Yes, I would like to support Hormones Matter. 

This post was published originally on Hormones Matter on September 21, 2015.  

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Sexual Pain: It Wasn’t the Ovarian Cyst

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Sexual Pain - Ovarian Cysts - Pelvic Therapy

In previous articles, I have discussed female sexual pain, some common diagnoses, and options for treatment via physical therapy. In this article, I’d like to describe a less common source of sexual pain that I encountered in a patient, and how we successfully treated it. I am describing her case with her permission, and we both hope that it is useful to other women who may be experiencing something similar.

Although it was assumed that her pain with sex was coming from an ovarian cyst, the source of her pain was actually elsewhere, and she is now essentially pain-free. When this woman arrived for treatment, she described a 30-year history of pain with vaginal penetration during sex (pain with penetration during sex is called “dyspareunia”). This pain was on the right side, deep and stabbing, and pierced from her front to her back and all the way up her abdomen. It occurred all the time, but she didn’t let it prevent her from having sex. In fact, she often didn’t tell her husband about the pain, because she knew that it was unavoidable and still wanted to have an intimate physical connection with him. Although some positions were better than others, the pain was always there.

She had made several attempts to evaluate and address the pain. In 1991 she was diagnosed with endometriosis and was told that the only cure would be to have children and then have a hysterectomy. Surgery for endometriosis didn’t improve her dyspareunia. When her doctor found a fibroid on the right side of her uterus, she had a partial hysterectomy (removing the uterus but leaving the cervix and ovaries). Unfortunately, the pain continued. From then on her and her doctors assumed the dyspareunia was related to chronic ovarian cysts. She came in for physical therapy treatment because she knew she had scar tissue from the endometriosis and surgeries. She believed that addressing this scar tissue could benefit her, and would hopefully improve her symptoms.

Pelvic Therapy For Dyspareunia

To understand what we were evaluating and treating, it is helpful to have some background information on what “pelvic health” physical therapy is and what treatment of the “pelvic floor” involves.

The pelvic floor is a group of muscles that are located in the area of the genitalia in both men and women. It functions to support the organs, to coordinate with the other “core” muscles for postural stability, to control urination and defecation, and to contribute to sexual function. Treatment of these muscles and pelvic structures can be done externally, vaginally, or rectally, and should only be done by a practitioner specifically trained in this area, such as a pelvic health physical therapist.

When she arrived for Pelvic Health physical therapy evaluation, this patient did have an ovarian cyst that was being actively monitored by her physician. The lateral location of her sexual pain, how it was triggered by deep penetration during sex, and the diagnosis of ovarian cysts, seemed consistent. I evaluated her with the initial presumption that her diagnosis was correct, and that her painful sex was indeed coming from the ovarian cyst.

However, during my evaluation, I found that I could reproduce her pain by palpating some of her deep pelvic floor muscles. I could also reproduce the pain by palpating around (but not on) the ovary externally. I found connective tissue restrictions in the area of her ovary, small intestines, and colon. Curious and encouraged, we started treating these areas, albeit very cautiously since she did have an active ovarian cyst that was being monitored. We didn’t want to risk irritating or even rupturing it.

By the end of her series of sessions (12 sessions spread out over 5 months), which were focused on treating the pelvic floor muscles, connective tissue restrictions, and visceral mobility, she had almost no pain with sex. Her ovarian cyst was still there, but she could have sex in almost any position without pain. This was an excellent outcome.

We will never know precisely, but I believe that due to endometriosis, surgeries, and chronic ovarian cysts, she had developed connective tissue restriction that limited her tissue mobility during sex. I believe that she also developed pelvic floor muscle dysfunction related to years of irritation and tension. While I do believe that the ovarian cysts probably contributed to her sexual pain, the major driver turned out to be connective tissue restriction and muscle dysfunction.

This was a good reminder for me as a practitioner to acknowledge the known issues, but also to stay curious and investigate further. This patient had suffered for 30 years, receiving multiple surgeries and even removed an organ (her uterus) to try to resolve her pain. Through specialized physical therapy, she finally found relief and is now able to have a pain-free sex life.

We Need Your Help

More people than ever are reading Hormones Matter, a testament to the need for independent voices in health and medicine. We are not funded and accept limited advertising. Unlike many health sites, we don’t force you to purchase a subscription. We believe health information should be open to all. If you read Hormones Matter, and like it, please help support it. Contribute now.

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Photo by Krista Mangulsone on Unsplash.

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Physical Therapy for Female Sexual Pain

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In a previous article, I discussed some of the many possible causes of female sexual pain. In this follow-up I will discuss how physical therapy can address some sources of pain with sex, give guidance on how to find a therapist, and offer tips to consider when engaging in this specialized type of physical therapy.

A thorough examination by a gynecologist is always the first step in addressing pelvic pain, as not all causes of pain can be treated with physical therapy. Physical therapy works best to address issues including nerve sensitivity, muscle dysfunction, alignment, fascial mobility, and scar tissue.

How Do You Know If Physical Therapy Can Help You?

Your gynecologist may refer you directly to physical therapy for treatment of your pain. Unfortunately, some physicians are not aware that physical therapy can address these issues, or may not know a therapist that they feel confident sending you to.

Here are some signs that specialized pelvic PT may be able to help you:

  1. The gynecologist has not found any medical issues causing your pain. If you have visited your doctor, had a thorough evaluation, and have not had any medical findings, your issues may be musculoskeletal. In that case, evaluation by a pelvic PT is warranted.
  2. Issues with urination or defecation. For example, delayed or incomplete urination, pain with bowel movements or urination, urinary frequency, or urinary leaking may indicate pelvic floor dysfunction.
  3. You have a history of chronic infections, inflammation, or physical trauma. These can cause restriction of the connective tissue in and around the pelvis and pelvic floor. This restriction, over time, builds up and can limit mobility or put strain on pain sensitive structures. Examples might be chronic yeast infections, endometriosis, falls to the tailbone, or sexual trauma.
  4. You have a history of surgeries or scar tissue. Scar tissue restricts the normal mobility of tissues and puts pressure on pain sensitive structures. Abdominal or pelvic scar tissue can cause pain at the site of the visible scar, or in areas that may not seem connected.
  5. You have other issues such as lower back pain, poor posture, or discomfort in sitting. The pelvis is integral to the function of the rest of the body, and dysfunctions here can lead to problems elsewhere.

What Does Pelvic Physical Therapy Entail?

Therapists in this field are specifically trained to treat pelvic structures, both internally (vaginally and rectally) and externally. The most common treatment methods that pelvic health PTs may employ are manual soft tissue work, exercise, biofeedback, and education.

Soft Tissue Work

There are many manual techniques that therapists can use to treat your muscles, joints, connective tissue, and even organs. These each of these techniques requires its’ own specialized training and should not be provided by untrained practitioners. While not a “massage,” these techniques do involve using gentle pressures, applied by hand, to improve function. The most common question I get on this subject is, “will it hurt?” This is an understandable concern – you are going to see the therapist because you have pain, and it can be a scary proposition to have someone touching already painful areas. This is certainly something to discuss with your therapist before treatment so that you are both comfortable with proceeding. In many cases the therapist will need to treat these sensitive areas in order to bring you relief. Because these areas are already irritated you may experience some initial discomfort as the therapist works with them. But the goal of treatment is NEVER to cause pain; in fact this is avoided at all costs. There are strategies that can be used, such as a physician-prescribed lidocaine gel, to make sure you are comfortable.

Exercise

When we think of exercise for pelvic health, most people think of Kegels. However, this is only a small piece of the exercises that can be helpful! Exercises may be prescribed to teach you to relax your pelvic floor, coordinate the pelvic floor with other muscles in your body, or relieve pressure on painful structures by improving posture, stability, or alignment. After evaluating you, your therapist will decide if any exercises are called for in your case. If they are, they will prescribe exercises targeted to improve your specific dysfunctions and will educate you on how to do them safely and effectively.

Biofeedback

Biofeedback is any method of giving you feedback on what your body is doing. In pelvic therapy this is commonly done to bring your awareness to your pelvic floor. Using a sensor, the biofeedback machine will determine how active your muscles are and give you a visual cue to help you learn what “relaxed” and “contracted” feels like. This is extremely useful, as many women who have pain with intercourse have muscles that have forgotten how to “relax.” They may be constantly contracted, tight, and painful. Sensors can be used internally (vaginally or rectally) or externally. There are also tools that you can use at home to continue your training outside of therapy.

Education

The primary job of any physical therapist is to educate, and this will begin on day 1 of treatment, with your evaluation. Your therapist will explain to you what s/he is doing and why, and once your evaluation is complete the results should be explained to you. From there you and your therapist will create a plan for your care. You may be educated sexual positions that might be more comfortable for you, lubricants, better toileting habits, sitting and standing postures to reduce stress on the pelvic floor, home treatments or exercises, relaxation techniques, breathing techniques, common irritants to the pelvic floor, and things to avoid as your treatment progresses. I have found that the more educated and informed my patients are, the better their outcomes tend to be! Your physical therapist can be both therapist and coach to better help you reach your goals.

So how do you go about finding a specialized pelvic therapist who can treat your pain? Your primary care doctor or gynecologist may have someone that they refer patients to on a regular basis.
If they do not, you can Internet search your city with the phrases “pelvic floor therapist,” or “women’s health therapist.” Other key phrases to help you narrow your results include “dyspareunia” (pain with intercourse) and “pelvic pain.”

You can also access directories of practitioners. For example, https://hermanwallace.com/practitioner-directory  and  http://www.womenshealthapta.org/pt-locator/. Therapists listed on these sites have taken continuing education courses in pelvic floor physical therapy. Be aware that not all therapists list themselves on these sites, as some require hefty membership fees to join.

Lastly, here are some helpful tips to consider when beginning pelvic physical therapy:

  1. Research your therapist. Not all therapists who work with the pelvis may have experience working with your particular issue. It’s okay to research the therapist online, or call them to discuss their background and training.
  2. Ask Questions. During your evaluation and subsequent treatment, ask any questions that come to you. When you get home, make a list of any questions or concerns that come up, and bring the list to your next session. The more educated you are on your body and treatment, the more comfortable you will be and the more productive your sessions can be.
  3. Communicate. During treatment please speak up if you are uncomfortable or have pain. We, as therapists, rely upon you for feedback. As I like to say, you are the only person feeling what you are feeling! Please do communicate during and after your sessions so that we can better help you.
  4. You are in charge. You will be asked for your consent to treatment before any treatment is undertaken. You can consent to all treatment, some portions of treatment, or none at all. You can also decline treatment at ANY point in a session, for any reason. Lastly, you can ask to have someone else in the room while you are treated. You are always in control of your treatment session.
  5. Keep a Journal. Keeping a journal of your symptoms may help you to track your progress over time. It can also give valuable information if you have a significant change and we are trying to understand the cause.
  6. Be Proactive. If your therapist gives you a home exercise or self-treatment plan, do your best to work with it. And if they haven’t given you one, it’s okay to ask for it. I find that the more engaged patients are with treatment, the better their outcomes tend to be.

Female sexual pain is more common than most people realize, and in many cases can be treated successfully with physical therapy. Please do not doubt yourself if you are experiencing this- you deserve to have full function, without pain, and it is worth your while to investigate treatment options.

We Need Your Help

More people than ever are reading Hormones Matter, a testament to the need for independent voices in health and medicine. We are not funded and accept limited advertising. Unlike many health sites, we don’t force you to purchase a subscription. We believe health information should be open to all. If you read Hormones Matter, like it, please help support it. Contribute now.

Yes, I would like to support Hormones Matter. 

 

This post was published originally on Hormones Matter on February 18, 2016. 

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Love Hurts – Sex with Endometriosis

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 “Bolts of electricity shoot around my abdomen and pelvis and down my leg as I lie on the pillow-topped hotel mattress, attempting in vain to remain silent. My husband’s arm, heavy from sleep, is draped over my aching body. I turn to look at him as he snores softly, blissfully unaware. No one told me the wedding night the night I dreamed about, would end with unbearable pain. Is this normal? Should it have felt like shards of glass stabbing me while moved inside me? I try not to let him hear me crying as I close my eyes and try to ignore the sharp electric-like currents terrorizing my body…

There is no one to speak to. I am the sole occupant of a vast and desolate island on which my innermost secrets cannot be shared, not even with my husband. Who to speak to? What to say? What to do when the event that should bring pulsating all-encompassing passion brings only excruciating pain instead? Who to tell when the one act that should create ecstasy and bliss causes pure agony?  I should adore the sense of unity I feel with my husband when we are together, treasure each second that my body fuses with his. But, instead, all I feel is the white-hot sear of pain when he enters me, the blackness of despair when I know that I cannot share my pain with him and the blushing red of embarrassment when he knows I am not being honest…

How can I share the feelings of torture that overwhelm my body when he is inside of me? How can I let him know that he, my beloved husband, is the cause of my misery? How can I share with him that his body alone creates immense wretchedness in mine. I will never do that to him. I will never make him aware that he is the source of the agony that rocks my body through and through. Instead, I will live with this agonizing, heart-wrenching secret of mine. This secret that isolates me, that creates a fissure so large between me and my husband that I wonder if we will survive as one. And I will continue to allow my body to be exposed to the beatings and abuse that are, in reality, tender loving touch.” 

Sound familiar anyone? Can you relate? Do you know what this girl means when she describes the pure agony that consumes her as she tries to have sex with her partner? Or the emotional turmoil she experiences as she tries to hide the pain from her partner? Well my friends, that girl is me, writing in my journal for the first year of my marriage.

You see, for many women with endometriosis, myself included, sex is not the erotic, passionate and pleasurable experience that we all wish it to be. In fact, according to a recent study in Italy, more than half of women with endometriosis experience dyspareunia, or genital pain associated with sex. Two types of dyspareunia exist. The first type, called superficial dyspareunia, is when the pain is felt at the opening of the vagina, and the lower part of the vagina. This pain is usually felt during the act of penetration and can easily be diminished by ceasing penetration. The second type, called deep dyspareunia, is felt deeper in the pelvis and thighs and can last for hours or even days. Women who have endometriosis, specifically recto-vaginal endometriosis and endometriosis on the cul-de-sac experience this type. There are many medical causes for dyspareunia other than endometriosis, such as vulvodynia, vulvar vestibulitis and interstitial cystitis. While this condition has historically been defined as a psychological issue, more recent treatment approaches lean towards the theory that dyspareunia is a combination of both physical and psychological causes. (More on dyspareunia theories).

In women with endometriosis, physical pain during sex is due to the presence of lesions found all over our insides, specifically behind the vagina and in the lower parts of the uterus. Having anything inside of us pushing or stretching those growths causes sheer agony, also described as burning, stabbing or deeply aching pain. It is intolerable, enough to make us scream, cry, or even throw up. This pain can start as early as the beginning of penetration and last up to 24-48 hours later. Women with endometriosis who have had a hysterectomy or who are going through hormonal treatments may experience pain due to vaginal dryness as well.

Dyspareunia has also been connected with more negative emotional attitudes towards sexuality as a whole. Studies have found that complaints of pain with sex are associated with low physical and emotional satisfaction, as well as decreased general happiness. Depression and anxiety were found more often in women with dyspareunia than control subjects.

Experiencing dyspareunia causes a loneliness inside of us that is worse than the most agonizing pain. Aside from simply not being able to connect sexually with people that we care about, we often feel compelled to hide our feelings from our loved ones so as not to hurt them. We would rather harm ourselves than tell our partners that they are hurting us. Keeping that a secret from them isolates us terribly, and fills us with a guilt that eats at our hearts. We are also consumed with incredibly strong guilt stemming from our inability to allow our partners the pleasure we know they deserve.

Fear of rejection is also a large part of the emotional pain associated with sex. We worry that our pain will cause our partners to reject us, whether because they have sexual needs that are lacking, or because they don’t want to cause us any harm. Ironically, many of us have experienced the strange situation in which we find ourselves begging our partners to have sex with us even though we know we will suffer.  Aside from the pain experienced by those of us actually suffering with this disease, it is also important to mention the emotional anguish that our partners who don’t have endometriosis go through. They too have feelings of rejection when we refuse to have sex, and can sometimes feel insecure about the relationship. Unfortunately, their need to be loved and love another is sometimes inadvertently ignored.

Due to endometriosis-associated dyspareunia, sex is often a dreaded nightmare fraught with worry. We worry that we’ll have unbearable pain if we choose to have sex and that we will offend our partners if we choose not to have sex. We worry that when we do want to have sex our partners will refuse for fear of hurting us. Instead of bringing us closer to our partners, sex puts a strain on the relationship that is hard to overcome.

This post was published previously on Hormones Matter in January 2013. 

 

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Love Heals: Improving Your Sex Life While Dealing with Endo

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After re-reading my previously posted article (Love Hurts-Sex and Endometriosis) about the emotional and physical pain women with endometriosis experience during sex, I found that I was a little disappointed in myself. Yes, love can hurt. Endometriosis-associated dyspareunia, or painful sex has the potential to be an physically agonizing and emotionally heartbreaking experience. But did I really have to make the article sound so negative? Did I have to end with the message that there is no way to improve sex for women like us?

My friends, if you are like the other endo-sisters I have out there: tough, resilient and irrepressible, you won’t let dyspareunia destroy your intimate relationships. Instead, you will work tirelessly in search of ways to fix this excruciating problem. You will not stop until you have spoken to every woman with endo, read every single article, or spoken to every professional out there in the hopes of figuring out ways to ease this struggle.

I am no different than you. I have read articles, spoken to fellow suffers, and attended classes by therapists who specialize in this very issue.  I have even gone to my own sex-therapist who has worked diligently with me to bring the passion and peace back into my bedroom.  I can’t tell you that all is perfect in that intimate place between my sheets. But I can tell you that the following ideas and advice that I am going to share with you have reintroduced intimacy and sexuality back into my life in a most wonderful way.

Communication

Ladies, this one word is the key to maintaining a healthy relationship, whether you have endometriosis or not. While communication seems like a simple, straightforward task, it is often not as easy as it seems. We fear offending our partners, or saying things we don’t mean.

Regardless of all of our anxiety, it is imperative to express to our partners what sex makes us feel like, both emotionally and physically, and what our concerns are regarding performing and/or abstaining from sex. On the flip side, we need to make sure we listen to how it all affects our partners as well.

Try this exercise: take a piece of paper, split it down the middle with a line, and write your name on one side and your partner’s name on the other. On your side of the paper, write down all of the ways you feel pain during sex is affecting just you:

  • Do you miss feeling like a sexual being?
  • Do you miss being able to convey your love in a sexual manner?
  • Do you miss feeling sexual pleasure?

Then, on your partner’s side, list the concerns you have regarding your partner’s feelings on the matter:

  • Are you afraid he or she will leave you and find someone who can have sex more easily?
  • Are you worried he or she will feel rejected by you?
  • Do you feel guilty that you might be making your partner feel like you don’t love him or her?

Have your partner do the same exercise and compare. When you finished comparing, try this follow-up exercise:

Write down three acts that you feel your partner can do to help you with your concerns. For example, if you miss being a sexual being, maybe your partner can be cognizant to mention how attractive you look more often. Or if your partner worries that you don’t love him or her as much as you used to, maybe you can make more of an effort to say “I love you” more often.

It’s Not All about Penetration

There are plenty of other sexual acts that can be used to bring us closer to our partners. Research shows that many couples in which one of the partners experiences dyspareunia tend to stop being sexually interactive at all. This causes an unhealthy and even harmful distance to grow. Sex and intimacy manifest in many different ways, and there is no reason to stop touching one another just because penetration hurts. Hand-holding, kisses, hugs, massages, and even just a light, sensual touch on the hand as you pass by your partner shows how much you care and prevents the physical relationship from becoming a thing of the past. In addition to all of those little gestures, mutual masturbation is a great and important way to pleasure your partner and connect sexually without intercourse.

Try New Ideas

There is more than one way to have intercourse. If sex hurts in the missionary position, try a new position. If it feels dry and chafing, try KY, or an alternative lubricant. There are plenty out there to choose from so find one that is right for you. You can even pick one out with your partner as a sexy bonding experience.  While experimenting, don’t forget to stay calm and open-minded and try not to get frustrated. It can be a very fun and intimate experience if you let yourself enjoy the process and worry less about the result.

Timing is Key

There are some women who find that they are more sensitive to pain during specific times of the month. For example, some women feel that sex during ovulation causes more pain than sex during the time right after they end their periods. Keeping a log to identify when those times are is a great way to be proactive about minimizing sex pain.

Mind and Body Readiness

Vaginal dryness is one of the key reasons why women feel pain during sex. A woman whose mind and body are not ready for sex due to fear of pain or lack of foreplay will not produce natural lubrication and will thus feel more pain on penetration. Increasing foreplay and meditation are two ways to prepare both the mind and body for sex and increase lubrication.

Ask for Help

Don’t try to deal with painful sex on your own. A sex therapist can help you work through your emotional issues and give you more suggestions on how to improve your sex life. It might feel a little intimidating to share your personal issues with someone else, but a therapist who is trained to deal with sex issues has seen and heard it all and will be more than happy to help you.

While it might seem a little overwhelming to try to tackle such a large and emotionally charged issue, you owe it to yourself to try to improve your sex life. Don’t forget that you don’t need to try all of the suggestions at once. If you can, discuss with your partner and pick one or two ideas that you feel you can try to implement. It’s not about perfection; it’s just about taking the time and putting in the effort. If anyone can do it, you, my endo-sister, can. You are stronger than you know.

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