sex pain

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

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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.

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

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Vulvodynia: The Silent Pain Syndrome

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I want to talk about a pain syndrome that most women have probably never heard of, but affects nearly 14 million women worldwide. It affects all races and ethnicities with Hispanic women suffering 80% more than other groups. It is a pain syndrome that those affected are reluctant to share with their partners, closest friends, or their doctors. This is because their pain revolves around and within the vaginal area, an area that we women often do not feel comfortable talking about in any company. Making this the “silent pain syndrome” and leaving women everywhere feeling alone and damaged.

This pain syndrome is known by a few names such as Vulvodynia, Vestibulitis, Dysaesthetic vulvar, vestibular adentis and vestibulodynia. It was given several names back in the 1980’s to help doctors refine and come up with treatment plans based on where the pain was located, the condition of the tissues in the vagina, or surrounding areas, as well as what provoked the pain. However, since the 80’s more and more studies have been done on the condition showing that most women who suffer with it have overlapping symptoms from one form to another. This has lead the medical community to start moving away from trying to categorize or compartmentalize it into one of these diagnoses. For the most part nowadays, it is just called vulvodynia.

Vulvodynia was recognized as far back as the 1800’s, when it was treated by surgically removing the vulvar area. Unfortunately, many of these women only got temporary relief. It unfortunately,  was left out of the medical books until the 1980’s when Dr. Edward Friedrich began reporting on it. Since then 80 studies have been done on the condition. It is not clear whether the increase in research is due increased awareness or an increase in the condition itself. The National Vulvodynia Foundation says that the average women suffering with this condition can see upwards of 15 doctors and it can take as long as 12 years to receive a correct diagnosis. This is because so many doctors are still ill informed and poorly educated on vulvodynia. The medical community is lagging in research when it comes to women’s health conditions, especially those that cause chronic pain in our genital areas.

Sadly, most doctors will push their patient’s pain syndrome off as a psychological problem, PMS, stress, lack of love for her partner or even sex in general. Many of these women find no help from the medical community and go on to suffer in pain silently, leading to other co-morbidities such as depression, anxiety, suicidal ideation, irritable bowel syndrome, interstitial cystitis and fibromyalgia. For many women who have been abandoned by the medical community, they will go on to question their own mental and emotional stability. They will often blame themselves for their condition, thinking they have somehow damaged their body physically through picking up an unknown STD or have psychologically thought themselves into this pain syndrome as many of their doctors have suggested. These women often are unable to continue having sexual intimacy, some get so bad that they reach a point of not being able to wear clothes, sit, walk or even tolerate a gynecological exam. Urinating or defecating can bring on horrific stinging pain that leaves many to cry out with the simple act of going to the bathroom, which in turn leaves them drinking less and eating less and holding their urine  or bowels for as long as they can so as to not experience that feeling. Unfortunately, doing some of these things can further the progression and pain from this syndrome as well as to create other dysfunctional conditions. For those women whose conditions continue to progress, they can be left  extremely disabled, unable to work or care for their families, which in turn leads to high divorce rates and financial losses. Couple all of that with a condition that a woman feels she has no one to share it with and it is no wonder that they often go on to suffer with depression, anxiety and suicidal ideation.

What is Vulvodynia?

Vulvodynia is known as a neuropathic or inflammatory pain condition to the genital area in women. As of yet it is caused by an unknown etiology. It is thought to be from the same family and act much like “phantom limb syndrome”. Vulvodynia causes a myriad of symptoms such as inflammation, redness around the vestibule (opening to the vagina), the vulva itself (outside vaginal lips also known as the labia major) and to the inner or small lips (also known as labia minor), as well as the vagina itself (the inside tissues). It can effect specific spots in or around the vagina, like the perineum, rectum, thighs, pubic bone or pubic hair, clitoris and the urethra. For some women it can affect all of these areas making their situation life  altering, disabling and agonizing. Women who have this condition experience stinging, burning, itching and razor cutting like sensations with the slightest of touch, making intercourse, tampon insertion, wiping or washing the area and the wearing of clothes painful to impossible.

Some women also complain of feeling as if they are dried up down there, while others feel as if their insides are falling out of them. Often when the clitoris is involved, it can cause agonizing pain that shoots up into the abdomen. In many of these cases, the women’s abdomen can become inflamed and reddened as well, leading to irritable bowel syndrome symptoms. For many the pain is so agonizing that they are left unable to wear clothes, walk or even sit. For some the pain can extend into the urethra or even the bladder setting off another pain syndrome known as interstitial cystitis. This condition can leave them in severe burning pain during and after urination.

Vulvodynia is unique to each woman with some having it constantly while others have it intermittently. Some will only suffer from specific areas of pain while others have it everywhere. Some will only have pain with intercourse while others have it with anything entering or touching  the vagina. Some will suffer with only hypersensation while others will suffer with all of them. For some the pain will be manageable while others it will be life altering. Each women’s pain level and frequency is different making this illness hard to understand and even harder to treat.

What Causes Vulvodynia?

Well that is a good question, and unfortunately, no one in the medical community has yet been able to answer. However, there are several theories about what increases the risk for developing vulvodynia.

Compressed Pudendal Nerve

We know that some women have a damaged, compressed or pinched off pudendal nerve. The pudendal nerve is a nerve that comes off the spine and innervates the pelvic floor region. It is what allows you to control urine flow or bowel movements. It is also, what activates your glands when aroused to produce the moisture in the vagina and allows you to have an orgasm. It has many important and enjoyable functions, but if it becomes damaged it can also create a lot of pain, dysfunction, and grief. Damage to this nerve can happen by a fall to the back or butt. It can be injured during labor. It can become inflamed or compressed by an arthritic condition or by a cyst or tumor. Some of these conditions can be fixed with surgery or nerve blocks, which in some instances may relieve the vulvodynia. Unfortunately, compressed nerve affects only a small number of vulvodynia sufferers.

Infections

It has also been shown in studies that 54% of all women with vulvodynia also test positive for HPV, however scientists has not been able to say with certainty that this specific viral infection is the cause for these women. Instead of it being the cause, it may just be the women’s own immune response to the infection. Researchers have also studied other viral infections that are known to cause neuralgic pain syndromes like this, such as cytomeglavirus and the herpes viral family, but have not found any evidence of these infections.

Researchers have looked at candidiasis infections as well; this is because so many women with vulvodynia have a long history with chronic fungal infections with many using repeated “azole” therapy to treat it. Yet again, they have not been able to find a link or correlation with any species of fungi. Although there is a question as to whether the use of any of the “azole” drugs could have possibly caused this condition or whether it is just associated with it because so many patients with vulvodynia are misdiagnosed with yeast infections. Due to this, the medical community warns women to be careful when using the OTC “azole” drugs and to follow the manufacturer’s recommendations. Additionally, if the yeast infection is not cleared with the usual course of treatment or a second infection develops, you should not use the cream again without first seeing your doctor.

Studies have also looked at bacterial infections as the cause, here they found that 17% of sufferers had an infection with what is known as ureaplasma, which is often seen infecting the Bartholin glands. For these women treating the infection often times cleared the vulvodyina. They also found a small number of women with the Streptococcus B infection and again in many of these cases, treating the infection cleared the vulvodynia. None of these studies have been able to state with certainty that any particular infection is the cause, but they do show that if you suffer with a long standing, chronic or hard to treat infection of any kind (viral, fungal or bacterial) you could be at a higher risk of developing vulvodynia.

Childbirth and Episiotomy

For other women there was no clear accounting of an infection but they could relate the start of it back to the birth of a child or the episiotomy. Here again we are looking at damage to the nerve or the soft tissues.

Hormonal Birth Control, Cancer Medications and Other Steroids

Other studies have implicated oral contraceptives and early childhood intercourse as a cause, both of these may be linked to hormonal imbalances. Some drugs have been implicated as the cause of it too, such as cancer drugs and both oral and topical steroids. Even though the topical steroids are used to help with the inflammation and itching in this condition, they are known to cause thinning of the tissues and sloughing. They tend to lower the immune system allowing for other infections to pop up making the situation worse.

Comorbid Fibromyalgia and Chronic Pain

Fibromyalgia has also been implicated in vulvodynia, mainly because so many women who suffer with fibromyalgia also suffer with vulvodynia. However, it is believed that fibromyalgia is due to an unknown muscular etiology and as if often seen alongside chronic fatigue. Both of which are thought to be caused by an abnormally high level of a neurotransmitter involved in pain sensation, so having this pain syndrome alongside of these would stand to make sense and put you at a higher risk for vulvodynia.

Oxalates

Older studies have suggested high oxalates in urine may be responsible for the pain. Oxalates are like little sharp slivers of glass made up of calcium that are excreted through our urine, but as of recently this theory is no longer being considered. This is because so many women have not tested positive for excessive oxalate output. Those who have gone on low oxalate diets have had some to no response, leading the scientific community to suggest that the oxalates themselves are not the problem but instead the fragile irritated tissues that the oxalates cross are more the issue. Now even though this may not be the cause, going on a low oxalate diet may be worth a try to lessen the pain. Another study suggests pH imbalances may be involved, but again cannot be confirmed as of yet and does not hold true for every women.

Inflammatory and Allergic Reactions

Recent studies have shown a correlation with inflammatory allergic reactions, like those seen in people with mast cell reactions. This is also seen and been implicated in interstitial cystitis too. However, we are still in the beginning phases of understanding not only this correlation but also Mast Cell Disease. If you suffer from this, you may be at a higher risk of developing vulvodynia as well.

Researchers at John Hopkins in Baltimore looked for two cytokines (immune stimulating cells) associated with inflammation. They found significantly higher levels of interleukin 1 beta and alpha necrosis tumor factors in test subjects. This would suggest that there is an inflammatory process going on, possibly due to an autoimmune problem. Then pathologists out of Rotterdam in the Netherlands found through biopsies chronic inflammatory infiltrates in all the patients and none in the control group. The infiltrate was composed of T-Lymphocytes as well as a small number of B cells, plasma cells, mast cells and monocytes. An immunoglobulin important in antibody reactions, IgG was found in plasma cells of 75% of the patients. This again suggests that there is an inflammatory process caused by an autoimmune reaction going on, however, they are not ready to confirm or deny this yet.

Finally, the University of Iowa has found impaired natural killer lymphocyte activity in the women effected as compared to a control group. Natural killer cells are needed to defend the body against certain cancers, so this finding may explain why some women with vulvodynia also suffer with dysplasia, despite having not contracted the aggressive cancer producing HPV strains. This finding may bring us back to implicating the HPV virus. However, this is all new information and nothing has been confirmed yet.

Diagnosing Vulvodynia

There is no specific test for this condition. It is diagnosed by ruling out other conditions and diseases. Physicians may want to test and treat for any infections first and see if that relieves the pain. If not, then it may be vulvodynia. Vulvodynia is frequently misdiagnosed as a chronic vaginal infection from fungi or bacteria. However, if your cultures are negative for an infection you may want to consider vulvodynia.

Treating Vulvodynia

This is the million-dollar question that both women and vulvar pain specialists are asking. Unfortunately, we really do not know what causes it. This means that without an identifiable factor, we are guessing at how to treat it. We also know that every woman experiences vulvodynia differently, making a “one size pill” that treats everyone impossible. Each woman will go through a trial and error with treatment modalities. This can often make the journey long and tedious, as well as, quite discouraging and even painful, especially when something heightens the pain instead of lowering it. This is why it is very important to get involved with a vulvar pain specialist, not just a pain clinic or pain doctor, but one that has been truly trained in treating this condition. Here are some of the many modalities in the arsenal to treat vulvodynia.

  1. Trigger point injections. This will numb the area for a few hours to days, giving some relief with the hopes that they will be able to shut off the nerve or reprogram it. Lidocaine is usually used for this. However, this procedure can be quite painful and risks damaging the nerves and tissues further, so for many women this is not an option. Now some doctors will also prescribe lidocaine jelly or even xylocaine jelly to be smeared on the painful areas. These can topically numb the tissues and nerves, giving some minor relief for a few hours. Although once again, for some women just putting this gel on can be too painful and does not last long enough to make it worth it.
  2. Topical steroids. These are often prescribed to help with the itching and inflammation, even though research has repeatedly shown them to be ineffective.
  3. Baking soda douches. If the vagina is too acidic, some doctors will recommend baking soda douches, which is non-toxic and in a few cases, it can help.
  4. Interferon. Several studies have tried treating women with interferon. This has shown some success, but the relapse rate is very high and one study showed that using interferon on women who do NOT have HPV actually worked better.
  5. Topical estrogen creams, progesterone and/or testosterone. Early research was promising. However, it may be painful for those women who cannot tolerate any kind of a cream placed around or in the vagina. It is important to note that estrogen cream can activate Mast Cell Syndrome.
  6. Prophyllin compresses. Some women find compresses made of prophyllin ( a prescription powder) to be soothing to the area.
  7. Low oxalate diet. Oxalates are in nearly everything we eat, but you can avoid the high oxilate foods. Doctors who prescribe this diet often times prescribe calcium citrate to go along with it. The calcium citrate helps to neutralize the oxalates in the urine. The Vulvar Pain Foundation reports the two most consistently helpful regimes for their members are the estrogen creams and low oxalate diet with calcium citrate. Another thing that sufferers report helping them is, drinking lots of water. Water dilutes the oxalates in the urine which decreases irritation.
  8. Anti-depressants and anti-convulsants. Fibromyalgia researchers have suggested that certain anti-depressant drugs may be useful in women also suffering with FMS.  Vulvar pain researchers have not done studies, however, clinical experience; they suggest that the SSRI’s are not effective in treating this condition. There is no research on the anticonvulsants.
  9. Capsaicin (an extract of the red pepper). Capsaicin has been used successfully in other neuralgic pain conditions like, diabetes, HIV, herpes infection and even in interstitial cystitis. An ongoing study of topical application suggests it may relieve pain, however, because Capsaicin produces significant burning when applied it may not be appropriate for those suffering with vulvodynia due to inflammation. It may not even be appropriate for those women with skin break down or seriously sensitized tissues.
  10. Opiates and other pain relievers. These may be effective in the short term, but long term they are problematic.
  11. Physical therapy. Specialized pelvic floor therapy has helped some women suffering with vulvodynia, especially those who also have FMS. Dr. Glazier, a psychologist from New York, states that biofeedback along with physical therapy to the pelvic floor can help to strengthen and relax the muscles in women with vulvodynia. This therapy is often also used in people with interstitial cystitis and irritable bowel syndrome too.
  12. Surgery. There are multiple surgical options but none appear to reduce the pain and many increase it.
  13. Cannabis oil. Cannabis oil applied topically has become all the rage, but as of yet, there are no studies to evaluate its effectiveness. Vulvodynia sufferers, however, report significant relief .

What is the Prognosis with Vuvlodynia?

I wish I had better news to report here and maybe one day I will have it, but for now this is not known as a curable condition. Do not be discouraged. We have many diseases that we are not able to cure but have the ability to effectively control. The first step is getting properly diagnosed and ruling out any other conditions or infections. The second step is finding a vulvar pain specialist or a vuvlar pain clinic to start the treatment process. Both of which can be found through your doctor or through the National Vulvar Pain Foundation. Once you reach this point, your journey to getting better will begin.

Please know that it may take quite a while to reach a point of lessened or no pain. It may also take several attempts at different or mixed modalities including medications, creams, diet, physical therapy and trigger point injections to find what works best for your condition. If you are also suffering with depression, anxiety or suicidal thoughts then you also need to find a psychologist to help you work through all of this as well. Please know that these mental and emotional conditions are very common in women with vulvodynia. This is due to many factors such as constant pain, loss of intimacy and all that goes along in a relationship because of it, including, a loss of self-sexual beauty and feeling damaged. Suffering in silence also causes distress. So, please if you take nothing else away from this article, just know you are NOT ALONE!

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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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