When Sex Is Painful…For People With Vulvas and Vaginas
Ideally, sex should feel good and be a pleasurable experience but sometimes it can be downright painful. Pain during and after sex can be caused by a number of things. This is by no means an exhaustive list of reasons for painful sex, but it is the majority of what I see in pelvic floor PT.
One common cause of painful sex is that the pelvic floor muscles are already tight or they tighten as a response to penetration or sexual stimulus. The tension can be in the deeper pelvic floor muscles or the muscles surrounding the opening of the vagina. This can happen in response to injury, infection, anxiety, trauma, posture and movement patterns, or because the vulva tissue is fragile and prone to tearing. Because of this, the approach to treating painful sex caused by pelvic floor muscle tension is two fold - the muscles need to relax and we need to find out why they are tight in the first place.
Another cause of pain can be damage, compression, or traction to the nerves that supply sensation to the vulva and vagina. This may happen after an injury to the spine or pelvis, after child birth, as a result of pelvic, back, hip or abdominal surgery or with suboptimal posture and movement patterns. Treating nerve related pelvic pain is a challenge because nerves heal more slowly that other tissues in the body. The three things that nerves like are blood flow, movement, and space. Through myofacial work, posture and alignment correction, and movement we create an environment in the body that gives the nerves the things they like so they have what they need to heal.
The other BIG contributing factor to painful sex is hormonal changes. The area around the vaginal opening is very sensitive to hormonal changes and can become fragile and sensitive without adequate estrogen and testosterone. Hormone levels can change as a result of pregnancy, breast feeding, menopause, gender affirming HRT, or with the use of oral hormonal contraceptives. When hormonal changes are the root cause of painful sex, topical, local hormones can be used on the vulva to improve tissue health and make the vulva happier and less sensitive.
Whew, that’s a lot! So now to figure out what exactly is causing pain with sex. How do we do that???
Get current and historical status of infection (yeast, BV, UTI, STI)
Get a medical history of injuries or surgeries to the pelvis, abdomen, hips, groin, and back - including child birth!
Are there a reasons to suspect hormone changes such as pregnancy, breastfeeding, menopause, HRT, history of oral contraceptive use?
Assess the context in which sex is happening - Does it feel safe? Is it pleasurable? Is there adequate arousal?
Is there a history of trauma that may impact the body’s reaction sexual stimulus?
Are there high levels of stress? How is sleep, diet, and physical activity?
How much sitting and/or standing is required for work and other activities?
Examine vulva, pelvic floor muscles, fascia connected to the pelvis, posture, alignment, trunk muscle tone and strength
Once root cause of pain is determined, you and your provider(s) can figure out a treatment plan. This often includes a combination of hormone balancing treatments, muscle relaxing suppositories, manual muscle release, fascial work, dilator use, stretches and breathing exercises, lifestyle modifications, sensation focused solo and partnered exercises, sex counseling or therapy, and postural education. And once the pain is gone, the focus shifts to finding what feels good so that you can have the enjoyable, pleasurable sexual experiences that you want!