“Yes, you are in agony, but don’t be in despair, there is hope.”

July 2, 2019

Sexual pain disorders in women:

  • Painful intimacy
  • Dissatisfied sexual life
  • Unconsummated marriage

Case 1

“Doctor, these days I am losing interest in having physical intimacy. I always tried to avoid sex after my second delivery, since it was a painful act. Penetration was giving me too much pain. My second delivery was normal, but it took some time to heal my delivery incision (episiotomy wound).”

Case 2

“Doctor, we are married to each other for more than 3 years. We never had sex. She is too fearful and scared about that. She was not even ready for a proper gynecological examination. Our gynecologist suggested a psychiatry consultation.”

Case 3

“Doctor, I don’t want to live like this. I have nagging pain in my private area all the time for the last 1 year. I can't do any activities which I was doing before. I was very keen on my regular jogging, yoga, and was very active in my office. These days I am feeling very low, down, anxious, sleepless, and even having thoughts of ending my life.”

Three painful stories of miserable lives whom I have seen in my clinic recently.

Sexual pain disorders! Is it very common? Under reported? Who can help me? What to expect?

Sexual pain disorders, Genito-pelvic pain, Penetration disorder (Dyspareunia and Vaginismus), Vulvodynia - different names with complex overlapping symptoms and contributory factors.

What is it?

Dyspareunia: Persistent or recurrent pain with attempted or complete vaginal entry and/or penile vaginal intercourse.

Vaginismus: Persistent or recurrent difficulties of the woman to allow vaginal entry of a penis, a finger and/or any object, despite the woman’s expressed wish to do so.

Vulvodynia: Chronic genital pain with no known etiology that lasts for more than 3 months and may or may not be associated with sexual intercourse.

How common is it? What percentage of people seek/get help?

Dyspareunia and Vaginismus: 14-34% of younger women and 6.5-45% of older women

Vulvodynia: 8%

Only 60% of afflicted women seek help and only half of them get a proper diagnosis - under reported, under treated.

Female sexual pain disorders, a highly prevalent condition; a distressing complaint for women and their partners.

Most clients have denied for years that their pain was real and feel enormously relieved when they finally meet a clinician who trusts their symptoms and commit himself/herself to a thorough understanding of the complex etiology of their sexual pain.

When can we diagnose?

At least one out of 4 over a period of 6 months.

Persistent or recurrent difficulties resulting clinically significant distress.

  1. Vaginal penetration during intercourse.
  2. Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts.
  3. Marked fear or anxiety about vulvovaginal or pelvic pain during or as a result of vaginal penetration.
  4. Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.

Four questions that you should ask yourselves to get a better idea about your problem are:

1. When did it start?

Since beginning: then it’s primary and may be associated with low libido & arousal disorders.

Started after a definite period of normalcy: then it’s acquired (should ask when did it start and what happened around that time).

2. Where does it hurt?

At the vaginal outlet (Introitus): poor arousal, inflamed vulvar area, painful outcome of vulvar physical therapies, perineal surgery, neuropathic pain, and Sjogrens syndrome are possible reasons.

Mid vaginal pain: Myalgia (perineal muscle inflammation)

Deep vaginal pain: Endometriosis, Pelvic Inflammatory Disease (PID), outcomes of pelvic surgery or radiotherapy.

3. When do you feel pain?

Pain before intercourse: Phobia is the most likely reason.

Pain during intercourse: Organic or structural reasons.

Pain after intercourse: Mucosal damage (poor lubrication, inflamed vulvar area) pain, and defensive contraction of pelvic muscles are the possible reasons.

4. Do you feel any other accompanying symptoms?

Vaginal dryness: low estrogen or due to poor arousal.

Pain or paresthesia in genital or pelvic areas: dyspareunia, hypertonic pelvic floor muscles, or neurogenic pain.

Post coital cystitis: hypoestrogenic state, hypertonic pelvic floor muscles.

Vulvar pruritis and vulvar dryness: Lichen planus, Sjogrens syndrome.

Always keep a diary of pain.

What would your therapist like to know about your sexual pain?

Pain characteristics: Timing, duration, quality, location, provoked or unprovoked.

Musculoskeletal history: Pelvic floor surgery, trauma, obstetrics.

Bowel and bladder history: Constipation, diarrhea, urgency, frequency.

Sexual history: Frequency, desire, arousal, satisfaction, relationship.

Psychological history: Mood disorder, anxiety, depression.

History of abuse: Sexual, physical, neglect.

The experience of sexual pain has wide reaching consequences for affected women and their partners’ psychological, sexual and relationship well being. Women with sexual pain report heightened psychological distress, including anxiety, depressive symptoms, lower self-esteem, and body image concerns. Women with a sexual pain disorder report disruptions to every aspect of their sexuality including lower desire, arousal, sexual satisfaction, and frequency of orgasm and intercourse. Women have also reported that their pain negatively affects their ability to feel close to and show affection toward their partners. They have reported feelings of guilt, shame, and inadequacy as a sexual partner as well as fears of losing or disappointing their partner because of the pain. Male partners of women with sexual pain also suffer consequences including decreased sexual satisfaction, and an increased prevalence of sexual difficulties like erectile dysfunction.

Whom should I meet for my problems?

  • Gynecologist
  • Urogenital expert
  • Psychiatrist
  • Sex therapist

What are the treatment options for the agony I am going through?

Proper sex education about genital and pelvic anatomy, physiology, sexual behaviors, and lifestyle modifications to be brought in.

General measures for sexual pain disorders in women:

Clothing and Laundry
  • Wear all-white cotton underwear, skirts or loose-fitting pants.
  • Wear thigh-high or knee-high hose instead of pantyhose.
  • Remove wet bathing suits and exercise clothing promptly.
  • Use dermatologically-approved detergent.
  • Double-rinse your underwear and other clothing that touches the vulva.
  • Do not use fabric softener on undergarments.
Hygiene
  • Use soft, white, unscented toilet paper.
  • Avoid getting shampoo on the vulva.
  • Do not use bubble bath, douches, or any perfumed creams or soaps.
  • Wash the vulva with cool to lukewarm water only.
  • Urinate before bladder is full and rinse the vulva with water afterwards.
  • Prevent constipation by adding fiber to your diet and drinking plenty of liquids, especially water, throughout the day.
  • Use 100% cotton menstrual pads and tampons.
Sexual Intercourse
  • Use a water-soluble lubricant that does not contain propylene glycol.
  • Do not use contraceptive creams or spermicides.
  • Ask your provider to prescribe a topical anesthetic like lidocaine to be applied 5 to 10 minutes before intercourse.
  • Wrap ice or a frozen gel pack in a thin towel and apply for 10 to 15 minutes after intercourse.
  • Urinate and rinse the vulva with cool water after intercourse.
Physical Activities
  • Avoid exercises that put direct pressure on the vulva like bike riding.
  • Limit intense exercises that create a lot of friction in the vulvar area.
  • Wrap ice or a frozen gel pack in thin towel and apply after exercise.
  • Learn stretching and relaxation exercises.
  • Do not swim in highly chlorinated pools or use hot tubs.
Everyday Living
  • Try using a specialized cushion or foam donut for long periods of sitting.
  • For temporary relief, wrap ice or a frozen gel pack in a thin towel and apply for 15 minutes, or take a sitz bath with lukewarm or cool water.
  • If you primarily sit at work all day, intersperse periods of standing.
  • Learn some relaxation techniques to use during the day.

Specific treatment measures for sexual pain disorders:

Drug treatment:
  • Anti-inflammatory drugs: Including steroids.
  • Analgesic drugs: Both topical (Lidocaine cream) and systemic (Amitriptyline, Pregabalin, Gabapentin, etc.)
  • Topical hormones: Estrogen creams.
Other medical treatment options:
  • Botulinum toxin
  • Nerve block
  • Surgical treatments: Vestibulectomy in Vulvodynia.
  • Physical therapy: Pelvic floor physical therapy allows the pelvic floor muscles to relax and retrains pain receptors. Other useful physical therapy measures are biofeedback, dilators, and electrical stimulators.

Psychosexual treatments and behavioral therapy:

  • Anxiolytics
  • Relaxation methods
  • Yoga
  • Mindfulness
  • Sex therapy including her partner
  • CBT (Cognitive Behavior Therapy)

The shift from pain to pleasure is the key.

“Remember that stress doesn't come from what's going on in your life. It comes from your thoughts about what's going on in your life.”

General measures:

  • Address underlying negative affects (fear, disgust, repulsion to touch, but also loss of self-esteem and self-confidence, body image concerns, fear of being abandoned by the partner) when reported.
  • Teach how to command the pelvic floor muscles and to control the ability to do so with a mirror.
  • Encourage self-contact, self-massage, self-awareness, through sexual education. If the woman has a current partner, encourage active sex play, to maintain and/or increase libido, arousal and possibly clitoral orgasm, with specific prohibition of coital attempts until the pelvic floor is adequately relaxed and the women is willing and able to accept intercourse.
  • When good pelvic floor voluntary relaxation has been obtained, teach how to insert a dilator under pelvic floor relaxation.
  • Discuss contraception, if the couple does not desire children at present.
  • Encourage the sharing of control with the partner; Give permission for more intimate play, inserting of penis with the woman in control.
  • Support the possible performance anxiety of the male partner with vasculogenic active drugs.
  • Support the couple during the first attempts, as anxiety is frequent and may undermine the result if not adequately addressed, both emotionally and pharmacologically. PDE-5 inhibitors are useful when performance ED is reported.
  • If possible, recommend concurrent psychotherapy, sex therapy, or couples therapy when significant psychodynamic or relationship issues are evident.
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