What's going on?

The medical term for painful sex is dyspareunia, and there are several possible causes:

Childbirth

Pain can come from episiotomy scars, vaginal tears, injured vaginal tissue from a forceps or vacuum delivery, or damaged pelvic nerves from the baby's passage through the birth canal. Low estrogen levels associated with breastfeeding can also cause vaginal pain.

Menopause

As estrogen levels drop, vaginal tissue becomes thinner, less lubricated, and less elastic.

Vulvar vestibulitis (VV) & Vulvodynia

This is pain or sensitivity caused by any pressure on the vulvar vestibule (the area around the vaginal opening). Intercourse is usually painful, if not impossible. Even sitting, walking, or wearing jeans or underwear can be irritating. The pain is often burning; sometimes piercing; sometimes accompanied by pain in the clitoris, abdomen, buttocks, or thighs. Vulvar skin often looks completely normal, but sometimes a doctor can detect microscopic red dots, inflammation, or "paper cuts."

The exact cause is unclear, but we know that women with VV have nerves with overly sensitive pain receptors- sensitized, perhaps, by past "insults" like childbirth, yeast infections, or even yeast medications. Musculoskeletal problems, especially in the back, hips, or legs, may play a large part. Some researchers believe that the culprit is high urine levels of a substance called oxalate. Many women with VV also have a bladder condition called interstitial cystitis, a pain condition called fibromyalgia, and a bowel condition called irritable bowel syndrome.

Vaginismus

Vaginismus is an involuntary tightening of the vagina in a subconscious effort to prevent penetration. In some cases, the body "remembers" painful medical procedures; childbirth complications; or sexual, physical, or verbal abuse, and the vagina "shuts down" to protect against further trauma. In other cases, the problem is rooted in fear of sexuality or intimacy, religious taboos or other guilt, relationship conflicts, or life stress. Tightness begets pain, which begets more tightness-and a vicious cycle is set in motion.

Other gynecological conditions

Dyspareunia can also stem from endometriosis; pelvic inflammatory disease; interstitial cystitis; vaginal infections, cysts, and lesions; and other conditions. For an accurate diagnosis, please see your gynecologist.

How physical therapy can help

Today there's a new breed of physical therapist: one practicing at the intersection of gynecology and physical therapy, one skilled in gentle and proven treatments for dyspareunia. Raquel Perlis, R.P.T., has specialized in the following techniques since 1993:

Pelvic-floor biofeedback

Safe and painless, this is one of the most effective treatments for vaginal pain. You insert a tiny probe into your vagina, then view your pelvic muscle function on a biofeedback monitor. (If you can't insert the probe, Raquel places sensors on the skin between your vagina and rectum.) This feedback guides your Kegel's exercises-vaginal contract-and-release exercises that are the gold standard for pelvic muscle rehabilitation. Kegel's help improve vaginal muscle tone, relax muscle spasms, promote blood flow to damaged tissue, increase elasticity, and decrease sensitivity. Home practice is vital to your recovery.

Soft-tissue techniques

Raquel uses gentle, hands-on techniques like myofascial release and trigger-point release to relax tight tissue, balance muscles, mobilize joints, and melt away tender points and trigger points (sore "knots" that refer pain elsewhere). If appropriate, she teaches postural changes and prescribes stretching and strengthening exercises. She may use ultrasound to help heal episiotomy scars or electrical stimulation to strengthen pelvic floor muscles. When you're ready, she begins trigger-point release and stretching inside the vagina.

Dilators

When you feel comfortable, Raquel shows you how to insert fingers, then tampons, then gradually larger dilators to gently stretch and desensitize your vagina. The average course of treatment is 8 to 12 weekly sessions. Afterward, most women report much less pain and can resume intercourse. Women with vaginismus may also benefit from psychological counseling and sex therapy. Those with other types of dyspareunia may also benefit from medication, topical estrogen, dietary changes, supplements, and self-care strategies. As appropriate, Raquel introduces these options and refers you to your gynecologist. She communicates regularly with your referring physician.

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