For Her

Many women suffer sexual pain, chronic genital pain independent of lovemaking, and/or pain duringsex. The landmark “Sex In America” survey estimates that sexual pain afflicts 20 percent of American women—15 percent before menopausal, 33 percent after.

Until recently, many doctors dismissed women’s genital pain (dyspareunia or vulvodynia) as “neurotic,” which left them doubly wounded—in pain and put down. Some men don’t believe women’s complaints of sexual pain. A few even believe that sex should hurt women. Wrong.

Pain is a mind-body experience with physical and emotional components. Stress, anxiety, and depression aggravate pain. It’s important to identify both the physical and psychological components because each responds to different treatments. If one component resists treatment, it may help to treat the other.

Sex should never hurt

Attention, men: Except for consensual BDSM, sex should never hurt. Some men feel so eager to plunge into intercourse that they dismiss women’s complaints of pain. Big mistake. If sex hurts her, she can’t become aroused, which means lousy sex for both of you.

Most sexual pain can be cured

In a two-year study, two-thirds of women with sexual pain reported significant improvement. The many causes include:

Lack of lubrication

Poorly lubricated intercourse is a major cause of women’s pain. Many perfectly normal women don’t produce much vaginal lubrication. After 40, as women become menopausal, lubrication problems become increasingly prevalent. Cunnilingus can supplement women’s natural vaginal lubrication. But any woman who feels dry and irritated should use a commercial lubricant—lots of it.

Nonsensual lovemaking

Before they can enjoy intercourse comfortably, most women need considerable warm-up time, 30 to 45 minutes. If men push in before women feel receptive, the women experience pain. Pain-free lovemaking is based on leisurely, playful, whole-body massage. Men should slow down, then slow down some more. Intercourse can wait. Give women all the time they need to become relaxed, aroused, and receptive. Sex therapists recommend at least 30 minutes of kissing, cuddling, mutual whole-body massage, and oral sex before attempting intercourse.

Inserting too quickly or deeply

Even if women are well lubricated and feel highly aroused, they may experience pain if men push in too forcefully. Don’t imitate porn. The vagina is not a hollow space. It’s tightly folded muscle tissue that relaxes as women warm up to sex, and yields most comfortably when the penis enters slowly.

Deep insertion may also cause pain, especially during rear-entry (doggie style). To enjoy this position without pain, the man should remain still and allow the woman to back onto the penis at her own pace. This way, women can lalert men to the depth they can comfortably accommodate. And in the woman-on-top position, again, the man should remain still so the woman can sit down on him, controlling the speed and depth of insertion for her comfort.

Relationship issues

If relationships cause women emotional pain, sex may trigger physical pain. For relationship issues, consult a couples counselor or sex therapist (below).

Birth control pills

An expert says today’s birth control pills are “a leading causes of women’s sexual pain.” Andrew Goldstein, M.D., editor of Female Sexual Pain Disorders, says the Pill causes overproduction of sex hormone-binding globulin, which attaches to vulvar tissue, and causes biochemical changes that produce pain. Goldstein says that women with sexual pain should get off the Pill and take supplemental estrogen and androgens to normalize their levels. With this treatment, he says most women with Pill-related pain are cured in six months.

Vulvar skin conditions

Women’s external genital skin is sensitive to irritation from douching, pubic shaving, sunburn, latex allergy from condoms, or contact dermatitis from harsh or perfumed soaps, feminine hygiene products, or underwear made from synthetic fabrics. If the vulva appears red or irritated, consult a physician.

Sexually transmitted infections

Chlamydia, genital warts, and pelvic inflammatory disease may cause pain on intercourse. If pain persists despite increased sensuality and lubrication, see a doctor for screening.

Other vaginal infections

Vaginal yeast or bacterial infection (vaginosis) may cause sexual pain, which may feel worse the day after lovemaking. Women in pain should be tested.

Emotional and sexual trauma

It may take many years for early life trauma to manifest as pain. Sextherapy can help. So can the excellent book, Healing Sex: A Mind-Body Approach to Healing Sexual Trauma by Staci Haines (Cleis Press).

Oxalate irritation

Some foods contain oxalates. Women sensitive to them may develop urethral irritation, which can cause pain. High-oxalates foods include: celery, coffee, chocolate, rhubarb, spinach, and strawberries. The Vulvar Pain Foundation (vulvarpainfoundation.org) publishes a more extensive list. It can take three to six months on a low-oxalate diet to experience improvement. Oxalate irritation may also improve with a calcium citrate supplement (Citracal).

Vaginismus

Vaginismus causes pelvic muscle spasm, which closes the vagina. In mild cases, intercourse causes discomfort. In severe cases, insertion is impossible and attempts cause sharp pain. Ask your doctor to check for vaginismus. It’s best treated by a physician-sex therapist team. Therapy includes Kegel exercises, biofeedback, and insertion of graduated dilator rods that gradually coax the vagina open.

Vulvar Vestibulitis (VV)

This poorly understood condition involves inflammation of the tiny vestibular glands inside the vagina. Testing for VV, involves pressing a Q-tip into this tissue. In women with VV, Q-tip pressure causes sharp pain. Some VV clears up with time and lubrication. Other treatments include: biofeedback, Kegel exercises, a low-oxalate diet, a support group, and surgery to remove the glands (vestibulectomy).

Other conditions

Women’s sexual pain may also be caused by: uterine prolapse, endometriosis, interstitial cystitis, irritable bowel syndrome, and gynecological cancers. A work-up should investigate all of them.

For more on genital/sexual pain, contact: the International Pelvic Pain Society or the National Vulvodynia Association, or the Vulvar Pain Foundation. Or consult a sex therapist by visiting the American Association of Sex Educators, Counselors, and Therapists, the Society for Sex Therapy and Research, or the American Board of Sexology.

Message to men

If women complain of genital/sexual pain, don’t criticize them for sabotaging sex. Instead, slow things down, use lubricant, embrace whole-body caressing, and urge her to consult a physician. If that doesn’t resolve the problem, as a couple, consult a sex therapist. Remember, for great sex, intercourse is not necessary. You can enjoy mutual pleasure using your hands, tongues, and toys. Women appreciate men who take their pain seriously, men who are patient and supportive during its evaluation and treatment.

References:

Bergeron, S et al. “A Randomized Comparison of Group Cognitive-Behavioral Therapy, Biofeedback, and Vestibulectomy in the Treatment of Dyspareunia Resulting from Vulvar Vestibulitis,” Pain (2001) 91:297.

Binik, Y.M. et al. “Female Sexual Pain Disorders: Genital Pain or Sexual Dysfunction?” Archives of Sexual Behavior (2002) 31:425.

Dunn, K.M. et al. “Systematic Review of Sexual Problems: Epidemiology and Methodology,” Journal of Sex and Marital Therapy (2002) 28:399.

Graziottin, A. “Clinical Approach to Dyspareunia,” Journal of Sex and Marital Therapy (2001) 27:489-501.

Graziottin, A. et al. “Vulvodynia: The Challenge of Unexplained Genital Pain,” Journal of Sex and Marital Therapy (2001) 27:503-512.

Graziottin, A and L.A. Brotto. “Vulvar Vestibulitis: A Clinical Approach,”Journal of Sex and Marital Therapy (2004) 30:125.