Individual Psychotherapy + Sex Therapy

Women & Painful Sex

If you are experiencing pain when having or attempting to have intercourse, you are certainly not alone. According to an article published in Harvard Health,

“Millions of women experience pain before, during or after sexual intercourse. Many women suffer in silence and don’t seek the help they need, or they have trouble finding a clinician who can diagnose and treat the causes of their pain.”

Let’s start by naming the different types of pain that occur for women.

Different Types of Painful Sex

Painful intercourse can happen at any age or stage in life. Pain or discomfort during penetrative sex in women may be diagnosed as dyspareunia, vaginismus or vulvodynia. There is often pain during intercourse for women who have endometriosis, and sometimes with PCOS — Polycystic Ovarian Syndrome, though there are often additional symptoms leading to these diagnoses.

Dyspareunia is more a general term for pain in and around the vagina and vulva and may be felt all over the surface. It also encompasses deeper vaginal pain that may include deep pain or pressure against the cervix. This could be caused by the penis actually coming into contact with the cervix — some women experience pain when this occurs, whereas other women may find this pleasurable. Sometimes there may be an infection involving the cervix. However, dyspareunia is often diagnosed by a gynecologist when they are not able to find a physical reason for the pain, such as infection.

Sometimes pain occurs along the outer opening of the vagina and this condition is called vulvodynia. This pain or discomfort is typically experienced as burning or stinging. Occasionally, a doctor is able to see some redness, or tests with a Q-tip at certain points around the vestibule, or entryway to the vagina, in order to diagnose it. However, there often isn’t actually any visible skin or tissue damage seen by your doctor. This lack of visibility can sometimes lead to doctors saying things like, “it’s all in your head,” which happens much more often than we’d like and is incredibly frustrating/infuriating to the woman. A good doctor will still diagnose this pain as vulvodynia and guide your to some resources for help.

Other times, it may feel as though you’re hitting a “wall” inside the opening of the vagina. This “wall” blocks the penis (tampon, finger, or toy), making it impossible to go beyond. Sometimes is feels like you have to go around it, which you can maneuver with a tampon, but usually not with a penis. The “wall” is actually a very small muscle or muscles (of the pelvic floor) that is involuntarily contracted or in spasm. This condition is called vaginismus. The pelvic floor muscles will relax when you build awareness and recognize this tension/tightness and learn to actively relax your entire nervous system and pelvic floor through deep breathing exercises, training, and practice.

Treatments and Tips

There are various ways to treat all of these different kinds of pain during intercourse. I will get more specific to each of these different pains as we continue, but first and foremost with each of these types of pain, relaxation and more playfulness are key.

Usually, by the time a women goes to the doctor, or certainly by the time she reaches my office, she has suffered through painful sex repeatedly and is now frustrated, very serious (for very good reason), and often feels betrayed by her body. It is important for her to find pleasure and joy in her body again (or sometimes for the first time). To find more pleasure, she will need to connect to her body with more kindness and compassion than ever before.

Even though there’s very good reason for you to be serious about getting help and feeling better, this seriousness may cause more harm (and continued pain) than good. Finding ways to engage with your partner in more relaxed, playful ways that you may have done prior to having pain.This is difficult to accomplish when the body is conditioned to anticipate pain or discomfort with intercourse.

Over time the pelvic floor muscles involuntarily contract in order to try and protect you from the anticipated pain. This conditioning and anticipatory anxiety often becomes the main problem — sometimes the physical problem has healed, but the emotional and psychological symptoms remain.

As Dan Savage says, “the broader your definition of sex, the more sex you’ll be able to have.”

Reset your frame of mind around sex and focus more on re-exploring each other physically without the pressure of intercourse. Take penetration off the table for a period of weeks to give yourself a break from anticipating pain. Make “sexy time” fun and enjoyable (again), rather than anxiety-ridden work.

As Emily Nagoski coined, “pleasure is the measure.” If you’re not getting any pleasure out of your physical time together, then what’s the point? If you need help coming up with different ways of having sex besides intercourse, check out one of my previous articles.

Additionally, try the following tips:

Playlist for Relaxation

Create a playlist of songs that you find relaxing. Set up a relaxing experience for yourself while listening to this music (candles, comfy clothing…think all five senses). Set up a ritual where you sit or lay down and breathe deeply and restoratively while listening to these songs. Practice this frequently enough that you start to relax quicker and more easily over time.

Once you’ve created a relaxation response to this music, start to listen to it during solo-sex (masturbation) and try using penetrative dilators, finger(s), and/or toys to the same music.

Eventually, you will listen to this same playlist while engaging with your partner. First you’ll just be touching and kissing — do not consider penetrative sex together yet. Make sure your partner knows that penetration is not on the table yet, but you’re getting closer. Tell your partner what you’re doing (don’t hide it from them). As you listen to the music and have time with your partner, notice if you feel more relaxed.

Hopefully, you will engage in solo-sex frequently in between times with your partner in order to build up your ability to relax and get comfortable with your vulva, vagina and pleasure.

The relaxation response with your partner may take several weeks, and sometimes months (depending on your frequency), before you’re ready to attempt using it as a way of relaxing prior to and during intercourse with your partner.

Masturbation

Solo-sex may be controversial for some, but it can really help you be more calm, comfortable and confident in your body and with your own pleasure. During solo-sex, you don’t have the pressures of a partner creating some inhibitions that are just a part of partnered sex.

You can start to hear your own inner critic or internal judge voice as you explore and separate that out from your partner (when you’re involved in partnered sex). We are often much more critical of ourselves than others are of us. You can also start to explore your own imagination and inner fantasies and eventually share at least some of them with your partner, but mainly learn more about what turns you on.

You can also take your time to learn how and where you like to be touched for yourself and take some ownership over your own pleasure. You can then guide your partner to do some things you discover and enjoy. It’s imperative that you know your own body and feel confident in how your body responds — you can’t expect a partner to know what works and doesn’t work for YOU.

Mindfulness Meditation

Mindfulness is the act of non-judgmentally noticing what is going on within you and outside of you. You spend your energy noticing (and maybe labeling — thinking, worrying, fidgeting, etc.) what is happening and gently guiding yourself back to your breath with kindness. It isn’t at all about silencing your mind. You will continue to have thoughts, but you will simply start to notice that you’re having thoughts.

Many studies show the effectiveness of mindfulness for women with painful intercourse, other gynecological pain, and overall better sex lives. This is because women especially find it difficult to be focused on the here-and-now, attuned to what’s going on in the moment. Women are more likely to be thinking ahead about what they need to do next, anticipating and/or running to-do list in their head.

Mindfulness can be used in every aspect of life and helps you feel more present. It can also help you be more connected to your body and be able to feel and respond to different sensations more fully.

Studies found that an eight-week mindfulness program can boost sexual satisfaction by 60%, according to Dr. Lori Brotto who wrote the book “Better Sex Through Mindfulness.”

So, creating a mindfulness practice may help with pain related to intercourse, and may also help you be more present and in the moment, which is a big turn on.

She Comes First

This is the title of an amazing book written by Ian Kerner about the advantages to having women in a heterosexual partnership climax first through clitoral stimulation — oral, fingers, vibrator or other toys. It is also an excellent idea for helping with painful intercourse — having her climax first.

Orgasms release all the feel-good chemicals in response to the release and relax the muscles of the pelvic floor. This can help aid in the relaxation response necessary for penetration and can be useful for all these different types of pain. So, it might be a good idea to at least try having an orgasm prior to attempting intercourse.

This will need to involve your own personal experimentation (as all these ideas do) to test and determine if its a good match for you. Some women find that once they have had an orgasm, they’re no longer interested in intercourse and don’t create as many of their natural lubrication afterward. Some women find that climaxing first is the key to everything and they continue this pattern forever once it has been discovered. And, everything in between…

Personal Lubricants

I recommend using personal lubricants for anyone at all ages. I especially recommend a silicone-based lubricant (like Uberlube) because it is very slick, doesn’t need to be reapplied (in most cases), can be used in water (shower), and dries nicely like powder (not sticky, like some water-based products). Be aware that it cannot be used with silicone toys however (silicone-on-silicone apparently doesn’t work well — they eat each other, I guess).

I recommend personal lubricants with some hesitation however. Lubes do offer more slip-and-slide to the overall experience, and may be helpful for vulvadynia. They don’t really help with some of the areas we’ve discussed like the muscle tension, pelvic floor tightness, and/or psychological aspects to the pain (conditioning and anticipatory anxiety). So many women will think that lube alone is supposed to just do the trick, but it often doesn’t fully. It helps make things slippery-er, but this isn’t the full story. You most certainly may want to give a silicone- or water-based lubricant a try though. It may help with lowering anxiety around the pain because it does make things slide more easily.

Please know that there is help out there. Try some of these tips, but also do your best to seek professional help sooner rather than later. By the time a woman or couple gets to me, they have already been suffering from painful sex for 2–5 years or more typically. The longer you experience pain or discomfort, the more challenging it is to change. There’s definitely hope — you can have enjoyable sex (again or for the first time) with some experimentation, practice and sometimes additional support and guidance.

 

Kimberly Atwood is a licensed psychotherapist and certified sex therapist working in private practice in Princeton, NJ.  She also provides telehealth therapy with clients living in Indiana, New Jersey, New York, Massachusetts, and Pennsylvania.  She specializes in sexual health, intimacy and relationship issues.  She also writes about sexuality and relationship on Medium.

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