Experiencing painful sex is more common than you think. Here we talk to two experts about the common causes, consultation tips, and why health professionals should ask their patients about it.
‘Dyspareunia’ is the medical term used to describe continuous, unremitting, or intermittent pain associated with intercourse.
There are two types of dyspareunia:
“With superficial, there can be issues with lubrication, vaginal dryness, atrophy, narrowing, infections or vaginismus”, explains Jean Hailes gynaecologist Pav Nanayakkara. “For deep, we want to exclude structural causes such as endometriosis, ovarian cysts and pelvic infections.”
While older women are more likely to experience atrophy or vaginal dryness and younger women are typically more affected by endometriosis, fibroids, or cysts, it’s not a hard and fast rule, says Dr Nanayakkara.
As in any consultation, taking a thorough medical history is key to successful treatment. Painful sex can be a tricky topic, as many women feel embarrassed to bring it up and don't volunteer the information. As a result, it is likely under-reported. Health professionals can, however, make it easier for women to raise it during a consultation.
“It’s important to specifically ask about the patient’s sex life because if we don’t ask, we won’t know”, says Dr Nanayakkara. “If we’re not encouraging a discussion on this issue, patients tend to suffer in silence, when there can often be contributing causes and treatments we can offer to help.”
For some health professionals, it will take time and effort to feel confident and comfortable in raising the topic of painful sex. “There is a skill in doing it respectfully and it is a learnt skill”, says clinical psychosexual therapist Dr Margaret Redelman OAM.
“It’s important to validate the woman. If she feels respected and heard, that’s almost 50% of the whole management. Women sometimes get shut down, told they have a mental health problem, or that they should ‘grit their teeth and get on with it’.
“If a GP validates her story, [if needed] he or she can segue into, ‘this isn’t my area of expertise, and I will refer you on’. Otherwise, the GP can schedule a longer consultation. There is a cascade of directions that can be taken.”
Women in same-sex relationships should be included in this conversation, too. While outercourse is common, so too is penetration and the use of strap-on sex toys and dildos, says Dr Redelman. It’s therefore important to remember that women of all sexualities can experience penetrative pain, an issue they, too, should be comfortable in raising with the GP.
Painful anal sex, known as ‘anodyspareunia’, is a significant problem for many of the (often young) women Dr Redelman sees in her practice. “They can be reluctant to talk about it with a doctor because it is still a bit of a taboo topic”, she explains.
“It can present as frequent UTIs, a prompt for the GP to ask [more] questions.” Dr Redelman believes that agency, coercion and consent should be raised in any discussion with a patient presenting with anodyspareunia.
Dr Nanayakkara suggests a layered approach involving conservative, medical and surgical strategies. The best outcomes for dyspareunia are achieved with a multidisciplinary team that may include a pelvic floor physiotherapist, a psychologist and a sexual health therapist.
“Treatment always depends on the cause, which is why a comprehensive medical history is critical”, explains Dr Nanayakkara.
Thinning of the vaginal wall, often a feature of postmenopause, can cause itching, burning, shrinking and bleeding, with resultant dyspareunia and sexual dysfunction, says Dr Redelman.
“For some women, hormones can help – topical oestrogen or menopausal hormone treatment (MHT) – or for others, it can be hormonal suppression to manage issues like endometriosis. If there is pelvic inflammatory disease, antibiotics or antivirals can be part of the treatment”, says Dr Nanayakkara.
Surgery may be required to increase the opening of the vagina – Fenton’s procedure – or a laparoscopy done if fibroids or endometriosis need to be treated.
A strong pelvic floor is vital for women, and patients should be encouraged to do pelvic floor exercises daily. However, an overactive pelvic floor is implicated in vaginismus and other causes of painful sex.
Research supports manual techniques administered in pelvic floor physiotherapy as important in the treatment of dyspareunia. They increase the woman’s awareness of her pelvic floor muscles (PFMs), may release trigger and tender points (musculoskeletal sources of dyspareunia), normalise the overactivity, and build PFM strength.
These aims are achieved through PFM exercises (as well as patient education, supervision, and instruction), myofascial release techniques, deep intravaginal massage and electrotherapeutic modalities.
You can find a pelvic floor physiotherapist by visiting the Find a physio webpage on the Australian Physiotherapy Association website, then under ‘Refine your search’ select ‘Special interest area: Women’s, Men’s and Pelvic health’.
Dr Redelman says it’s important to remember that any medical condition will also have a psychological implication. “Sometimes you can treat the medical condition, but the sexual function doesn’t improve.”
Improving the symptom of painful sex can take several months – or, in the case of chronic or complex conditions, treatment might be ongoing for many years, and involve a woman’s partner. It may also require different specialists or a team approach. It is therefore important, says Dr Nanayakkara, to provide realistic expectations to the patient. And, as always, communication is key.
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