Sex hurts!!! Part 1

A Little TMI

"It hurts to have sex, so much that I just don't want to do it anymore".
"My husband wants to have sex more often, but I just don't enjoy it".
"He can't even get inside me, it hurts so bad".
"My vagina literally pushes him out, like it's got a mind of it's own".
"I have such intense cramps after sex, that it's not even worth it."
"Orgasm hurts, so what's the point?"

What makes sex hurt?

Painful sex, also known as dyspareunia, is persistent or recurrent pelvic or genital pain that occurs just before, during or after sex. Pain can be external with just touch, upon entry (penetration), with deep pushing (deep penetration), or afterwards. The more common causes are:

- Pelvic, vulvar or vaginal infection
- Urinary tract infection
- Vulvar skin disorders
- Trauma to the vagina
- Fibroids or endometriosis
- Vulvodynia/Vestibulodynia- a chronic pain disorder of the vulva/vestibule
- Vaginismus- a reflex contraction (tightening) of the muscles at the opening of your vagina
- Pelvic floor dysfunction (PFD) with trigger points (see my previous blog "When Ovary Pain Isn't Coming from your Ovary")
- Interstitial cystitis/Bladder Pain Syndrome (see my previous blog "Gotta Pee!! Recurrent UTI, or Bladder Pain Syndrome?")
- Irritable bowel syndrome (IBS)
- Menopause or peri-menopausal vaginal atrophy

That big list above...

That big list up above is a lot of doctor speak. So what are all those things? Some of them you've probably never heard of and that's ok. Let's do a quick overview of the more interesting ones I treat, and I'll go in to more detail about them in upcoming blog posts.

Vulvar skin disorders

The vulva is the area of skin around the outside of your vagina, encompassing all of your external genital organs. Most of the skin disorders of this area start out as itchy/scratchy problems. The itching is usually really intense and cannot be ignored, sometime waking people from sleep! This can then turn in to pain when you've scratched so much that the skin breaks down or gets thickened from repeated scratching. Some of these skin problems can also cause bleeding with sex, and discharge from the vagina.

Trauma to the vagina

The easiest was to traumatize the vagina is to push a baby through it. Episiotomies and vaginal tears from delivery are pretty common and can continue to cause pain if they don't heal well or involve the nerves to the overlying skin. Sometimes you can get trauma to the vulva or vagina from a quirky fall, like on the edge of a pool.

Fibroids and Endometriosis

Fibroids are non-cancerous growths of the muscle that makes up the uterus. They can get pretty big and usually cause too much bleeding or bad pain with your periods. Sometimes, depending on their position, they can also cause pain with sex.

Endometriosis is it's own thing...and deserves a few blogs by itself. I'll get to that eventually. But for now, we'll make it simple. Endometriosis is when the tissue that you're supposed to shed every month with your period gets out into the abdomen, attaches to something (like your ovaries or bladder) and starts growing there. It responds to your hormone cycles and causes bleeding into the abdomen every month. It's associated with heavy and painful periods, as well as intermittent pain throughout the month, but can be associated with painful sex if the endometriosis is growing around or inside the vagina or bladder. It's the most common cause of cramping after sex.

Vulvodynia/Vestibulodynia

Now we're getting interesting. This is "vulvar discomfort in the absence of relevant physical findings or a specific clinically identifiable neurologic disorder". It's really a symptom, but we use it like a diagnosis too. There's different kinds, like pain that you have all the time, or only with touch or attempted sex. It can be all over the vulva, or just the area right at the edge of the vaginal opening, called the vestibule. When it's at the vestibule, this causes burning pain with attempted penetration of the penis or a tampon. 

Vaginismus

Vaginismus is when your vaginal muscles tighen up spontaneously, without your intentional help. This makes penetration with sex, or even placing a tampon, painful or almost impossible. It can also push things out of the vagina after they've been placed there.

Pelvic Floor Dysfunction

My first blog was really about this. It's when your pelvic muscles are all tight, often in response to pain from elsewhere. When something "down there" hurts, your body alters the posture and muscle tension to minimize pain. This can fatigue the muscles and cause knots. For more info on this one, see my blog "When Ovary Pain Isn't Coming from your Ovary".

Irritable Bowel Syndrome

IBS is a group of symptoms including abdominal pain accompanied by changes in stool consistency (constipation or diarrhea), changes in color, as well as feelings of bloating or gas. There's different kinds which are treated differently. It's often associated with other chronic conditions like fibromyalgia and interstitial cystitis as well as generalized pelvic pain.

Resources:
https://www.vaginismus.com/
https://www.ncbi.nlm.nih.gov/pubmed/26745618
https://www.ncbi.nlm.nih.gov/pubmed/22672388
https://www.ncbi.nlm.nih.gov/pubmed/23551753