Good Health (Australia) - - Be Informed -


When Anna Em­mer­son* had a hys­terec­tomy seven years ago, she ex­pected her health to im­prove. In­stead, she de­vel­oped a prob­lem that has af­fected her phys­i­cally, men­tally and emo­tion­ally. It has been too hard for the nor­mally confident life coach to talk about. That prob­lem is painful sex, and 57-year-old Anna is not alone. Ac­cord­ing to the Amer­i­can Col­lege of Gyne­col­o­gists, nearly three out of four women will ex­pe­ri­ence painful in­ter­course at some time. The prob­lem can be tem­po­rary, but stud­ies have shown that up to a third of women will have per­sis­tent prob­lems. The med­i­cal term for pain be­fore, dur­ing or af­ter vagi­nal in­ter­course is dyspareunia. Ac­cord­ing to women’s health or­gan­i­sa­tion Jean Hailes, it af­fects women of all ages. It’s com­mon in menopausal and post­menopausal women due to hor­monal changes lead­ing to vagi­nal dry­ness and de­creased elas­tic­ity. Left un­man­aged, it can lead to loss of sex­ual in­ter­est, mood changes and re­la­tion­ship is­sues. Man­age­ment starts with ac­knowl­edg­ing the prob­lem. Gy­nae­col­o­gist Dr El­iz­a­beth Far­rell, a founder and med­i­cal di­rec­tor of Jean Hailes says, “There is help avail­able. See your doc­tor and talk about it.” If you don’t feel com­fort­able dis­cussing it with your doc­tor, try a dif­fer­ent one, or a com­mu­nity or women’s health nurse.

What causes it?

There are two types of dyspareunia. The first is su­per­fi­cial, which is pain on at­tempted pen­e­tra­tion. Causes in­clude in­fec­tions, vagin­is­mus (spasm of the pelvic floor mus­cles), and size dis­par­ity (where the erect pe­nis is too big for the vagi­nal en­trance). The sec­ond is deep dyspareunia, which is pain at the top of the vagina, of­ten ex­pe­ri­enced with thrust­ing. Causes in­clude pelvic dis­eases such as en­dometrio­sis, ovar­ian cysts and pelvic in­flam­ma­tory dis­ease. Lack of lu­bri­ca­tion can cause dyspareunia, says Dr Char­lotte El­der, an ob­ste­tri­cian, gy­nae­col­o­gist and spokesper­son for the Royal Aus­tralian and New Zealand Col­lege of Ob­ste­tri­cians and Gy­nae­col­o­gists. This of­ten af­fects women at menopause, and those who are breast­feed­ing. “They gen­er­ally have lower oe­stro­gen lev­els, so they tend to make less lu­bri­ca­tion them­selves,” she ex­plains. An­other cause of poor lu­bri­ca­tion is in­ad­e­quate fore­play, ex­plains Dr El­der, who prefers the term ‘sex pain’ to dyspareunia, be­cause it is less med­i­calised. This can be a prob­lem for older women who haven’t had sex for a while and may not be confident ar­tic­u­lat­ing their needs. Dr El­der likens fore­play for a woman to an erect pe­nis for a man – a pre­req­ui­site for in­ter­course. “Fore­play is not an op­tional thing, a fun thing, or some­thing that you do for ex­tra to sex. It’s ac­tu­ally re­ally im­por­tant.” She rec­om­mends women speak to their doc­tor about lu­bri­ca­tion is­sues. If low oe­stro­gen is the cause, sup­ple­men­ta­tion – whether as a vagi­nal cream or tablet, or a patch

‘Fore­play is not an op­tional thing. It’s ac­tu­ally re­ally im­por­tant’

‘In­ti­macy is dif­fer­ent from sex, and sex is not just about pen­e­tra­tive sex’

‘Many women don’t re­alise that a hys­terec­tomy changes the po­si­tion, length and shape of their vagina’

that works through the body – can be help­ful. She re­it­er­ates that be­ing com­fort­able with your doc­tor is cru­cial, so find one that’s com­fort­able with women’s health. Your GP may re­fer you to a gy­nae­col­o­gist if they have con­cerns or you have a com­plex gy­nae­co­log­i­cal his­tory. When it comes to lu­bri­cants, oil- and even fruit-based ones may work bet­ter than wa­ter-based ones. “The main thing is to try them,” Dr El­der ad­vises. “Test them on your skin, your vulva, then on your vagina and see how you feel.” Man­age­ment of painful sex might in­clude a break. “If peo­ple are feel­ing anx­ious or stressed, any pain will be worse – es­pe­cially sex pain,” Dr El­der ex­plains. “Be­ing in a si­t­u­a­tion where they’re not go­ing to feel pres­sured to have in­ter­course means that they can re­lax and it makes in­ti­mate ac­tiv­ity more plea­sur­able.” Dr Far­rell agrees, not­ing that some cou­ples – whether het­ero­sex­ual or same-sex – will choose to have ‘out­er­course’, or in­ti­macy with­out pen­e­tra­tion. “In­ti­macy is dif­fer­ent from sex and sex is not just about pen­e­tra­tive sex,” she says. Cou­ples can ex­plore other ways to give and re­ceive plea­sure. She adds that some part­ners will be re­ally con­cerned and won’t want to hurt you, whereas oth­ers may try to make you feel guilty. Seek the sup­port you need – from your doc­tor, coun­sel­lor or friends. Anna says tak­ing some­one along to med­i­cal ap­point­ments with you is also a good idea.

Think­ing about sex

Women needn’t be em­bar­rassed to seek help. “It’s im­por­tant for women not to feel shame about painful sex,” Dr El­der says. “It’s re­ally com­mon and it’s some­thing that women and their part­ners – with some sup­port – are able to man­age well.” Cather­ine Wil­lis, a phys­io­ther­a­pist and chair of the Aus­tralian Phys­io­ther­apy As­so­ci­a­tion’s na­tional Women’s, Men’s and Pelvic Health Group, agrees. Prob­lems can start with “a teenager think­ing, ‘This is what sex is like – I’m not sup­posed to en­joy it,’” she says. “Or a woman af­ter hys­terec­tomy think­ing, ‘I have to keep do­ing it to keep my part­ner happy.’” Cather­ine notes that while sex pain is com­mon, it isn’t nor­mal, and a lot can be done to help. In sit­u­a­tions like Anna’s, for ex­am­ple, many women don’t re­alise that a hys­terec­tomy changes the po­si­tion, length and shape of their vagina, es­pe­cially if the cervix is re­moved. This can mean they de­velop pain with thrust­ing. A women’s health phys­io­ther­a­pist can be an im­por­tant part of your man­age­ment team. Physios are good lis­ten­ers, Cather­ine says, and will­ing to re­fer you to other prac­ti­tion­ers as needed. A phys­io­ther­apy as­sess­ment will in­volve tak­ing a de­tailed his­tory and as­sess­ing fac­tors that might be in­flu­enc­ing your symp­toms, in­clud­ing blad­der and bowel func­tion, pelvic floor mus­cles, hip joints, stress and sleep. “We tend to look at the big pic­ture rather than just fo­cus­ing in on some­thing like the thrush,” she ex­plains. Treat­ment might be as sim­ple as sug­gest­ing more com­fort­able sex po­si­tions or teach­ing you deep breath­ing. This can help the pelvic floor mus­cles to re­lax. Stretches for the hips and pelvic floor can also help re­lieve ten­sion.

More spe­cific treat­ments might in­clude de­sen­si­tis­ing the gen­i­tal area by teach­ing you gen­tle touch­ing tech­niques or us­ing a TENS ma­chine (a ma­chine that de­liv­ers a small elec­tri­cal cur­rent to the body through elec­trodes at­tached to the skin, also used for pain re­lief). For women with prob­lems with pen­e­tra­tion, which can oc­cur not only dur­ing in­ter­course, but also with tam­pon in­ser­tion and med­i­cal ex­ams like the cer­vi­cal screen­ing test – ‘dila­tors’ can help to gently stretch the vagina. You start with a small one and grad­u­ally in­crease the size. Phys­io­ther­apy tech­niques like trig­ger point re­lease or gen­tle mas­sage of the pelvic floor mus­cles can re­duce ten­sion and help you to learn the dif­fer­ence be­tween tense and re­laxed mus­cles. Physiotherapists also use ma­chines that mea­sure mus­cle ac­tiv­ity for this pur­pose. Cather­ine notes that find­ing the right physio to help with sex pain is im­por­tant, and it mightn’t be the lo­cal one who treats your neck. “Find a physio who’s got the ap­pro­pri­ate ed­u­ca­tion and train­ing and ex­pe­ri­ence to deal with these other is­sues,” she says.

Men­tal health and re­la­tion­ship ef­fects

Aside from the phys­i­cal ef­fects, painful sex can have dev­as­tat­ing men­tal health con­se­quences. “The big­gest mis­take is the one that I made and that’s bot­tling it all up,” ad­mits Anna. It also af­fects re­la­tion­ships. For Anna, in­ti­macy with her part­ner de­clined be­cause he didn’t want to hurt her. “We have a lov­ing re­la­tion­ship, but we’re not in­ti­mate very of­ten,” she says. “I like sex a lot and that’s been taken away.” These is­sues are all too com­mon. Dr Janet Hall, a clin­i­cal psy­chol­o­gist, sex ther­a­pist, hyp­nother­a­pist and au­thor, says, “Just one neg­a­tive ex­pe­ri­ence can re­sult in a per­son try­ing to avoid hav­ing sex again. Psy­cho­log­i­cal fac­tors are of­ten as­so­ci­ated with pre­vi­ous sex­ual trauma (such as rape or abuse), feel­ings of guilt, or neg­a­tive at­ti­tudes to­ward sex.” Dr Hall ex­plains that psy­cho­log­i­cal treat­ment is of­ten nec­es­sary be­cause the pain has caused fear due to an­tic­i­pat­ing fu­ture pain. Treat­ment may in­clude strate­gies for chang­ing neg­a­tive thoughts, jour­nal writ­ing to iden­tify fears, work­sheets to help change mis­taken be­liefs, and us­ing af­fir­ma­tions and vi­su­al­i­sa­tion to de­velop pos­i­tive ex­pec­ta­tions about sex. Se­condly, phys­i­cal strate­gies are used to fos­ter pos­i­tive bod­ily re­ac­tions. These in­clude deep-breath­ing to lessen anx­i­ety, pro­gres­sive mus­cle re­lax­ation to re­lax and ex­pe­ri­ence body sen­sa­tions, pelvic floor mus­cle ex­er­cises, and

‘many women have suf­fered in si­lence be­cause they feel like a fail­ure’

grad­ual prac­tice of touch­ing your own gen­i­tals and in­tro­duc­ing pen­e­tra­tion into your vagina. Hyp­no­sis is an­other ef­fec­tive tool. “Hyp­no­sis trains you to change your in­ner view and ex­plore your real feel­ings,” Dr Hall ex­plains. “In hyp­nother­apy you learn how to con­vert neg­a­tive re­pres­sive im­ages into pos­i­tive, re­leas­ing ones.” Dr Hall says that “many women have suf­fered in si­lence be­cause they feel ‘dif­fer­ent’, like a fail­ure and think that they are the only one with this prob­lem.” How­ever, with the right help, they can “ex­pe­ri­ence sex as a plea­sure and not a pain.” Dr Far­rell, too, urges women not to suf­fer when help is avail­able. “Go and see some­body who is in­ter­ested and sees that… it’s taken [you] a lot of courage to come and talk about it.” Anna re­grets not seek­ing help ear­lier. Her ad­vice to any­one suf­fer­ing pain with sex is “Get sup­port quickly”.

* Not her real name

FOR FUR­THER IN­FOR­MA­TION, VISIT: sex­u­al­healthaus­tralia.com.au/ dyspareunia.html­jean­hailes.org.au/health-a-z/sex­sex­ual-health/painful-sex-dyspareunia

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