When Love Hurts: A Guide to Painful Sex for Newlyweds

Are you getting married soon? Already tied the knot? If you are concerned about painful sex, this is a must read!

Anna’s Story

Anna married the love of her life last year. She and her husband were so excited for this new phase of their lives. On their honeymoon, attempting insertional intercourse was excruciatingly painful. She even bled a little. Her husband felt awful for causing her so much pain and she didn’t know what was wrong with her. They tried a handful of more times over the next couple months with the same painful experience; she started dreading physical intimacy.

They began meeting with a sex therapist and made some good progress, but Anna still couldn’t tolerate penetrative sex. Their therapist recommended that she may have some physical factors that could be playing into her pelvic pain and referred her to a pelvic floor physical therapist.

Alright let’s break it down. What’s going on and most importantly, what can we do to help?!

Anna is experiencing something broadly termed “dyspareunia” which is the fancy term for painful sex. There are numerous subcategories including vaginismus, vulvodynia, vestibulodynia, and so on. A person can experience dyspareunia with initial insertion or with deeper penetration. The pain can be immediate or somewhat delayed. What all dyspareunia conditions have in common is that it is NOT normal and can seriously impact all facets of your
life!

Dyspareunia can lead to decreased sexual desire and arousal, strained sexual relationships, and can have a significant impact on physical and mental health. Research has shown it can lead to depression, anxiety, hypervigilance to pain, negative body image, and low self-esteem. It is crucial to talk with your pelvic specialist about this and receive prompt and effective management. Don’t suffer through this!

Signs you should never ignore…

• Burning, stinging, or raw feeling at your vaginal opening
• If you have ever felt like your body won’t allow anything to enter your vaginal canal… For example, if you have never been able to comfortably use a tampon or menstrual cup/disc.
• Painful or traumatic speculum/gynecological exams
• If your OB/Gynecologist has ever told you that you have a really tight pelvic floor
• History of painful and/or traumatic sexual activity

Any of those symptoms indicate that you would likely greatly benefit from an examination by a pelvic specialist. If you live in Utah, you don’t even need to wait to be referred by your doctor. You can make an appointment right away.

What can Pelvic Floor Physical Therapy do?

A good pelvic physical therapist will do a thorough full body assessment. They will look at your posture, abdomen, hip strength, and muscular tension/trigger points in your inner thighs, glutes, back, and abdomen. With your consent, your pelvic PT will also perform an external and internal pelvic exam. This is different from the gynecological exam with a speculum. Your pelvic floor physical therapist will evaluate the bony pelvis, vulvar tissues, and pelvic floor muscles intra-vaginally, assessing muscular mobility and coordination, nerve symptoms, and any painful muscular trigger points. (All skeletal muscle can get trigger points, or knots, just like the knots that you might get in your upper traps and shoulders. They are bands of really tense muscle tissue that can refer pain to other areas of the body. Imagine a tension headache but in your pelvic floor!) For more information on what to expect during your first Pelvic Floor physical therapy evaluation, check out this blog post.

Based on the exam findings, your physical therapist will recommend a variety of evidence-based treatment approaches. This could include a variety of manual therapy using myofascial release, cupping, dry needling, massage, instrument-assisted soft tissue mobilization (IASTM), and more. Your therapist may lead you through re-training and optimizing your body’s movement patterns to take the strain off your pelvic floor muscles.

Another key focus of pelvic floor physical therapy for dyspareunia is getting your body’s nervous system on your side. Your nervous system is trying to protect you from pain, that’s one of its main jobs! If there is a repeated painful stimulus or trauma to any area of the body – including the pelvic floor – the body’s “alarm system” is going to become even more heightened, hypervigilant of anything that could cause you pain. This can get out of hand, and your nervous system may need help resetting to a healthy level. Your physical therapist will help you throughout this process of neural downtraining, progressive relaxation exercises, powerful breathing strategies, mindfulness, desensitization, and more. If you are already sexually active, your therapist may introduce you to resources like Sensate Focus – a process of how to reintroduce sexual intimacy with your spouse/partner without activating the painful alarm system!

For individuals concerned that they might struggle with dyspareunia upon becoming sexually active, or if you’ve already been dealing with it, your physical therapist may suggest some tools you can use at home to keep making progress towards your goals in between therapy sessions. This includes vaginal dilators, pelvic wands, and various lubricant options including lidocaine or hyaluronic acid infused, silicone vs water based, and vulvar creams and lotions. There is a wide variety of shapes, sizes, and special features; not all tools are created equal. Your PT will recommend brands that come in medical grade silicone, with specific ergonomic shapes that will be the most effective for your goals.

Finally, dyspareunia can be complex. Your physical therapist will make sure to refer you to the appropriate provider as needed to ensure we get to the root of your problem. We work closely with vulvar dermatologists, OBGYNs, mental health and sex therapists, among others. For example, during your pelvic PT appointment we may find that you still have hymenal remnants blocking the entrance to the vaginal canal which makes insertion of a tampon or intercourse very uncomfortable or even impossible. (It is much easier to find this out in a doctor’s appointment instead of on your honeymoon, trust me!!) We would then refer you to your gynecologist to perform a simple procedure to remove that excess tissue.

The Bottom Line

• Sex should not be painful!
• If it is, there are answers and there is hope!
• Don’t struggle with months or even years of painful sex. Book your appointment with a specialized pelvic floor physical therapist today.