When sex hurts, physical therapy can help

As a women’s health physical therapist, I see many women devastated by pain during intercourse. Please know that there is hope, there is help—in most cases, there is even a cure.

If intercourse hurts or is impossible; if inserting a tampon is a struggle; if gynecologist’s visits are painful ordeals . . . you’re not alone.

Believe it or not, millions of women feel your pain, confusion, and desperation. Fortunately, during the past two decades the medical profession has learned much about vaginal pain: everything from what to name it to how to treat it—as well as physical therapy’s vital role in recovery.

What’s going on?

The medical term for painful sex is dyspareunia, and there are several possible causes:

Vaginismus. This is an involuntary tightening of the vagina in a subconscious effort to prevent penetration. In some cases, the body "remembers" painful gynecological procedures; childbirth complications; or sexual, physical, or verbal abuse, and the vagina shuts down to protect against further trauma. In other cases, the problem is rooted in fear of sexuality or intimacy, relationship conflicts, life stress, guilt, or religious taboos. Tightness begets pain, which begets more tightness—and a vicious cycle is set in motion.

Pregnancy and childbirth. Painful sex can result from a C-section, vaginal tears, episiotomy scars, injured vaginal tissue from a forceps or vacuum delivery, or damaged pelvic nerves from the baby’s passage through the birth canal. Low estrogen levels associated with breastfeeding can also cause vaginal pain.

Menopause. As the body’s estrogen levels drop, vaginal tissue becomes thinner, less lubricated, and less elastic. The vaginal opening, walls, labia (lips), and clitoris can get smaller. These changes may cause pain during intercourse.

Cancer treatment. Chemotherapy and radiation can trigger hormonal changes and early menopause. Vaginal tissue may become thinner, dryer, and less elastic; vaginal muscles may tighten and weaken; and the vaginal opening may narrow. All can lead to painful sex.

Vestibulodynia or vulvodynia. This is pain or sensitivity in the area around the vaginal vestibule (opening). Pain can be provoked (triggered by touch) or unprovoked (constant). Intercourse is usually painful, if not impossible. Even sitting, walking, or wearing jeans or underwear can be irritating. The pain is often burning; sometimes pinching or stabbing; sometimes accompanied by pain in the clitoris, abdomen, buttocks, or thighs. Vulvar skin (the skin around the outside of the vagina) often looks completely normal, but sometimes a health care professional can detect microscopic red dots, inflammation, or "paper cuts." (Note: Vestibulodynia and vulvodynia were previously called vulvar vestibulitis.)

The exact cause is unclear, but we know that sufferers have nerves with overly sensitive pain receptors—sensitized, perhaps, by childbirth, menopause, yeast infections, or even yeast medications. Musculoskeletal problems, especially in the back, hips, or legs, can overwork and stress the pelvic floor muscles and may play a large role. Many sufferers also have a bladder condition called interstitial cystitis, a pain condition called fibromyalgia, or a bowel condition called irritable bowel syndrome.

Painful orgasm. Weak or tight vaginal muscles can lead to painful orgasm, sometimes called dysorgasmia.

Other gynecological and urological conditions. Dyspareunia can also stem from endometriosis; pelvic inflammatory disease; vaginal infections, cysts, or lesions; vaginal skin conditions such as lichen sclerosis; incontinence; overactive bladder; or pelvic organ prolapse.

How physical therapy can help

Today there’s a new specialty at the intersection of physical therapy, gynecology, and urology. Called women’s health physical therapy or pelvic floor physical therapy, it’s a first-line treatment for dyspareunia and pelvic floor muscle dysfunction. Specially trained physical therapists employ these gentle, proven techniques, tailoring treatment to the patient’s individual needs.

Manual therapy. Hands-on techniques—for example, myofascial release and trigger-point release—help relax tight tissue, balance muscles, move stiff joints, and melt away tender points and trigger points (sore "knots" that refer pain elsewhere) in the abdomen, back, hips, and thighs. Your physical therapist may also use ultrasound or cold laser to heal and soften any vaginal tears or thick, sore scars. When you’re ready, she may begin trigger-point release and stretching inside the vagina.

Therapeutic exercise. Your therapist may also teach you core-stabilization exercises, postural exercises, and exercises to strengthen your abdomen, back, hips, and legs. All help relieve pelvic pain.

Pelvic floor biofeedback. Safe and painless, biofeedback trains you to isolate, relax, and tone your pelvic floor muscles. You insert a tiny probe into your vagina or rectum, then view your pelvic muscle function via a graph on a biofeedback monitor. (If you can’t insert the probe, your physical therapist may place sensors on the skin between your vagina and rectum.) This feedback guides vaginal-release exercises called pelvic drops. After your pelvic muscles learn to relax, you begin vaginal toning exercises, also guided by biofeedback. This exercise program relaxes vaginal muscle spasms, promotes blood flow to damaged tissues, increases elasticity, and decreases pain sensitivity. Home practice is vital to your recovery.

Dilators. When you feel comfortable, your therapist shows you how to insert fingers, then tampons, then gradually larger dilators to gently stretch and desensitize your vagina.

(Note: Ultrasound, cold laser, and biofeedback are not advised for pregnant women.)

After a course of pelvic floor physical therapy, the majority of women report a drastic reduction in vaginal pain. Most can start to enjoy pleasurable, pain-free intercourse—some, for the very first time.

In addition, women with vaginismus may benefit from psychological counseling and sex therapy. Those with other types of dyspareunia may benefit from medication, topical estrogen, dietary changes, supplements, and self-care strategies. Please talk to your gynecologist or urogynecologist.

For more information, visit:

American Association of Sexuality Educators, Counselors and Therapists

American Physical Therapy Association Section on Women’s Health

International Pelvic Pain Society

The International Society for the Study of Vulvovaginal Disease

National Vulvodynia Association

The North American Menopause Society

The V Book: A Doctor’s Guide to Complete Vulvovaginal Health, by Elizabeth G. Stewart, M.D.

The Vulvar Pain Foundation

Raquel Perlis