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.
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What causes pain during sex?
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.
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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."
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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 »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 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