Overcoming pain during sex

Did you know that the same nerve endings stimulated during orgasm can also trigger pain for people during sex? Known as dyspareunia, painful sex is a common condition but one that we shouldn’t have to suffer from. In this article, Oxford Women’s Health Gynaecologist Olivia Smart and Pelvic Health and Musculoskeletal Physiotherapist Niamh Clerkin discuss ways to treat painful sex and how to rediscover pleasure.

Enjoying a healthy sex life should never be painful, yet for many people it can cause significant discomfort. This can lead to isolation and affect a person’s physical, emotional, and social wellbeing. In 2007, Australian researchers found that up to 20% of women aged between 16 and 59 experience physical pain during sex. In addition, it is estimated that up to 85% of post-menopausal women live with Genitourinary Syndrome of Menopause (GSM), which is caused by low estrogen levels, and is a major cause of dryness and discomfort after menopause. Because of the reluctance to talk about pain during sex, and the normalisation of women’s pain (childbirth, periods) within society, the path to reporting and diagnosis can be delayed. The good news is that there is much that can be done to help people experiencing these symptoms. Openly discussing your sexual health with a specialist and/or General Practitioner is often the first step to accessing support.

What is dyspareunia?
Niamh: People who experience painful sex may feel a sharp pain during penetration (even when inserting a tampon); it may hurt deep inside the vagina or around the outer vulvovaginal area; and the pelvic floor muscles may tense or tighten during attempted vaginal penetration (vaginismus). Fear and anxiety can also be a significant part of this condition. There are many possible causes, including pelvic floor dysfunction, hormonal changes, skin conditions, and endometriosis.

Changes in the vulva and vagina caused by menopause may also cause pain during sex, and 60% of women who have urinary incontinence will also have coital, orgasmic, and/or penetrative incontinence, or coital urinary urgency. These conditions can be distressing and embarrassing, but they shouldn’t prevent you from speaking with your GP or specialist. We are experienced at treating people of all ages, sexual identities, backgrounds, and cultures. There is so much we can do to help, and to empower people to rediscover happy, healthy sex lives.

Olivia: We understand that describing the feeling of discomfort or pain in the vagina or vulva can be a challenge but explaining exactly where you experience pain, and what it feels like, will help your doctor better understand what’s going on. Let them know if the pain is constant, or only occurs with touch, during an examination, or with penetration. An examination is not always needed on the first appointment, but if it is recommended, you are welcome to have a chaperone join you in the room. 

During an appointment, it is likely you will be asked about the types of products and fabrics you use on your skin, and how often you wash and moisturise. This is to rule out conditions that may be caused by unknowingly disrupting the skin barrier and vaginal microbiome (the healthy bacterial balance). You will also be asked about your medical history and the medications you are using.

Niamh: From a physiotherapy perspective, I would be checking to see if you experience persistent pain around the pelvis, and if there is a history of endometriosis, back pain, or hip dysfunction, as these can all be linked to pain during sex. Sometimes, treating hip or lower back pain can provide relief without any further intervention. A pelvic floor examination may also be required to identify hip dysplasia, a labral tear, prolapse, or another type of pelvic floor dysfunction.

What are the treatment options?Olivia: Treatment for painful sex often works best by taking a multi-disciplinary approach, which we offer at Oxford Women’s Health. Alongside a gynaecologist, the role of the pelvic physiotherapist is essential, and counselling can also be very helpful if required.
 

Dr Olivia Smart 

Niamh Clerkin

Simple solutions to prevent pain include always remembering to use a lubricant during sexual activity, whether you are having penetrative, non-penetrative, partnered, or non-partnered sex. We recommend oil-based lubricants as being the kindest to sensitive skin but bear in mind that you cannot use an oil-based preparation with a condom as it will degrade the latex. Only wash the genital area with water as vaginas are "self-cleaning" and chemical products can be very irritating and cause problems like bacterial vaginosis. Douching can also interrupt the healthy bacteria in the vagina, so this is not advised. If you have sensitive skin and need to use a product, aqueous cream can be used as a soap substitute. Depending on your diagnosis, you may be prescribed vaginal estrogen to help restore tissue dryness, thickness, and elasticity. It is a safe and easy option to help. A referral may follow to a gynaecologist, pelvic pain physiotherapist, psychologist, or therapist to best manage the situation for you.

Niamh: When dealing with any kind of sexual pain, the goal is to reestablish the connection to pleasure. For women, the brain is the main sex organ, and we need to manage sexual stimuli from a psychological, emotional, and physical perspective, because living with pain or fear of pain can disrupt desire and arousal. Pelvic and musculoskeletal physiotherapy techniques can achieve really good results. Examples of techniques include myofascial release and graded exposure, which involves gradually desensitising areas that have become hypersensitive, or other evidence-based practices.

I also spend time explaining the anatomy and function of the pelvis to patients and explain why they may be experiencing discomfort.  When people understand pelvic functionality and anatomy, they can often feel empowered to progress and feel better. For example, they often aren’t aware that the clitoris extends far behind the labia, and that the pelvic floor needs to move in a dynamic and functional way. People are fascinated when they realise there’s so much more going on than they ever knew before. Taking people on the journey from living with pain to living with pleasure in the same area is a process and requires long-term gentle exposure. This can be achieved by working alongside a cognitive behavioural therapist, sex-therapist, or clinical psychologist. There are also many excellent sexual health and wellbeing products available to help. Options may involve the use of dilators; vibration therapy; stimulating sensory somatic exposure; diaphragmatic breathing; internal and myofascial release work; using a TENS machine; and discussing lifestyle, exercise, nutrition, and pleasure prescriptions.

Olivia: Remember: “Sex should not be painful”.

How diet can influence pelvic pain

If you’re living with pelvic pain, it can be tempting to follow online advice to relieve your symptoms but Oxford Women’s Health Nutrition Consultant and Dietitian Kate Collins is warning people not to adopt harmful, restrictive diets to ease their symptoms. Below, she explains why working with a dietitian to get the basics of bowel health right is a better option.

The connection between pelvic pain and the food we eat is important. In the human body, the bowel and uterus sit side-by-side, so if the bowel is full, bloated, or irritated, it can increase the pain from endometriosis or painful periods. You may have even noticed that during your period your bowel motions loosen due to the release of prostaglandins. Maybe you experience constipation around the time of menstruation, or an irregular combination of both. While the pain of endometriosis or heavy periods still needs to be managed separately with the support of a specialist, a dietitian can help to ease the discomfort caused by bowel issues.

After searching around online, people living with pelvic pain will often try cutting out foods, such as gluten or dairy, to see if their symptoms improve, but I always encourage a much broader approach – looking at the person’s core bowel health first and then exploring other options further down the track, if necessary.

Keep it simple – the 60 second checklist
When considering someone’s bowel health, I first look at the foundations of what makes us all function well.

Regular eating patterns
The bowel loves regularity, but the busyness of daily life can mean meals are skipped or we find ourselves grazing throughout the day. It’s important to eat breakfast and not to skip lunch. If you aren’t a big fan of breakfast begin by introducing a morning snack and work up from there. It’s all about forming regular eating patterns.

Balanced meals
When preparing a meal or snack, we often talk about the rule of threes. This involves making sure your plate of food is made up of one quarter protein, one quarter high fibre carbohydrate (fist sized), and half of colourful vegetables or fruit. These core fundamentals of nutrition really help. A good daily meal plan would be having oats for breakfast at 7.30am topped with milk, nuts, seeds, and fruit, followed by a coffee at 8.30am. By 10.30am, have a morning snack such as yogurt and fruit, and at lunchtime, you could enjoy some leftovers from dinner the night before. At 3pm, have a light snack such as crackers and hummus to get you through until dinnertime.

Adequate hydration
I often see people experiencing constipation who are only drinking a glass or two of water a day, and maybe a coffee or an energy drink. The aim should be to have 1.5L to 2L of fluids per day. 

Increase fibre gradually
Fibre is like a toothbrush that scrubs the gut to keep everything moving and regular. Rather than increasing fibre all in one go, it can help to spread it throughout the day.

I find a lot of people front-load their day with fibre by having a fibrous breakfast but then levels reduce in subsequent meals. A simple adjustment could involve adding chia seeds to yogurt for an afternoon snack. 

You don’t need to turn to supplements

Kate Collins

to achieve these goals, fruits and vegetables are a great source of both soluble and insoluble fibre. For example, did you know that kiwifruit is one of the highest fibre fruits?

Maintaining adequate nutrient levels
The key micronutrients to have on your radar include iron, vitamin D, magnesium, and Omega-3. If your periods are quite heavy, it will be essential to maintain good iron levels. Vitamin D is another important nutrient with anti-inflammatory properties, yet studies indicate that many women have low levels – particularly those with endometriosis. It can be worthwhile checking to see if you are getting enough ‘safe sunshine’. All it takes is 20 minutes a day, so roll up your sleeves and take your lunch break outside. Magnesium provides muscle contraction support, but it is worth knowing that some supplements can affect bowel function if they contain magnesium citrate. There’s also some great evidence starting to come out about Omega-3 being helpful for endometriosis symptoms because of its anti-inflammatory properties. Increasing fish in your diet is a good start, and an Omega-3 supplement can be beneficial for endometriosis patients.

What helps to alleviate pelvic pain?
If we know the foundations of good bowel health are covered and all other options have been considered, an elimination diet conducted under the guidance of a dietitian can be helpful.

Anti-inflammatory diets
There's a lot of evidence around the benefits of the Mediterranean style of eating, which includes consuming fish, wholegrains, and fruit and vegetables that are high in antioxidants. Rich, oily fish such as salmon, has higher levels of Omega-3 than tuna. Studies have also shown that 75% of people with endometriosis felt their symptoms improved on a low wheat diet, so this could be something to trial once other options have been exhausted.

The FODMAP diet
FODMAPs (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols) are the natural fermentable sugars found in food that some people struggle to process. If constipation is bothering you, then FODMAPs won’t make a lot of difference. However, if loose bowels with persistent bloating and flatulence are the problem, then it could be helpful. A FODMAP diet needs to be followed thoroughly and is usually one of the last options. The crucial part is reintroducing each group in one by one to clearly identify what is causing someone to react to food.

People with pelvic pain often benefit from Oxford Women’s Health’s multidisciplinary approach. For example, our gynaecologists will help determine what is causing it; if it is affecting your mental wellbeing, we can easily refer you to one of our clinical psychologists; or if the issue is musculoskeletal, a pelvic floor physiotherapist may be able to help.

If you would like to talk to me or our other dietitian Sara Widdowson, please call 03 379 0555 to book an appointment.

Breath Tekapo presentation

At the end of May, some members of our team travelled to Lake Tekapo to present at Breath Tekapo.

Gynaecologist Dr Olivia Smart, Pelvic Floor Physiotherapist Hazel Cutler, Dietitian Sara Widdowson, and Mindful Physiotherapist Jo Hopkinson-Haigh together delivered an interactive two-hour workshop titled “The Wisdom of Your Body: Exploring, Restoring and Rebalancing Through Menopause and Midlife.”

The session explored some key aspects of women's health during midlife, including understanding hormonal changes, pelvic floor health, the importance of connection and community, and the vital role that 
 

Oxford Women's Health clinicians pictured from left include: Gynaecologist Dr Olivia Smart, Dietitian Sara Widdowson, Pelvic Floor Physiotherapist Hazel Cutler, and Mindful Physiotherapist Jo Hopkinson-Haigh.

protein and fibre play in supporting overall wellbeing and gut health. 

The feedback from attendees was very positive and our team were grateful for the opportunity to share knowledge, answer questions, and support women in navigating this important stage of life.

Change of name for PCOS

You may have seen that Polycystic Ovarian Syndrome (PCOS) has been renamed Polyendocrine Metabolic Ovarian Syndrome (PMOS) to more accurately reflect the condition. 

The change followed a global petition led by experts and patients, which was supported by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). 

Oxford Women’s Health will now be referring to the condition as Polyendocrine Metabolic Ovarian Syndrome (PMOS). Read more here: https://tinyurl.com/3bb9yzur or for more evidence-based information on PMOS, visit https://www.askpcos.org/
 

Are my symptoms menopause?

There’s a lot of discussion on social media and online about menopause these days but how do you know if you are actually going through it?

On average, women experience menopause around the age of 51 with symptoms that may include night sweats, hot flushes, nervousness, irritability, sleep disturbance, and loss of libido and self-confidence. These can start to become an issue up to four or 

five years before menopause. Thirty five per cent of women will enter perimenopause in their late 30s. If you are under the age of 45 and notice a cyclical pattern to your symptoms, it may be a good idea to discuss this with your GP who can arrange for hormonal blood tests to be completed.