Sex is a sensitive subject. Maybe that’s why I get so many private questions about it through the “Just Ask” box on the Poise website. Women tell me they’re too embarrassed to talk to their partners or their doctors about certain things they worry about, like experiencing leaks or pain during intimate moments.
I reached out to Jessica L. McKinney, PT, MS. She helps women with pelvic floor issues, and is the co-founder and Director of The Center for Women’s Health at Marathon Physical Therapy & Sports Medicine, LLC and Executive Director of The Women’s ACTION Initiative. Since many women worry about the reactions they might get from medical professionals, I asked her, “What goes through your mind when a woman tells you that sex is painful, or that she leaks? Do you ever judge her situation or right to be concerned?” Her response? “Not at all!!! I think, ‘Thank goodness you came in to see us! My goal is to help you do anything you want to do sexually. You’re putting trust in us, and there’s no room for judgment - period. We feel so strongly that you should not be ashamed for wanting this part of your body to work. Why should an ankle sprain get tended to, but not this? We understand how this can be embarrassing, AND you deserve to attend to it.”
Professionals like Jessica who specialize in this area of sensitive women’s health issues have the knowledge and empathy needed to help women become strong, empowered, and informed about their pelvic health.
Different Causes There are many different factors that can lead to pain or leakage. “For some women a bad bladder or yeast infection may lead to temporary pain with sex,” Jessica said, “Someone else may have had long standing back pain which ultimately created enough changes in her muscles and body alignment that she develops pain within the pelvis, which then may or may not also cause painful sex.” Finding the cause and appropriate solution is something Jessica experienced first-hand, and she is passionate about helping others. “I care so much. If I didn't, I wouldn't do what I do,” Jessica said.
When Did the Pain Start? For some women, pain during sex is new. For other’s it’s something they've always experienced. “They heard that ‘the first time’ can be painful, so they didn't question it, even when the pain didn't go away,” said Jessica. She helps women demystify and understand their pain – what triggers it, what likely caused it, and how they can help get it under control. Due to the rapid and dramatic hormonal and structural changes associated with each timeframe, a common time to experience pain and leakage is after childbirth or during menopause. However, it’s not the only time. Younger women and those who have never had children can experience it too. Seeking help from a qualified medical professional is an important step toward getting it under control.
Childbirth Many women come in to see Jessica when their youngest is around five or six years old and say they've noticed changes “down there”. In some cases, painful scar tissue is part of the cause, such as from a perineal tear or episiotomy that is healed but still tight and painful when stretched. Tightness in the muscles of the pelvic floor can develop for a number of reasons and can frequently be a source of pain. “We use manual techniques to get those muscles to loosen up, and provide awareness exercises to give women more mobility and relief,” she said. When they finally seek help, they ask, “You mean I’m not crazy?” Jessica often tells them, “Absolutely not! You've got weakness, tightness, or imbalance of your muscles and connective tissues and we just need to address those things.”
During Menopause Hormonal and tissue changes are common during menopause. “If pain begins around that time in life, it may be due to a loss of elasticity and fullness in the tissue and less lubrication. Changes in sexual desire are also common,” Jessica explained. Seeing a menopause specialist can help you select the best approach for managing it. Options may include local hormone replacement (applied directly in the vagina) or alternative therapies such as acupuncture or nutritional modifications. Vaginal dryness specifically can be an irritating condition and can also be a cause of painful sex. Jessica agrees with specialists who insist that every single woman should use lubricant and also recommends the use of a vaginal moisturizer. She says, “The use of a lubricant is important for virtually all women. It should be readily available and used without embarrassment for sexual activity.”
Structural Changes Symptoms of uncomfortable heaviness or pressure in the pelvic area are often associated with structural changes in the pelvic support system leading to pelvic organ prolapse. Jessica encourages women to speak with a physician soon after they notice such symptoms because, “Prolapse is not something that goes away like a cold or a sprain. It’s a structural change, a mechanical issue” she said. “Think about a car that’s making a suspicious noise, but it’s still running. You take it to the shop to get it checked out because you know that noise is an indicator of an issue somewhere in the system and it won’t resolve itself by ignoring it.” You and your doctor may choose to do nothing and just monitor a prolapse over time, or may choose a conservative intervention, such as a pessary – a small device that acts like a little brace inside the vagina. It comes in different sizes and provides support where you’re lacking support. “It doesn't fix a prolapse,” Jessica said, “but may keep it from getting worse. In certain circumstances surgery may be recommended.” Physical therapy is also a good option for women who experience pelvic organ prolapse. “A pelvic floor physical therapist reviews the habits you've formed over the years that may be affecting your bladder and other pelvic organs – habits like the way you pick up a child, carry your laundry, or lift your groceries,” said Jessica. A pelvic floor physical therapist will review the way you exercise, when you’re leaking, and anything you may be doing that puts you at risk of the prolapse progressing, so you can take some ownership and rein it in. If sex is uncomfortable due to a prolapse, Jessica suggests that gravity-diminishing positions may be helpful (such as using pillows under the hips to place the pelvis higher than the abdomen, for example).
Emotional Pain Physical pain can lead to emotional pain. “These symptoms aren't in your head, but they can get in your head,” said Jessica, “Experiencing leaks and pain during sex can challenge a woman’s identity and feelings of self-worth.” When women have painful experiences, they may start anticipating pain. The anticipation alone can cause muscles to tighten, creating physical pain.
Calm Down the Pain Response So what can you do if you’re experiencing pain? “It helps to choose a position that allows you to control speed and depth of penetration (if engaged in penetrative sexual activity). You can also use mechanical massage devices to help desensitize the tissues and calm down the pain response,” said Jessica, “They also can be helpful to explore your boundaries (for pain free sexual activity) on your own and there’s no partner to disappoint if it doesn't work.” Jessica also recommends behavior changes, like agreeing ahead of time to only go to “1st base” with a partner on a particular occasion, or otherwise taking any foreplay and sexual activity slowly and gingerly. Being able to relax and able to feel more in control of the situation will help in controlling and responding to the pain.
Be persistent The most important thing Jessica wants women to know is this - It’s never okay to accept that sex has to be painful. You shouldn't have to grin and bear it. It should feel good for you, too. If you approach a doctor who doesn't have answers for you, request a referral. Ask to see a pelvic floor physical therapist, a urogynocologist, vulvovaginal specialist, or nurse practitioner who specializes in pelvic health issues. By being persistent, you’ll find the resources you need to begin enjoying your intimate relationships.
What about you? Have you sought the help of a pelvic floor specialist?