The PG Spot - Breaking the Silence on Painful Sex

In this episode, we'll explore the physical, emotional, and psychological layers of this experience, bust some harmful myths, and talk about how to start advocating for your body and pleasure.  Whether you're personally impacted or supporting someone who is, you'll walk away from this episode with insight, validation, and real tools for healing. 

Let's get into it!

Some resources that are mentioned in today's episode include:

International Pelvic Pain Society - IPPS - https://www.pelvicpain.org

International Society for the Study of Women's Sexual Health - ISSWSH - https://www/isswsh.org

Herman & Wallace Pelvic Rehabilitation - https://hermanwallace.com

American Association of Sexuality Educators, Counselors and Therapists - AASECT - https://www.aasect.org

Books:  

Come As You Are - by Emily Nagoski

You Are Not Broken - by Dr. Kelly Casperson

Sex Without Pain - by Heather Jeffcoat

Healing Painful Sex - by Dr. Deborah Coady and Nancy Fish

Pure - by Linda Kay Klein

If you want to learn more about sexual health, sexual dysfunction, or how to improve your sex life, follow me on Instagram at @thepgspot or check out my website at doctorpattyj.com for blogs and resources related to sex positivity and real talk about sexuality.  As as always, stay curious, stay empowered, and stay you.

Transcript

Speaker 0:08

Welcome to the PG spot, where our goal is to take the X out of sex by breaking down the barriers that prevent open communication about sexual health. I'm Dr. Patty Jalomo, a dual certified nurse practitioner, pelvic floor therapist, and certified sexual counselor. I'm here to provide expert insights, debunk myths, and empower you to embrace your sexual wellbeing. Whether you're looking for answers or simply curious, join us as we open up the conversation around sex, intimacy and everything in between. I want to take this opportunity to acknowledge that some content may not be appropriate for all listeners. I'm a huge proponent of honest and accurate information regarding sexuality. But I'm also mindful that this should be age appropriate. Therefore, if you are under 18, this may not be the podcast for you. Additionally, some of the language used in this podcast may be offensive to some listeners. Please take these things into consideration before going forward with your consensual participation in this podcast. The opinions expressed by myself or my guests are just that, and these opinions are neither expected or required to be shared by all listeners. The information that is provided is for educational and entertainment purposes only, and should not be mistaken for individual medical advice if you do find the information that we cover in the PG spot. Helpful. Interesting or informative. Please rate and review the podcast wherever you're listening from. If you think this information is important, I would love for you to share it with your friends or family. This is a great way to get the information out to more people. So thank you for listening and let's get on with the show.

Patty 1:48

Hey everybody. Welcome to the show. Today we are diving into an important but often overlooked sexual health issue, and that is pain with sex, also known as dyspareunia. Did you know that three in four people with vaginas will experience painful sex at some point, yet less than half will ever talk to a healthcare provider about it. In fact, a 2019 study that was published in Obstetrics and Gynecology found that only 25% of women who experienced pain during sex ever sought medical advice. So today I wanna break the silence, share some insights from my clinical practice, talk about possible causes. Offer some guidance for healing. This episode is all about empowerment, education, and support, and most of all, letting you know that you are not alone. So let's get into it. So let's start with defining the problem. Pain with sex. It's more than just discomfort. It can be life altering. It impacts relationships, self-identity, feelings of self-worth, confidence and emotional wellbeing. The medical term is dyspareunia, which refers to pain during and after intercourse. So this could be broken down into several different categories and we'll discuss those. The first one relates to the onset of the pain. Is it primary versus secondary? So primary would be those patients who have always had pain with any kind of penetration. I may ask a patient, have you had this pain with other partners or have you ever been able to use tampons? Oftentimes patients will express that it's always been difficult to have penetration. Maybe they tried, to use tampons when they first started having their menstrual cycles and found that it was difficult to insert the tampons and this could cause some trauma that then they carry on throughout their life. Oftentimes they don't ever try again. And so this would be an example of primary dyspareunia, whereas secondary dyspareunia is a situation where they've been able to have pain-free intercourse or penetration. Previously, but now for some reason they're experiencing pain. This could be related to things like vaginal atrophy or thinning of the vaginal tissue. That can happen in menopause, perimenopause, even with breastfeeding or people on birth control pills. It could be related to other scar tissue or physical, irritation, infection problems with the tissue. So we'll talk more about that later in the podcast. It can also be situational versus generalized. So is this with every partner? Is it positional? Does lubrication help? Those are some questions that might help to determine whether this is something that happens. Just with certain partners or if this is a general problem that happens all the time. so these details matter and they really can point us toward the right treatment path. So let's talk about some of the physical contributors to painful sex. I mentioned vaginal dryness that can occur with menopause, so this is due to reduced estrogen in the vaginal tissues. The vagina, the urethra, the bladder. These areas are all very estrogen dependent, so they have a lot of estrogen receptors, and when our ovaries stop producing estrogen, such as slowing down during perimenopause and then completely stopping after menopause, this then can lead to a lack of estrogen in the tissues. Which causes dryness. It can cause the vagina to lose that elasticity. There can be changes in the pH, so we may be more apt to get vaginal infections. Certainly an increased risk of urinary tract infections, and so it really just makes that tissue much. Less healthy, and that can oftentimes be a cause of pain with initial penetration. When I see women, especially menopausal women, or those who are on birth control pills or even breastfeeding, Those are some other situations that may cause that pain with initial penetration. So vaginal atrophy or vaginal dryness in menopause is also known as genital urinary syndrome of menopause. And treatment of that is fairly simple, just really replacing the estrogen in the vaginal tissues. There are several different options for vaginal estrogen replacement. there are options of vaginal tablets that are inserted a couple times a week called Vfe or UFM. There are les called vei that can be inserted twice weekly to provide estrogen to the vaginal tissues. There's also suppositories of DHEA, which is a precursor to estrogen and testosterone called intrarosa that is used nightly. There are vaginal rings, something called the estring that is inserted vaginally and changed out every three months, but probably the easiest and most cost effective option is simply a vaginal estrogen cream. The reason I really like the creams is that you can just use a little bit on your finger and you can put the cream in the. Areas that really need the estrogen, such as, uh, right around the opening of the vagina, the urethra, the clitoris, and just rub this in every night, just like you're moisturizing your face, but just providing that estrogen to the vaginal tissue. So for many women that have pain with penetration due to menopause or vaginal tissues, this extra estrogen in the vagina in itself can take care of that issue. the vaginal dryness can also be helped with simply using a lubricant during penetration. And I feel like lubricants really get a bad wrap. I think that if we just took that stigma away from lubricants and just used. A lubricant. Every time we had penetration with a toy or a penis or anything else, it would just become much more common. We wouldn't even think about it. and I think that sex would be much more enjoyable all the way around. So there's different types of lubricants. the two main common ones are silicone based lubricants and water based. Now, I typically prefer silicone lubes just because they don't get that tacky feeling. They have a nice texture. It doesn't dry up quickly as opposed to water-based You have to use it more often just because it will dry up some. Now I typically don't recommend oil-based lubricants. or things like coconut oil, Vaseline. Petroleum based products just because number one, they can break down latex if fused with condoms. And secondly Sometimes they can increase the risk of vaginal infections just by, affecting the pH of the vagina. So usually a silicone based lubricant is what I would recommend. the one issue with silicone based lubes is that you technically shouldn't use them with. Silicone toys, they could break down that silicone surface. Usually if you wash your toys right after use, I don't see that being a big issue. So let's look at some other physical causes of dyspareunia. Scar tissue, whether that's related to birth trauma surgery, this can be an issue because again, when you have that tight scar tissue, it affects the elasticity of the vaginal tissue, and that can be a cause of pain. Um, cancer patients' radiation. I often see scar tissue being an issue. For those patients. other skin conditions. So something like, lichen sclerosis, for example. this is a dermatologic, skin condition that causes the tissue to be very itchy. And then when women scratch a lot, and a lot of times women will scratch at night when they're sleeping without even realizing it. But over time, that can develop into more of that thick, scarred tissue. So this is a condition that is usually treated with a steroid ointment, such as clobetasol. But this would be another reason why it's important for women to. Be having yearly checkups and whether they need a pap smear or not. It's important to have somebody looking at the vulva and at the vaginal tissue Just to be sure there isn't any issues like lichen sclerosis That could potentially lead to vulvar cancer as well. other physical causes might be infections, so yeast infections, bacterial vaginosis, uh, sexually transmitted infections. Any of those things can cause pain with penetration. So this is something that, can simply be ruled out with a culture. other physical causes may be something like endometriosis or interstitial cystitis. So these are more chronic pelvic pain issues. So endometriosis is. Basically where the endometrium or the uterine lining that tissue grows outside of the uterus. So somehow, and there's a lot that we don't know yet about endometriosis, but somehow this tissue gets deposited outside the uterus and In normal functioning endometrial tissue, it changes as our hormones change throughout our cycle. So, for example, estrogen tends to cause the endometrium or the lining of the uterus to thicken in preparation for pregnancy. so that if there is a pregnancy, it has a nice rich area to attach, then we ovulate and have a rise in progesterone for 10 to 12 days or so. And then if there's no pregnancy. Our body has a period and that tissue sloughs off and bleeds. So with endometriosis, if you have that tissue outside the uterus, it's going to, proliferate and to get thicker and then start to bleed. And that fluid outside of the uterine space can cause some pain. So endometriosis is, pretty common and unfortunately the most accurate way to diagnose endometriosis is through a. Diagnostic laparoscopy or a surgical procedure. So it's not uncommon for women to see multiple providers before they actually end up with an accurate diagnosis and have this treated, but it can cause that chronic pain in the pelvis and over time, that pain causes the pelvic floor muscles to become very, tight and hypertonic. So. Chronic pelvic pain can definitely lead to pain with intercourse. Interstitial cystitis is more of a chronic bladder pain. This is a diagnosis of exclusion. So oftentimes people who have interstitial cystitis can have. Symptoms that are very similar to urinary tract infections. They may have urinary frequency, painful urination. they may have urgency, feel like they have to rush to get to the bathroom, and then they go in to their provider and leave a urine sample, maybe, hopefully get a culture and find that there's no infection. So this, chronic bladder pain can also cause. This high tone or tension in the pelvic floor muscles, and that can be related to pain with intercourse. And so we'll talk about that, again in a little more detail when we talk about vaginismus and pelvic floor dysfunction. So all of these things can trigger, that chronic pain cycle that causes this high tone in the pelvic floor muscles And can make intercourse more painful and this can worsen over time. Okay, so speaking of pelvic floor dysfunction, let's take a minute to talk about that. So, pelvic floor dysfunction can be a big contributor to painful sex, and this is when the muscles in the pelvic floor are hypertonic or too tight, causing. Painful penetration. I mentioned vaginismus. Um, vaginismus is when the pelvic floor muscles contract involuntarily, and this can make penetration not only painful, but oftentimes impossible. our muscles are there to protect us from pain, and oftentimes when a woman has pain with penetration, whether it is from a tampon or from a menopausal vaginal dryness, or just a situation where they have penetration too soon and their body's not ready for that and it causes pain, then the muscles in the pelvic floor tend to remember that pain And they may tighten up just in anticipation of penetration. So oftentimes in my practice, If I'm seeing a patient with Vaginismus, it may be a situation where her and her partner have been married for a long time and they've never actually even been able to have penetrative intercourse. So I use technology, something called EMG or electromyography. to really get a look at what the pelvic floor muscles are doing. with vaginismus I'll use external sensors, Similar to when you are looking at the heart muscle getting an EKG, you use these little sticky sensors. It picks up the electrical activity of the heart, and puts it on the computer screen so you can see that the same thing is true with muscles in the pelvic floor or other skeletal muscle using something called EMG or electromyography. So I would use two small sticky sensors. externally that can pick up that electrical activity and put it on the computer screen so the patient can see where their baseline muscle function is. I might then ask them to contract the muscles so they can see it go up and then have them relax and I wanna see if they are. Able to actively relax the muscles or if it just goes back down to baseline. So working with patients to actively down train the muscles or learn how to actively relax the pelvic floor muscles, can be very helpful with chronic pain, but also with vaginismus, the goal is to be able to have something inside the vagina. And not have those muscles contract. And one of the ways that we do that is with dilator therapy. So dilator therapy is not simply just stretching the tissue or stretching the vagina out. Oftentimes people think that using dilators where you start with a very, small dilator and then you just gradually insert to larger. dilators that it's really about stretching the tissue, but really it's more about retraining the muscles, that it's okay to have something there and they don't have to get tight. So. I find that it's difficult to do that if you don't actually know how to actively relax the muscle, and so that's where EMG or some biofeedback can be very helpful prior to just starting dilator therapy on your own. it's interesting because oftentimes. I'll have them on the monitor and they can be watching their baseline tension, and I'll take the smallest dilator and just start to barely move the drape. And you can see that muscle tension just rising, just from that anticipation that something's going to be coming close to the vagina or that they're gonna have any kind of penetration. Now, obviously, I would never insert anything in anyone's vagina without their consent. Usually I would just let them insert the dilator. But it's very interesting for them to see when I just move that drape, how that causes that tension to rise without. Them actively doing it themselves. So it can be powerful for them to see that, hey, I am not trying to tighten this muscle. It's just happening on its own. So that's where using EMG for or biofeedback for dilator therapy can be very helpful. Other techniques that can be helpful for, hypertonic pelvic floor muscles that might be done in, pelvic floor therapy or with a pelvic floor physical therapist would be manual techniques, scar massage, releasing that scar tissue trigger point release. tight muscles can develop trigger points that can be painful. And so, There are techniques that patients can learn to massage these trigger points out. dry needling is another technique. I'm not trained in dry needling. I don't do that, but some pelvic floor physical therapists are, So there are a lot of different modalities that can be used by pelvic floor specialists to treat hypertenicity in the pelvic floor. So pain isn't just physical, it's emotional, relational, psychological. So let's look at some of those emotional and psychological factors that contribute to pelvic pain. Research shows that women raise in environments that promote abstinence or shame around sexuality, often internalize as fear and develop significant guilt and shame around sex. This can be from religious or cultural conditioning and is common in conservative religions. Or those who were brought up in a purity culture. So purity cultures promote the idea that women are responsible for maintaining that sexual purity. I'm actually reading a book right now called Pure by Linda K. Klein. It's a great read and it discusses how the abstinence movement and conservative religions instilled shame when it comes to sexuality. It Discusses how the burden of sexual restraint is more often put on women. And because of that stigma of shame around sexuality and the lack of conversation and education, many people in this generation may enter into marriage with very little knowledge about sex, and that can be very fearful. I definitely see that in a lot of patients that I see in my practice in pelvic floor therapy where they've. never even had sex until their wedding night. And automatically they're supposed to know what to do. many patients don't even know their anatomy and they don't feel safe exploring their body. So sometimes I literally have to use a vulva puppet, and this can teach them about basic anatomy. I have to show them this is where the clitoris is, this is the labia mana, this is the G-spot, this is the vagina. so oftentimes it's just an issue of education. Also, trauma and past abuse can be very significant in women with Dyspareunia or Vaginismus. In a 2021 systematic review and meta-analysis that was published in the Journal of Sexual Medicine, it found that women with a history of sexual abuse had a 1.53 times higher likelihood of experiencing dyspareunia than nose without a history. So. There's definitely a link between those things. However, not everyone who has vaginismus or Dyspareunia has experienced sexual trauma or abuse. So let's talk about taking action and seeking support. So what can the patient do? One thing I think is very important is to track the symptoms. So keeping a pain journal to keep track of when the pain occurs is important. It is important to know, is this something that happens all the time? Does it change with your menstrual cycle? Where are you having the pain? Is it just at the opening of the vagina? Is it with initial penetration? Is it deeper in the deeper pelvic floor muscles? Is it positional? All of those things are important to know when you're talking with a provider and trying to rule out what the root of the problem is. So looking for providers, you want to try to find providers who are trauma informed, who collaborate with other therapists or pelvic floor physical therapists, and who take your concerns seriously. you can always set up a visit just to go in and discuss those things with your provider. some of the questions that you might want to ask would be things like. How do you approach treatment for painful sex or for pelvic pain? Do you coordinate care with physical therapy or mental health providers? You might ask if they have experience working with patients who have a history of sexual trauma or sexual shame. Those are all important and appropriate questions that you can ask your provider while you're advocating for yourself and. Also using social media or support groups. joining communities online on social media can be helpful. A lot of times just knowing that there are other people that are experiencing the same thing, that you're not alone in this, that is quite common. those things can be very helpful, when you're going through this healing journey. So how do you find trauma informed providers or providers that are educated on and knowledgeable about painful intercourse or pelvic health issues? One way is to look in provider directories. So a lot of the societies or professional organizations have directories that would list. Providers in your area That are specialized in pelvic floor dysfunction or pelvic pain. The International Pelvic Pain Society is an example of a professional organization. There's also isw, which is the International Society for the Study of Women's Sexual Health. If you are looking for pelvic floor therapists or pelvic floor physical therapists, Herman and Wallace Institute is a great place to find trained therapists. BCIA, which is the Biofeedback Certification International Alliance. That is where I got certified as a specialist in pelvic muscle dysfunction. They have a list on their website of providers also as act or the American Association of Sexuality Educator Counselors and Therapists is a great place to find sex positive counselors and therapists that are well-trained and used to working with patients with sexual trauma. or just that are open to talk about sexual function. The Menopause Society is a great place to find menopause experts, People that are knowledgeable about treating genital urinary syndrome of menopause. Um, and then Psychology Today also is a great place to find trauma informed mental health professionals. So these are all great ways to find the providers and to get the help that you need. Another important thing to remember is that painful sex affects both people in a relationship. So it's really important to have communication with your partners open. Shame-free communication is essential, so if you're unsure how to talk about it, you could always check out some of my blog posts on my website. And that is@drpattyj.com, and that's spelled out D-O-C-T-O-R-P-A-T-T-Y j.com. I have several blog posts about communicating in relationships, and I also have, some on painful intercourse or, painful sex. So check those blogs out. So let's talk about treatment options again And just know that the treatment varies based on the cause. so some treatments may include vaginal estrogen therapy as we discussed dilator therapy. And again, I would encourage. an evaluation with a specialist first and learning how to actively relax the pelvic floor muscles to find out if dilator therapy is going to be helpful for you. Um, pelvic floor physical therapy or a pelvic floor therapist. There's also somatic or body-based therapies, so somatic therapists work with touch and can oftentimes be helpful for patients who have grown up With sexual shame in a conservative religion, somatic therapy can help people become more comfortable with their bodies. And so these types of therapists, have specialized training in this. So can be an important part of the solution. Um, also just looking into trauma informed sex education. Again, Looking at that ASEC website to find certified therapists, counselors, and educators. That can be a, a great resource and looking into mindfulness or mindfulness practices that can help to decrease stress. Encourage muscle relaxation, that can be helpful. So just remember, healing takes time and compassion. I have been working with patients for the past 20 years who have struggled with dyspareunia and vaginismus painful intercourse. I've seen patients go from zero penetration to pregnancy after treatment. So it certainly is something that can be treated. You can heal, but you just really have to. Be compassionate with yourself. Know that you're not broken, you're not alone. And realize that painful sex is not something that you just have to live with. So be patient Healing is a journey. It's not a race. And having a supportive partner can make all the difference. So again, the resources that I mentioned above the websites, I'll put those in the show notes. There are also some excellent books that, Can be helpful Come As You Are is a book by Emily Naski, and this is a great book that helps to really prioritize pleasure. you are not broken by Dr. Kelly Casperson, sex Without Pain by Heather, Jeff Coat and Healing Painful Sex by Dr. Deborah. Cody and Nancy Fish are some great resources. So again, I'll put those in the show notes and links to the directories and websites that can be helpful. So thanks for listening. If this episode helped you, please share it with a friend or leave a review. And remember, you deserve pain-free, pleasurable intimacy always. so until next time, stay curious, stay empowered, and stay you.

Speaker 26:36

That's it for today's episode. Thanks for listening, and be sure to rate and review the podcast on whatever platform you're listening from and share it with your friends. That's a great way to help reach new listeners and make this a more sex positive world. Also, I'd love your feedback and questions, so send me a message. It's at email@doctorrpattyj.com, and that's doctor spelled out, D-O-C-T-O-R-P-A-T-T-Y-J.com. Until next time, stay curious, stay empowered, and stay you.