If sex is painful, you have options

There are lots of reasons women may experience pain during or after sex. Whether you've just given birth, are experiencing hormonal changes, or are under a lot of stress, you have options to address the pain. In this episode of Life Kit, reporter Andee Tagle talks to pelvic floor physical therapist Janelle Frederick about how to communicate with sex partners about it, when to see a doctor or physical therapist and what exercises you can try at home to relieve the pain. Follow us on Instagram: @nprlifekit https://www.instagram.com/nprlifekit/?hl=en Sign up for our newsletter here. https://www.npr.org/newsletter/life-kit Have an episode idea or feedback you want to share? Email us at [email protected] mailto:[email protected] Support public media with NPR+ and enjoy perks for over 25 podcasts like this one. This show’s perks include sponsor-free listening and convenient playlists of popular help topics like personal finance, getting healthy, and more. Learn more at plus.npr.org http://plus.npr.org/. See pcm.adswizz.com https://pcm.adswizz.com for information about our collection and use of personal data for sponsorship and to manage your podcast sponsorship preferences. NPR Privacy Policy https://www.npr.org/about-npr/179878450/privacy-policy

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:01Speaker 00

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• 0:24Speaker 01

  Is painful sex normal?

• 0:25Speaker 02

  It's never normal, but there are times in life when it is more common. But painful sex is always a sign that there is something going on that needs more attention.

• 0:37Marielle Segarra?

  Hey, it's Marielle. You're listening to Life Kit. And you just heard a little bit from a conversation that reporter Andy Tagle had with Janelle Frederick. She's a pelvic floor physical therapist who specializes in care for painful sex. And she says there are a lot of reasons why you might be hurting: stress, menopause, childbirth.

• 0:57Speaker 02

  But we should not be seeing prolonged pain with intercourse or with any type of intimacy. Even arousal can sometimes be painful. And a lot of people have pain after sex, too. All of those things are not normal, even on your first time. So this is definitely a discussion that we need to start having more and more often because there's millions of couples and women and people living with the pain because of either shame or they think that it is normal.

• 1:27Marielle Segarra?

  Of course, this is a hard topic for a lot of us to talk about.

• 1:30Speaker 02

  You know, I think because we are people who typically assume sex is just perfect and normal. We grew up seeing videos of people coming home from a date and getting thrown against the wall, and you just like rip their pants off and they're having sex. You don't see sexual dysfunction normalized in society. And while it is a really common problem, we don't see it talked about. A lot of people feel guilty, even though it's not your fault. It's not one's fault. This is a medical condition, just like any other condition, like endometriosis or fibroids or, you know, menopause.

• 2:12Speaker 02

  It happens, and there is help, and there's no shame.

• 2:17Marielle Segarra?

  On this episode of Life Kit, what to do when sex is painful. Andy and Janelle talk about how to communicate with your sex partners, when to see a doctor or PT, and what exercises you can try at home to relieve the pain.

• 2:35Speaker 01

  Take away one: don't suffer in silence. Sex should not be painful, not just before, or during, or after penetration. So if you're experiencing stinging upon entry, or aching pain in the moment, or cramping afterwards, your body is trying to tell you something. And you need to speak up about it.

• 3:02Speaker 01

  For people who have a hard time talking about this topic with their partner, do you have any helpful starters for us?

• 3:08Speaker 02

  Yeah, I would say definitely bringing it up outside of the actual act. I think people are more inclined to hear and process when those sexual hormones are not raging. And so having a conversation while cuddling in bed, or while going on a walk, or, you know, on a long commute, you know, saying, hey, is it OK if we talk about intimacy at this time? So it's like a planned conversation where you're saying, you know, after dinner tonight, I want to tell you a bit more about intimacy and how I've been feeling. And then letting them know, you know, I love being intimate with you, if you do. Don't lie.

• 3:51Speaker 02

  If you do love being intimate with them, letting them know, I've been feeling pain that is making it difficult for me to enjoy the moment. You can even be a little bit more descriptive. It feels like sharp pain, or I feel burning during penetration. And I haven't been able to forget about it, or I haven't been able to breathe through it, or whatever. And I want to know if we can explore some other options while I start working on this, or while I seek support for this, because it's making it difficult for me to enjoy intimacy, and I don't want to give up intimacy. So I think that's a good way to put it. If you do want to remain intimate with this person, but you're also acknowledging your

• 4:35Speaker 02

  body and the needs that your body has, your partner for sure needs to know about it.

• 4:40Speaker 01

  It sounds like any other, starting off with any other conversation you might have as a couple, you know? You don't want to have a hard-money conversation when you're in the middle of paying your bills. You don't want to have a hard parenting conversation when your kid is having a tantrum.

• 4:56Speaker 02

  Exactly. I 100% agree, just because you want the other person to have the highest likelihood of actually being receptive. And also, you want to have that space, too. You want to be in a clear frame of mind. And I think during sex, you may feel a pressure to like, oh, I want to please them, because it's already started, it's hot and steamy. But when you're having a conversation and sex is not actively happening, you can think more clearly. I would even suggest even asking your partner, how do you think we can work through this? You're giving your partner an opportunity to join you on that healing path and not feel like this is something you have to fix all alone. This is your fault.

• 5:40Speaker 02

  You're messing up the relationship. But this is something that you tackle together.

• 5:44Speaker 01

  On that note, if not everyone has a partner, if you're dating, if you have a new sexual partner, what does that conversation sound like? You know, I feel like that might be nerve-wracking for someone. How do you start that?

• 5:55Speaker 02

  So I think, to me, timing is most important for that. Meaning, I personally wouldn't bring it up on the first date. I wouldn't be like, hey, my name is Janelle, and I can't have penetration. Hi, my name is Janelle, and sex hurts. Hold on. Like, I wouldn't bring it up on day one, because the same way, they're not going to bring up their childhood traumas on day one. You know, we're not bringing our heaviest things to the table first thing. So I think, like, first establishing, does this person seem like a respectful person? Do they respect me? Do they feel genuinely interested in getting to know me?

• 6:34Speaker 02

  But I would say, as you feel it moving towards a more physical nature, that I would bring up, hey, I want to let you know that I do struggle with pelvic pain. And how that impacts me is, it makes it very painful for me to experience insertion. And I think it's important to zoom out and say, OK, yes, I'm having pain during sex, but bigger than that, I have pain in my pelvis. It's not just the sex itself. And I think if we frame it that way when we're talking to our partners, I carry pelvic pain. And maybe this shows up with pelvic exams. Or maybe if I sit for a long time, I have pelvic pain.

• 7:18Speaker 02

  Also, when I have intercourse, I feel burning, sharp pain, or whatever it is you're feeling. So that your partner understands, no, it's not just you being scared of sex, or, you know, needing a ton of time with sex, or whatever they think it is. This is a medical condition that is impacting my sex life. And be honest with where you are in that healing journey. So I think most partners want to know that this is something you're working through. If they're not the person for you, then you move on. There are so many people, again, who are willing to walk with you on this journey of life, which includes medical issues.

• 7:58Speaker 01

  And to be clear, experiencing persistent or recurring pain during sexual intercourse is a medical issue. There's even a medical term for it: dyspareunia. It's a condition that can affect any sexually active person, because we all have a pelvic floor. But it's most common in women, or people with vulvas. It's hard to say exactly how common. One recent report said anywhere from 8% to 56% of women and an unknown number of gender-expansive people have suffered from dyspareunia at some point in their lifetime. Another report says 3 out of 4 women will experience pain during sex at some point

• 8:42Speaker 01

  in their lives. The good news: it's a condition that's often very treatable, if not fully solvable, for a lot of people. But it can also be a bit hard to pin down, because...

• 8:55Speaker 02

  There are multiple medical conditions that can cause painful sex.

• 9:01Speaker 01

  And unsurprisingly, the cause of your pain will determine the best way forward. More Life Kit after the break.

• 9:13Marielle Segarra?

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• 10:05Speaker 06

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• 10:31Speaker 01

  Takeaway two, pain during sex can come from a lot of different places. And so can the corresponding treatment. Top recommendation here, set up an appointment with your primary care provider or your OB-GYN to get a diagnosis, especially if you're experiencing things like bleeding, new or worsening pain during intercourse, or other irregularities like abnormal discharge, lesions on your genitals, or irregular periods. At your visit, your doctor might ask you where you're experiencing pain, and how often, what the pain feels like, and how long you've been dealing with it for. And based on those answers, they might ask to perform a pelvic or erectile exam, collect

• 11:15Speaker 01

  samples of bodily fluids for testing, or do something like a transvaginal ultrasound.

• 11:20Speaker 02

  But we can also try and sort of take things off of the list that we can rule out.

• 11:25Speaker 01

  Because some root causes are easier to spot and easier to fix than others. Sometimes the solution could be as simple as avoiding certain sexual positions, for example. Or if you suffer from pain upon entry, it's possible you might just need to use more lubrication. But it's also possible you have an underlying condition that's causing that vaginal dryness.

• 11:48Speaker 02

  We want to look at hormones. So am I going through menopause? Or am I on medications or on birth control that could be blocking how my body produces testosterone and estrogen, which is really important for lubrication and sexual function overall? So let's say you've been on birth control for like 15 years, and you've noticed that sex is painful. That is actually shown by research to contribute to painful sex. So we can consider exploring other options that may allow your body to produce its natural level of sex hormones. So hormones is a big one that could potentially be leading to painful sex if there's a depletion. Okay? And for menopause, we would want to get on some hormonal support.

• 12:33Speaker 01

  For others, insertion might be so painful, it's not even possible. There are a handful of different conditions that are commonly at work in that scenario. One is called vaginismus. In this case, the muscles around the vagina involuntarily contract or spasm.

• 12:50Speaker 02

  Vaginismus is a condition that can prevent all types of insertion, not just intercourse, but pelvic exams, tampons, finger insertion, anything that you would typically need vaginal insertion for. Vaginismus can cause severe muscle tension, tightness, and pain that can make insertion so painful, and obviously, relationships and intimacy as well.

• 13:11Speaker 01

  The next is called vulvodynia, or chronic vulva pain.

• 13:16Speaker 02

  Which is like the burning, the stinging, the pain on the outside. Either the opening, the clitoris, or even the labia can get painful.

• 13:23Speaker 01

  And a final common category is infections, like UTIs, yeast infections, or sexually transmitted infections. For all of these, there's likely a corresponding medicine. And some of those might be quick fixes.

• 13:37Speaker 02

  So medications that can relax the muscles, medications that can sort of calm the nerves from driving like that sharp shooting pain. So your doctor would help you through figuring out what would be appropriate.

• 13:49Speaker 01

  If you're dealing with deep pain or pain after the fact, that could potentially be related to other bodily systems or other underlying conditions.

• 13:58Speaker 02

  So if you're dealing with painful sex, and you know that you have severe endometriosis or fibroids, or something going on with your cervix, maybe an abnormal pap smear, then we want to make sure, are we taking care of that problem?

• 14:13Speaker 01

  If none of these things sound familiar, it's possible the fix you're looking for is in the brain-body connection category.

• 14:20Speaker 02

  Mental health. So let's say you're just going through a really tough time, and you're depressed. Depression can contribute to pelvic floor tension, anxiety. If you have been abused sexually, that risk goes up significantly for painful sex and/or vaginismus. If there's been trauma or just really hard transitions in your life that haven't really been addressed or processed, then mental health alone literally could be driving someone's pelvic pain.

• 14:52Speaker 01

  In this case, the right treatment might look like seeking out a therapist or counselor to work through the emotional side, in addition to someone like Janelle, who can provide physical support to your pain, AKA...

• 15:04Speaker 02

  Pelvic floor. So a very non-invasive option, where we go in, we start retraining that pelvic floor, we're reducing pain, we're showing you how to breathe, we're showing you how to actually relax your muscles and not tighten them. Pelvic floor physical therapy is definitely an option that should be explored more whenever pain is happening with sex, because there's high rates of success with it, and it's such a non-invasive option for care.

• 15:31Speaker 01

  After the break, how pelvic floor therapy practices can help reduce pain in your sex life.

• 15:40Speaker 07

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• 16:23Speaker 07

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• 16:28Speaker 01

  You're listening to Life Kit, and it's time for takeaway three. If your sex life's a pain, it's probably not a bad idea to pay more attention to your pelvic floor. So when someone gets to a pelvic floor PT, what are some of the common treatments? What can you expect?

• 16:43Speaker 02

  Sure. So first thing is it's going to be like a long conversation. You're going to get asked the most questions you've ever had about your poop, your pee, your sex life, your pelvis in general. It's not going to be just sex, because the muscles that help support your pelvis deal with more than just sex. So they're going to gather your information, your medical history, what you're dealing with, and what your goals are. And then you can expect an examination. So this may actually include an internal pelvic floor muscle exam. Before they get to that internal, they'll look at your posture. They may check your hip strength. They may look at your core muscles. They may look at your sacrum and your low back. So they'll be screening the muscles, the ligaments, the tissues that interact with your pelvic floor.

• 17:28Speaker 02

  And then you may lay on a table, very similar to how you do when you go to see an OB-GYN. So you'll get on a table, obviously, they'll glove up a finger. And this is all only with consent, and it's with forewarning. If you agree to it, it is an internal pelvic floor muscle exam. So they're actually assessing the muscles internally to see, how do these muscles feel? Do they feel stiff or guarded? Or do they feel lax and loose? Do they feel weak? So they do the testing of strength, endurance, coordination. Can you coordinate your pelvic floor contraction with your breath? Do you know how to push out correctly, like for pooping or giving birth? And they'll be able to feel where your pain is coming from, essentially.

• 18:14Speaker 02

  After that initial assessment, then we'll start thinking through intervention. So we're going to use movement and exercises. We call it therapeutic exercises. We're going to use manual therapy to not just test the muscles, but now we're going to be releasing them. So that may look like trigger point release with a finger. That may look like massage, external massage. It could also be like neuromuscular education. So things like your posture, or even biofeedback. So those are, I would say, the primary interventions that we use.

• 18:50Speaker 01

  So if you've spotted any signs of pelvic floor dysfunction, like pain during sex, of course, also, problems with urination, chronic constipation, needing to rush to the bathroom, or going very often. And this dysfunction is fairly likely, by the way. At least one in three women will experience a pelvic floor disorder in her lifetime. There are pelvic health tools you can use at home, like vaginal dilators. Those slowly stretch the pelvic floor muscles and desensitize the vaginal canal to reduce pain. One aspect of Janelle's work is helping patients with things like vaginismus use dilators

• 19:34Speaker 01

  for remote physical therapy. Janelle, if you're going through treatment with, say, a pelvic floor therapist, how long before you can expect to see relief? Is this something you'll be dealing with forever? Is it something, you know, will everyone see a solution?

• 19:48Speaker 02

  It depends. Oh, gosh. So that's the answer we all hate, but it is very true. So in our practice, we work with a lot of women who have already gone to pelvic floor physical therapy. It may have helped them somewhat, but they are not having pain-free sex. So you could go to therapy and it take six months. For someone else, it'd take a year. I will say, when the care is coming from an expert that treats this problem on a regular basis, I would be looking at a three to four month timeframe, where there should be a significant improvement. Our programs, our shortest programs are eight weeks.

• 20:32Speaker 02

  So some people are better in eight weeks. You know, that doesn't happen for everyone. But two to four months, this is not like, we're not trying to cure cancer here. We're trying to help your body do what it already wants to do. Like sex is not this foreign concept, right? So two to four months of time, we should be seeing a considerable improvement, if not, you know, full resolution, with an expert.

• 20:56Speaker 01

  Okay, that's really good to know.

• 20:58Speaker 02

  And it could take longer. And I don't want to make it seem like it can't take longer. Well, if someone has multiple problems they're dealing with, or if they're just going through a really hard time, multiple mental health issues, or you travel a lot for work, and so you have to reschedule. There's so many things that can contribute. But regular care, that's at least once a week, I do think two to four months of care should be enough to help someone at least 80%, you know, in terms of improvement.

• 21:23Speaker 01

  So takeaway four, stretch your pelvic floor muscles.

• 21:29Speaker 01

  Some pelvic floor PT tools will be specific to certain conditions, but then there are a few, Janelle says.

• 21:36Speaker 02

  That I think could help almost anyone with pelvic pain, pelvic tightness, or sexual pain. Child's pose is a very, very good one. It opens the pelvic floor. And when you're breathing deeply through your belly, it lengthens the pelvic floor. So you actually can create more space in your vagina. And obviously, that's helpful for sex, just by being in that position and deep breathing. So child's pose. Another good one is happy baby. Lay on your back. Hug your knees towards your chest and your shoulders. Open your legs. That is a really, really good one. You're going to feel like your vagina is just open to the air. So you should get a nice breeze through the pelvic floor area. Yeah.

• 22:21Speaker 02

  So that's another good one. And then literally just diaphragmatic breathing. This is sort of indirect with the pelvic floor, more targeting your nervous system. So almost everyone who struggles with painful sex has anxiety, or they get nervous before sex, or maybe they just feel like their body can't relax. And so, deep breathing, you can lay on your back, you can lay on your bed, on a yoga mat. Put your hands on top of your belly. And when you breathe in, try to slow your breath down and allow your belly to rise underneath your hand, and also on the sides of your rib cage. So if you think of your belly like a balloon, it should

• 23:04Speaker 02

  be expanding everywhere, the front, the back, even the bottom, which is the pelvic floor. Everything should be expanding as you breathe in and then slowly exhaling. Just doing that for five minutes can help calm your nervous system and turn on rest and digest, which is what we need for pleasure and sex. We can't be in fight or flight and expect to have pain-free sex, or even enjoyable sex.

• 23:30Speaker 01

  Janelle Frederick, the vagina rehab doctor. Thank you so much for your time. Any final thoughts, anything I missed?

• 23:35Speaker 02

  No, I just want everyone to like have buttery, scrumptious sex and to actually look forward to it and not dread it. And, you know, everyone deserves to be happy and have fun in their sex life. So get the help that you need. And I hope that this episode was educational and helpful for everyone listening.

• 23:54Speaker 01

  It really was. And I am the first, I'm the first person in line there. Absolutely.

• 23:58Speaker 02

  Thank you.

• 23:59Speaker 01

  Buttery and scrumptious, yes. All right, let's recap. Takeaway one, sex should not be painful before, during, or after penetration. Sensations like stinging, aching, cramping are all signals from your body that something is wrong or needs to change. Listen to it. Talk to your partner and your healthcare provider about it. Because, takeaway two, pain during sex, or the condition known as dyspareunia, can come from a lot of different places. In many cases, it's treatable, even fixable. But you have to first understand the true source of the problem. Better lubrication isn't going to solve endometriosis,

• 24:44Speaker 01

  for instance. So start with your primary care provider or an OB-GYN. Takeaway three, that said, no matter your specific ailment, it's never a bad idea to give a little more love to your pelvic floor. At least one in three women will experience a pelvic floor disorder at some point in their lifetime. And a healthy pelvic floor doesn't only contribute to a healthy sex life. It also sustains bladder and bowel control and helps stabilize your core overall. So finally, takeaway four, stretch your pelvic floor muscles regularly. It's easy to start. Just go on ahead, add a child's pose to your nightly routine.

• 25:32Marielle Segarra?

  That was reporter Andy Tagle talking to pelvic floor physical therapist Janelle Frederick. And that's our show. If you love Life Kit and you want even more, follow us on Instagram at NPR Life Kit. There you'll find videos featuring some of our favorite tips. You can find those by following at NPR Life Kit. This episode of Life Kit was produced by Claire Marie Schneider. Our digital editor is Malika Garib, and our visuals editor is CJ Riechelmann. Megan Kane is our senior supervising editor, and Lauren Gonzalez is our executive producer. Our production team also includes Margaret Serino and Sylvie Douglas. Engineering support comes from Tiffany Vera Castro. Fact checking by Andrea Lopez Cruzado. I'm Marielle Segarra. Thanks for listening.

• 26:20Speaker 07

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