painful sexCoffee and dinner conversations with my 50-something girlfriends usually revolve around what’s new with our kids, our work, our aging parents, or our mutual friends. Our sex lives? Rarely mentioned.

But judging from the few times I’ve whispered the subject to a close friend, many of them have a distressing and misunderstood condition called dyspareunia—which means they have pain before, during, or after sexual intercourse. It can range from mild to excruciating, like someone’s sliding a knife inside you. Dyspareunia can make you dread intimacy and feel embarrassed, anxious, alone, and inadequate as a partner. And it can affect your overall quality of life.

Women of any age can find that sex hurts, but roughly one-third of women who’ve reached menopause do. (Accurate numbers are tough to come by because so many suffer in silence.). Estrogen loss is a major culprit in our demographic group. Whether it happens naturally with age or suddenly from surgery or another medical treatment, decreased estrogen can make vaginal tissue become thinner and less elastic. Vaginal atrophy, as it is called, can be felt as dryness, burning, itching, irritation, and pain.

Dyspareunia has other causes, too. These include vestibulodynia (a chronic pain syndrome affecting the nerve-rich area around the vaginal opening), skin diseases in the genital area, assorted medical conditions such as cystitis or endometriosis, injury from childbirth, and emotional factors such as stress or depression. Vaginismus, another cause, is a condition in which a woman’s vaginal muscles clench up during any attempted penetration, even a routine pelvic exam. A male partner may have his own sexual issues that prolong intercourse and increase vaginal friction and discomfort.

Often, many things are at work.

Unfortunately, an estimated 40 percent of women with sexual pain don’t seek medical care, and some have trouble finding a clinician equipped to help them. Some women spend years searching for a diagnosis and treatment.

The good news—as I discovered when researching a story for a health newsletter—is that dyspareunia treatments are out there. Depending on the cause, they can include medications such as low-dose vaginal estrogen (in cream, ring, or tablet form), vaginal lubricants and moisturizers (there are many brands, so shop around), extended foreplay, relationship counseling, vulvar care like regular rinsing, and pelvic floor physical therapy.

Pelvic floor physical therapy?! I was fascinated and went to see Raquel Perlis, a registered PT in Wellesley, Mass., who specializes in treating sexual pain with physical therapy techniques to address tender, tight, or weakened vaginal and pelvic floor muscles and tissue.

“How are you? And how’s your vagina?” Perlis might ask to break the ice with a patient.

After discussing her patient’s sexual and health history, she typically begins a multi-week treatment that uses massage and gentle pressure—including inside the vagina—to relax and stretch the pelvic floor and encourage blood flow. She teaches muscle-control exercises and then monitors the woman’s progress on a computerized biofeedback machine.

For homework, Perlis encourages her patients to try vibrators and vaginal dilators—rubber penis-look-a-likes that help you get more comfortable with penetration. It takes time and practice to learn new habits, and there’s no guarantee of cure. But Perlis says she gets excellent results and stresses the positive.

“Hope is always in our vocabulary,” she comments. “This therapy is a journey that will help improve your sense of well-being and self-esteem. It will give you strength to move forward and find the power to heal and reclaim your sexuality.”

Pelvic floor PT is a relatively new field, and finding a specialist may not be easy. Perlis sees 40-50 patients a week and has a waiting list. One woman, she recalls, was so desperate for relief that she flew from Alaska to Boston to see Perlis—and then stayed in the area for three months for care.

Not everyone has to go to such extremes, of course. For dyspareunia sufferers, it’s comforting to know there are options for putting the pleasure back into your sex life.


For more on painful sex and pelvic floor physical therapy:

When Sex Hurts: A Woman’s Guide to Banishing Sexual Pain, by Andrew Goldstein, MD, Caroline Pukall, PhD, and Irwin Goldstein, MD (2011)

 The V Book: A Doctor’s Guide to Complete Vulvovaginal Health, by Elizabeth G. Stewart, MD, and Paula Spencer (2002)

Institute for Sexual Medicine at

National Vulvodynia Association (Vulvodynia is chronic, unexplained vulvar pain)

Vulvodynia Matters

American Physical Therapy Association to locate a physical therapist near you

Debra Bradley Ruder is a Boston-based freelance writer specializing in health care and education.



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