Sexual pain: what getting help looks like

Women experiencing sexual pain often have a terrible time getting help from their healthcare practitioners. The process can be long, hard and embarrassing.

Finding a practitioner who can help can be tricky, because it’s not necessarily a comfortable situation to discuss very intimate sexual details with a stranger. This situation is compounded when the practitioner is unable to help for whatever reason. On to the next you go. Or not. Giving up entirely on sex is not uncommon, but is the worst possible outcome.

Dealing with shame at the doctor’s office

Intense shame. It’s overwhelming, and very common when approaching a practitioner about sexual issues. We often think it’s something we are not doing right, not doing sex right, not doing vaginas right.

The urge to run away when you are in the waiting room or healthcare practitioner’s office may be strong, and talking about sex may be incredibly difficult.

Finding the right practitioner to help you may take a very long time, a lot of hunting around, and at times, giving up entirely. The long wait between a problem arising and getting the right help can mean you get lost in your own head, ending up with self-doubt, anxiety, depression or worse. Sexual pain can result in strong negative emotions, usually directed at the self.

Doctor hopping

The cause of sexual pain has a variety of causes. An accurate diagnosis can be elusive, resulting in shuffling from practitioner to practitioner. This variance in causes can cause difficulties for both practitioner and patient.

Causes of sexual pain

• Vulvodynia
• Recurrent vaginal infections
• Birth control
• Breastfeeding
• Menopause
• Vulvar dermatoses
• Pelvic floor dysfunction
• Pudendal neuralgia
• Sexual abuse or trauma
• Sexually transmitted infections

Making it through your appointment

Your practitioner will ask you lots of questions to try to figure out what’s going on. These detailed questions will include topics such as:

• When you started experiencing symptoms and how they began
• Where the pain is felt
• Triggers (tampons, tight pants, penetrative sex)
• The nature of the pain (stabbing, aching, sharp, etc.)
• How long the pain lasts for
• When the pain begins and ends
• Treatments you’ve previously attempted
• Anything that relieves symptoms

The pelvic exam

Then, you will need to undergo a physical examination that will help to determine the nature of the pain.

Your practitioner will explain the procedure to you and what they are about to do. They will be gentle, careful and make sure you are comfortable. The exam isn’t about causing you pain, so don’t be afraid of more pain. This is a delicate procedure and your practitioner is trained to do this with the utmost care.

Your practitioner will visually examine your vulva, and use what’s known as the Q-tip test of your vestibule. The vestibule is the area between your vaginal entrance (bottom) and the clitoris, a soft, spongey area.

Your pH will be taken (which helps determine infections or menopausal state), and your doctor may examine your vaginal fluids under the microscope (wet mount).

Your pelvic floor function will be tested – the muscles, bladder and urethra. Any suspicious lesions found will likely need a biopsy.

You’ll have the opportunity throughout to ask questions – it’s just you and your practitioner, so ask anything. This is the first part of your care completed, but this is just the beginning.

Treating sexual pain

This may be a long journey into understanding and treating your pelvic pain, and include more than one treatment strategy. You may be referred on to other practitioners, depending on the findings.

When you have pelvic floor dysfunction

You will be referred to a pelvic physiotherapist, who is best suited to treating pelvic floor dysfunction. Pelvic physiotherapists have specialised, unique treatment methods and focused training techniques.

You will need to be an active participant in pelvic physiotherapy, as you’ll need to do exercise at home.

Seeing a sex therapist

You may benefit from seeing a qualified, experienced sex therapist during your journey. You can do these sessions on your own or with a partner. Sexual pain can have either a psychological cause or a psychological impact, and getting support for your emotional and mental wellbeing is important.

Your pain is real! Your practitioners understand that, and acknowledge its impact on your life and relationships.

Vaginal hormones or drugs

You may be prescribed topical or oral hormones or drugs. These medications could include:

• Vaginal oestrogen and/or testosterone
• Lidocaine ointment (an anaesthetic)
• Oral medicine (amitriptyline, duloxetine, gabapentin)
• Vaginal Valium
• Betamethasone or anoaboulinumtoxiA injections (Botox)
• Laser and/or radiofrequency treatments
• Surgical interventions
• Cessation of the birth control pill
• It is unlikely you will be prescribed opioids for pain relief

References/more information

Bazin S, Bouchard C, Brisson J, Morin C, Meisels A, Fortier M. Vulvar vestibulitis syndrome: An exploratory case-control study. Obstet Gynecol. 1994;83(1):47-50.

Bazin S, Lefebvre J, Fortier M, et al. Evaluation of an estrogen vaginal cream for the treatment of dyspareunia: A double-blind randomized trial. J Obstet Gynaecol Can. 2011;33(8):838-843.

Becton Dickinson and Company, United States. BD affirm VPIII microbial identification test.

Bertolasi L, Frasson E, Cappelletti JY, Vicentini S, Bordignon M, Graziottin A. Botulinum neurotoxin type A injections for vaginismus secondary to vulvar vestibulitis syndrome. Obstet Gynecol. 2009;114(5):1008-1016.

Boardman LA, Cooper AS, Blais LR, Raker CA. Topical gabapentin in the treatment of localized and generalized vulvodynia. Obstet Gynecol. 2008;112(3):579-585.

Bohm-Starke N, Rylander E. Surgery for localized, provoked vestibulodynia: A long-term follow-up study. J Reprod Med. 2008;53(2):83-89.

Burrows LJ, Goldstein AT. The treatment of vestibulodynia with topical estradiol and testosterone. Sex Med. 2013;1(1):30-33.

Dahir M, Travers-Gustafson D. Breast cancer, aromatase inhibitor therapy, and sexual functioning: A pilot study of the effects of vaginal testosterone therapy. Sex Med. 2014;2(1):8-15.

De Andres J, Sanchis-Lopez N, Asensio-Samper JM, et al. Vulvodynia-an evidence-based literature review and proposed treatment algorithm. Pain Pract. 2015.

Foster DC, Kotok MB, Huang LS, et al. Oral desipramine and topical lidocaine for vulvodynia: A randomized controlled trial. Obstet Gynecol. 2010;116(3):583-593.

Goldstein AT, Belkin ZR, Krapf JM, et al. Polymorphisms of the androgen receptor gene and hormonal contraceptive induced provoked vestibulodynia. J Sex Med. 2014;11(11):2764-2771.

Pelletier F, Parratte B, Penz S, Moreno JP, Aubin F, Humbert P. Efficacy of high doses of botulinum toxin A for treating provoked vestibulodynia. Br J Dermatol. 2011;164(3):617-622.

Reed BD, Caron AM, Gorenflo DW, Haefner HK. Treatment of vulvodynia with tricyclic antidepressants: Efficacy and associated factors. J Low Genit Tract Dis. 2006;10(4):245-251.

Swanson CL, Rueter JA, Olson JE, Weaver AL, Stanhope CR. Localized provoked vestibulodynia: Outcomes after modified vestibulectomy. J Reprod Med. 2014;59(3-4):121-126.

Tieu KD, MacGregor JL. Successful treatment of vulvodynia with botulinum toxin A. Arch Dermatol. 2011;147(2):251-252.

Witherby S, Johnson J, Demers L, et al. Topical testosterone for breast cancer patients with vaginal atrophy related to aromatase inhibitors: A phase I/II study. Oncologist. 2011;16(4):424-431.

Zolnoun DA, Hartmann KE, Steege JF. Overnight 5% lidocaine ointment for treatment of vulvar vestibulitis. Obstet Gynecol. 2003;102(1):84-87.