If sex is painful, you have options

0:00This message comes from Charles Schwab with their original podcast, Choiceology. Choiceology is a show about the psychology and economics behind people's decisions. Download the latest episode and subscribe at schwab.com slash podcast. Is painful sex normal? 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. Hey, it's Mariel. 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.

0:42And she says there are a lot of reasons why you might be hurting. Stress, menopause, childbirth. 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. Of course, this is a hard topic for a lot of us to talk about.

1:21You 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. It happens and there is help and there's no shame.

2:07On 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.

2:26Takeaway 1. 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. For people who have a hard time talking about this topic with their partner, do you have any helpful starters for us? 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?

3:26So 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. 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.

4:05And 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 body and the needs that your body has, your partner for sure needs to know about it. It sounds like any other, starting it off with any other conversation you might have as a couple, you don't want to have a hard money conversation when you're in the middle of paying your bills.

4:43You don't want to have a hard parenting conversation when your kid is having a tantrum. 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?

5:21You'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 along. This is your fault. You're messing up the relationship. But this is something that you tackle together. On that note, if not everyone has a partner, if you have if you 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? 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.

5:59Hi, my name is Janelle and sex hurts whole bad. 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? 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.

6:44And I think it's important to zoom out and say, okay, 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. 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.

7:29And 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. And to be clear, experiencing persistent or recurring pain during sexual intercourse is a medical issue. There's even a medical term for it. Dysparunia. 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.

8:13It'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 three out of four women will experience pain during sex at some point 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 there are multiple medical conditions that can cause painful sex. And unsurprisingly, the cause of your pain will determine the best way forward.

8:57More Life Kit after the break.

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10:35Takeaway 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 OBGYN 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 rectal exam, collect samples of bodily fluids for testing, or do something like a transvaginal ultrasound.

11:24But we can also try and sort of take things off of the list that we can rule out. 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. 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.

12:07So 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. 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.

12:46One is called vaginismus. In this case, the muscles around the vagina involuntarily contract or spasm. 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. Or vaginismus can cause severe muscle tension, tightness, and pain that can make insertion so painful. And obviously relationships and intimacy as well. The next is called vulvodynia, or chronic vulva pain. Which is like the burning, the stinging, the pain on the outside. Either the opening, the clitoris, or even the labia can get painful.

13:27And 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. 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. 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. 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?

14:17If none of these things sound familiar, it's possible the fix you're looking for is in the brain-body connection category. 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. 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, a.k.a.

15:08Pelvic 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. After the break, help help explore therapy practices can help reduce pain in your sex life.

16:04need to clear your head. That's the perfect time to hit the play button on NPR's All Songs Considered. It's not the news, it's not work, or whatever else is weighing you down. It's just a good time with good friends and great tunes. Listen to All Songs Considered every Tuesday in the NPR Music Podcast. You're listening to Life Kit, and it's time for Takeaway 3. 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? Sure. So first thing is, it's going to be like a long conversation.

16:43You'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.

17:19So they'll be screening the muscles, the ligaments, the tissues that interact with your pelvic floor. And then you may lay on a table very similar to how you do when you go to see an OBGYN. So you'll get on the 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.

17:58Can 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. 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.

18:37So things like your posture or even biofeedback. So those are, I would say, the primary interventions that we use. 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.

19:25One aspect of Janelle's work is helping patients with things like vaginismus use dilators 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? It depends. Oh gosh. So that's the answer we all hate, but it's 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.

20:03So you could go to therapy and it take six months. For someone else, it 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. 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 okay a really good job and it could take longer and i i don't 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.

21:08There'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. So takeaway four, stretch your pelvic floor muscles. Some pelvic floor PT tools will be specific to certain conditions, But then there are a few, Janelle says.

22:00pose. 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. 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.

22:39And 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 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.

23:20We can't be in fight or flight and expect to have pain-free sex or even enjoyable sex. Janelle Frederick, the vagina rehab doctor, thank you so much for your time. Any final thoughts? Anything I missed? No, I just want everyone to have buttery, scrumptious sex and to actually look forward to it and not dread it. And 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. It really was. I am the first person in line there. Absolutely. Thank you, girl. Buttery and scrumptious, yes.

23:58All 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 health care 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, for instance. So start with your primary care provider or an OBGYN.

24:45Takeaway 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.

25:28That was reporter Andy Tegel 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 Ricalon. Megan Cain is our senior supervising editor and Lauren Gonzalez is our executive producer. Our production team also includes Margaret Serino and Sylvie Douglas.

26:03Engineering support comes from Tiffany Vera Castro. Fact-checking by Andrea Lopez Cruzado. I'm Mariel Segarra. Thanks for listening.

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