Here, Dr Jennifer Gunter, author of The Vagina Bible, opens up about the various methods you can use to keep that burning sensations at bay. Just stay away from the oral muscle relaxants.
Chances are, if you’re a female with a close group of girlfriends, someone will be struggling with painful sex. Whilst it’s a topic people are reluctant to discuss with their friends or partners, it’s an increasingly common problem amongst women and it quite frankly sucks. But, despair not, there are endless treatment options in store.
If Sex Hurts, Should I Keep Having it?
This is a question only you can answer. If sex is excruciating, it will likely feed into the cycle of pain, muscle spasm, and anticipation. Sex is also supposed to be pleasurable. Some women tell me the physical bonding is worth the pain, but many have not been able to tell their partners about their pain. A sex therapist or other psychologist may be helpful in explaining the pain situation to a partner.
If you continue to have sex while you are working through PFMS, then make sure you are getting adequate foreplay. If sex is “twist a nipple and stick it in,” that would hurt most women. Use plenty of lubricant and focus on areas that do not hurt, such as the clitoral glans and labia. Aim for an orgasm (or more than one) before any penetration. If you have a male partner, consider giving him the book. She Comes First – the title itself is great advice. Some women find after an orgasm or two their pelvic floor begins to relax, and then penetration is easier.
If penetration is too painful, many women who partner with men find that masturbation and oral sex are not painful. Taking penetration off the table while you are working on your pelvic floor muscles still allows you to have satisfying sexual contact without the pain or with much less pain.
There are a variety of considerations, and what works for you may depend on what is available locally and what you are comfortable with.
Vaginal dilators help de-sensitize the nerves and muscles. You proceed at your own pace in your bedroom with no pressure. They come in sets of four or five. You start with the smallest, inserting as far as you can go and stopping when you feel pain, and then holding it in place for five minutes. Focus on slow, deep breaths to help relax your pelvic floor. Some dilators are vibrating, and many women find that helpful. Dilator exercises depend on forming muscle memory; it is more important to do them 5–10 minutes a day every day than thirty minutes once a week.
Pelvic floor physical therapy can be very helpful. These are specialized physical therapists with advanced training. There are a variety of techniques. For women who cannot tolerate any insertion, the therapy should start externally. Some use biofeedback machines that give a visual representation of the muscle spasm on a computer screen; this can be a helpful aid for some women. A pelvic floor physical therapist will eventually work with her gloved fingers inside your vagina and should prescribe a home exercise regimen. There are some bodywork practitioners who claim to treat PFMS, but I would advise against seeing anyone who is not a physical therapist certified by the APTA (American Physical Therapy Association).
Working with a psychologist to address trauma, anxiety, and any relationship issues may be part of the treatment plan. This doesn’t mean that your pain is in your head, it means that pain affects your life. Addressing this impact can help reduce suffering. Women who have extreme anxiety responses to the thought of or attempts at penetration may find working with a therapist especially helpful.
Managing constipation if you are overworking your pelvic floor muscles is also important, as straining will feed the cycle of spasm.
Another option is botulinum toxin injections. Yes, Botox for the vagina. This is done with sedation, as it is painful. Botulinum toxin treats muscle spasm – that is its mechanism of action. While approved by the FDA for some types of muscle spasms, it is not FDA approved for PFMS. For some women, botulinum toxin injections can help break the cycle of pain and spasm. The medication wears off after 10–12 weeks, and so this is most effective when combined with dilators and physical therapy.
What doesn’t work?
Oral muscle relaxants are largely ineffective. They sometimes are used to treat acute spasm (think sudden-onset back pain), but they are not very good for chronic muscle spasm. Some people advocate for vaginal diazepam (Valium); however, two studies show that it is ineffective.
Diazepam works on the spinal cord and brain – there are no receptors for the medication vaginally, so if any benefit is felt it is because the medication is absorbed into the bloodstream, which negates the point of using it vaginally.
The Vagina Bible: The vulva and the vagina – separating the myth from the medicine by Dr. Jennifer Gunter is available in trade paperback (Piatkus, £14.99)