There are about 17,000 Google searches per month for the phrase “painful sex.” Tellingly, all the top pages that come up under a “painful sex” search are geared toward women, not men. In a study published in 2017 sampling more than 15,000 women, researchers noted that “Painful sex (dyspareunia) is a common but neglected female health problem. The population prevalence is estimated to vary from 3 to 18% globally, and lifetime estimates range from 10 to 28%.” That’s a lot of women who are experiencing pain from what should be a pleasurable experience! Even worse, there are probably a lot more women who are suffering in silence, perhaps out of the embarrassment, shame, or frustration that can sometimes accompany the experience of painful sex.
In an article for Natural Womanhood, Liz Escoffery discussed the phenomenon of painful sex before your period, and how tracking your cycle and getting treatment from a pelvic floor physical therapist can potentially help. But in addition to painful sex before their periods, women are experiencing painful sex at different times in their cycles as well, which speaks to the reality that painful sex may be due to different causes in different women. To delve a bit further into the various causes of painful sex, I spoke with Dr. Nicholas Kongoasa, MD, FACOG.
Dr. Kongoasa, or “Dr. K” as his patients call him, practices gynecology and restorative reproductive medicine (RRM) at Reproductive Health Medicine & Gynecology, and is also the medical director of the Center for Restorative Reproductive Surgery, both of which are in the Atlanta, GA area. Dr. Kongoasa is a board-certified OB/GYN, who is also formally trained in the Creighton and FEMM methods of fertility awareness and their restorative reproductive medical protocols. He is familiar with various root causes of painful sex in women and how to identify and treat them in ways that respect and restore a woman’s reproductive health.
Muscle pain as the source of painful sex
As discussed in the Natural Womanhood article “Painful sex before your period,” painful sex is often due muscular pain. That is why pelvic floor physical therapy, which can help relax tight pelvic muscles, can provide effective relief for painful sex. But Dr. Kongoasa says before turning to pelvic floor physical therapy, it’s imperative to first dig a bit deeper: to get to the bottom of painful sex, he says you have to first figure out what is causing the muscular pain.
“I think that muscular pain, while a significant factor of pelvic pain, is only secondary to something else,” says Dr. Kongoasa. “Muscular pain is reactive pain, meaning that there is typically an underlying cause resulting in the muscle spasm.” For example, one common root cause of pelvic pain and painful sex is endometriosis. Endometriosis causes inflammation and scarring, which in turn causes pain. “The body’s natural response to this pain is to tighten the muscles surrounding the area to protect that area (think about a bulging disc causing back pain),” explains Dr. Kongoasa. “And, if a muscle is in a perpetually tight state, it becomes weak, and weak muscle spasms faster.” This spasming “causes a magnification of that pelvic pain.”
This is why Dr. Kongoasa believes that pelvic floor physical therapy is typically more effective if the underlying cause of the patient’s pelvic pain is also being treated or controlled adequately. In the case of endometriosis, this would mean inflammation control, which is most effective via surgical excision of endometrial lesions.
“On the other hand,” says Dr. Kongoasa, “if the root of the pelvic pain is not adequately treated, pelvic floor PT may only be beneficial temporarily,” or the physical therapist might “hit a roadblock after a few sessions,” unable to take the muscle out of spasm. Therefore, getting to the root cause of what is causing the muscular spasming is imperative to proper treatment.
Determining the root cause(s) of painful sex
Dr. Kongoasa says that muscles in the pelvis may spasm, causing pelvic pain and painful sex, due to a few different root causes. He puts those root causes into the following categories:
1. Focal inflammatory disorder
This includes disorders that are known to cause inflammation in the pelvic region, such as endometriosis, interstitial cystitis, and polycystic ovary syndrome (PCOS), and so on. Once Dr. Kongoasa has deduced that the pelvic pain is a result of some kind of focal inflammatory disorder, he will recommend treatment to reduce inflammation. The first line of treatment is typically nutrition and lifestyle changes, and anti-inflammatory supplements, as well as charting to aid in the diagnosis of one or more of these issues. After this first-line approach, further work will indicate if surgery, or other more aggressive treatments are warranted.
2. General inflammatory disorder
This includes disorders such as gluten sensitivity, ulcerative colitis, and Hashimotos thyroiditis, among others, which are known to cause widespread inflammation across the body. “If the body is inflamed,” says Dr. Kongoasa, “it magnifies your pain.” He says you can think of it “as if you have the flu, and also have a wound on your hand from a cut. Your wound will be more painful and heal more slowly if you have the flu at the same time.”
3. Infection
This includes things like chronic endometritis, and vaginitis, and so on. In the case of an infectious source of pelvic pain in a patient, Dr. Kongoasa says keeping a fertility cycle chart will be particularly helpful, as “the chart will show signs of lingering bleeding.”
4. Hypoestrogenic state
Women who have severe estrogen deficiency have a condition called hypoestrogenism. Women in a hypoestrogenic state include those who are post-menopausal, women whose cycles are suppressed by hormonal birth control, female athletes with hypothalamic amenorrhea, women under a huge amount of stress, or women with eating disorders. Again, Dr. Kongoasa notes, that a woman’s menstrual chart can be an invaluable source of information in determining whether pelvic pain may be due to a hypoestrogenic state.
5. Uterine abnormalities
“Is it the uterus itself that is causing the pain?” Dr. Kongoasa asks. For example, women with adenomyosis (a condition where the lining of the uterus grows into the wall of the uterus) “will have pain with sex that is very specific to uterine pain, causing a painful sensation of the uterus being ‘hit’ during sex.” Adenomyosis is “also associated with heavy bleeding, and the heavier the bleed, the more pain there is.” “Again,” notes Dr. Kongoasa, “correlation with a fertility chart is needed.”
6. Central sensitization syndrome (fibromyalgia, etc.)
In women with central sensitization syndrome, Dr. Kongoasa says that “the brain is re-programmed to perceive certain normal stimuli/touch as pain.” He notes that this root cause of painful sex is particularly difficult to treat. Fortunately, research is being done into this mysterious collection of syndromes, which may also include endometriosis. The Department of Obstetrics & Gynaecology at the University of British Columbia notes that:
“People with central sensitization experience a heightened sensitivity to pain and may experience pain even with light touch. The Endometriosis and Pelvic Pain Research Laboratory found that people with bladder and/or pelvic floor tenderness and/or painful bladder syndrome, which are thought to be clinical markers of central sensitization, had more severe sexual pain with deep penetration, regardless of their severity of endometriosis. These findings suggest that central sensitization may play a role in sexual pain with deep penetration rather than the endometriosis lesions in some people. We are now looking further into central sensitization and its relationship to this pain, as this may lead to individualized treatment plans and better care.”
Restorative reproductive medical treatment for painful sex
After figuring out which of the categories above is the likely root cause of a woman’s pelvic pain, “Then we go down to muscle,” says Dr. Kongoasa. “The muscle, after all, is reacting to one or more of the causes above.”
This careful, methodological approach to addressing the root causes of painful sex as outlined by Dr. Kongoasa is an excellent example of the power of Restorative Reproductive Medicine (RRM). RRM doesn’t seek a “quick fix” solution to cover up symptoms, but instead seeks to heal the root problem while protecting women’s reproductive capacity.
If you are experiencing painful sex, you don’t need to live with it for the rest of your life. With 10-28% of women reporting painful sex in their lifetime, this is a neglected women’s issue, but you are not alone, and as this article details, there are treatments available. You deserve the compassionate care of someone who will seek to treat and heal your condition effectively, so that you can enjoy sex naturally.
Additional Reading:
Painful sex before your period? How tracking your cycle could help stop sex from hurting
Sex after Birth: How to Know if (and When) You’re Ready
Shocking Reasons why Birth Control Lowers Women’s Sex Drives
When Libido Issues Are Not All In Your Head
Cycles and the Change: Fertility After 35
5 Ways Stress Can Affect Your Period and the Rest of Your Cycle
