Tackling pain and difficulty with penetrative sex Information from the Psychosexual Service 2 Psychosexual Services

Some estimates suggest that around 15% of women experience some kind of pain during sexual intercourse. Given the personal and embarrassing nature of seeking help for any sexual problem, it’s highly likely that the actual figures may well be significantly higher than that.

Many women who experience difficulty with penetrative sex feel as though they’re on their own. They often don’t know anyone else who has the same problem. Yet the figures would suggest that you’re not alone. And, in this service, 25-30% of all our referrals are for this condition.

This booklet aims to share with you a little of what we know about the problem, and what works in helping resolve it. Tackling pain and difficulty with penetrative sex 3

Vaginismus and Dyspareunia (also known as Genito-Pelvic Pain/Penetration disorder or GPPPD)

GPPPD is defined in the medical world like this: For at least 6 months, a person experiences persistent or recurrent difficulties with one (or more) of the following:

• Vaginal penetration during • Marked vulvovaginal or pelvic intercourse pain during vaginal intercourse or • Marked fear or anxiety about penetration attempts vulvovaginal pain in anticipation • Marked tensing or tightening of of, during, or as a result of vaginal the pelvic floor muscles during penetration attempted vaginal penetration

These symptoms cause significant distress. The diagnosis only applies if it cannot be better attributed to:

• A nonsexual mental disorder • Other life stressors • Relationship distress (i.e. domestic • Any other medical condition, violence) substance or medication effect

Symptoms may have appeared as soon as the person became sexually active or may begin after a period of normal sexual functioning. The condition can be specified as mild, moderate, or severe depending on the amount of subjective distress it causes.

Some research suggests that women who suffer from vaginal or vulval pain often have non-relaxing/hypertonic/overactive pelvic floor muscles. Sometimes this results in a combination of bladder, bowel and sexual problems. Getting to know your body and learning how to relax the pelvic floor muscles can lead to comfortable, pleasurable penetrative sex as well as an improvement in any bladder and bowel symptoms.

There can be various reasons for the pattern of pelvic floor over-activity to become habitual but, essentially, the muscles can tire, become tender, and affect one’s ability to have sex.

An analogy to illustrate how we can get into habits of holding tension would be to consider what can happen when are driving a car. We can grip the steering wheel really tightly, without realising, until we draw our attention to it. Once we relax our arms, we see that we have as much control over the steering but without tiring our bodies in the process. 4 Psychosexual Services

The pain/fear cycle

Your brain remembers pain, and things that cause it, so may try to protect you from the same situation in the future depending on the circumstances. This can be very helpful in avoiding burning your hand when taking a hot pan out of the oven. You only do that once! This is an appropriate response by your brain to protect you and prevent you from touching the hot pan without a glove on.

If we look at this from a pelvic pain point of view, you may experience pain with penetrative intercourse due, for example, to lack of lubrication, (not aroused enough, or due to low hormone levels following childbirth), or even just feeling nervous. Next time you attempt it, your brain may decide it needs to protect you from potential pain and tightens the pelvic floor muscles. This hurts, and the cycle can be perpetuated. Pain causes fear and fear leads to higher levels of stress and anxiety, which, in turn, leads to a more sensitive nervous system so pain is experienced with less provocation. In fact, your whole nervous system becomes more sensitised and more likely to react to less of a stimulus.

Another response is to try and avoid the pain trigger, so you find yourself making excuses not to have sex.

Some people interpret this as “it’s all in your head”. THIS IS NOT TRUE! Whilst the pain response is a brain reaction, the pain is very real and treatment is aimed at reducing the sensitivity of the nervous system and tissues to calm the system down. This needs to address all the aspects of pain - the physical, the emotional and the social.

6. Avoidance of intimacy, lack of 1. The body anticipates pain; fear desire may develop and anxiety may contribute

5. Body reacts by ‘bracing’ more 2. The body automatically on ongoing basis tightens vaginal muscles

4. Pain reinforces/intensifies 3. Tightness makes sex painful; reflex response penetration may be impossible Tackling pain and difficulty with penetrative sex 5

Exploring and getting to know your body

The first step to overcoming problems with pain and muscle tightness is to get to know your body and understand better what’s happening.

Find a time when you can have some privacy in a relaxed atmosphere. You could begin by doing one of the suggested relaxation exercises at the end of this sheet or find another that suits you.

When you’re feeling relaxed, take a mirror and have a look at your vulval area (see the picture below). See if you can get a sense of your anatomy and how it all fits together.

Whilst you have the mirror there, see if you can tighten and relax your pelvic floor muscles and watch your perineum, (the area between your vagina and your anus), move slightly.

If you have had a baby, you probably learned to do pelvic floor exercises (sometimes called Kegel’s) in antenatal classes. The exercises involve lifting the muscles of the pelvic floor – the same muscles you would contract if you were on the toilet urinating and wanted to stop the flow of urine. You should contract your muscles, hold for 3-4 seconds, then relax. Initially, you can do the exercises on the toilet to make sure that you are contracting your pelvic floor muscles and not your abdominal or thigh muscles instead; however, as soon as you are certain that you are doing them correctly, you should no longer do them on the toilet but whenever you think about it during the day.

Each time you do them, do about three contractions, building up to a maximum of 10, and work towards holding the contraction for 5 seconds. You can do these exercises in any position or any place, but remember to allow time to be able to concentrate on the exercise. Put your phone away, try to remove yourself from distractions. The best exercise is always performed when you’re concentrating fully on it. 6 Psychosexual Services

Don’t forget to relax the muscles for a few seconds after each contraction. These are the slow hold contractions, which stand you in good stead if you’re about to lift something heavy.

Once you feel comfortable doing this, you can add 10 quick contractions – fast twitch contractions - pulling up quickly and then letting go immediately. These contractions help you when you sneeze or cough.

Working with vaginal trainers

This treatment provides a simple method to relax the vaginal muscles to allow for penetration. As you become consciously aware of relaxing and contracting the vaginal muscles around an object, you will gain a sense of control over vaginal penetration. If you have vaginismus, these exercises will help you to eliminate any tendency to tense the muscles that occurs at penetration. If you have dyspareunia (pain on intercourse), these exercises can give you a sense of control over genital stimulation and penetration so you can focus on reducing pain and increasing comfort and pleasure.

It is important to approach these exercises with a relaxed frame of mind. Use some relaxation exercises to set the tone for exercises with the trainers. Give yourself private time, and allow yourself as much time as you need to feel comfortable.

You need to prepare yourself by getting your set of vaginal trainers and lubricant ready. Vaginal trainers which are sometime referred to as dilators, are available from your GP on prescription. Some women prefer to use a finger to start with. Make sure that your nails are short and smooth, and still use lubricant. The benefits of using your finger(s) is that you have maximum control and can easily feel the tightening and relaxing of muscles. The drawback is that your fingers are limited in size. Only use lubricants that are recommended for this purpose.

Find a quiet, comfortable and private place in the house where you can be alone and undisturbed and allow around half an hour for the exercises. It’s easiest if you take your clothes off from the waist down and you may want to place a towel under you in case the lubricant drips.

Making friends with the trainers!

Take the smallest trainer, apply plenty of lubricant and, once you’re feeling ready, lightly place your finger or trainer on the vulval area and feel a sense of calm and hopefulness. Imagine the trainer as part of your body over which you have full control. It will remain still when you want it still and move gently and slowly when you wish to move it. Lightly rub the trainer over your vulva and let it run into the Tackling pain and difficulty with penetrative sex 7

dip around the entrance to your vagina. Repeat this process every time you use the trainers to ensure that you’re feeling relaxed and ready to begin.

Using the trainers

Once you’re feeling relaxed, you’re ready to start using the trainers. The exercise is basically the same for each size and you should repeat it every day (or as indicated by your sex therapist or physiotherapist) until you can comfortably insert the largest trainer.

Attach the trainer to the applicator, or use your finger inside the trainer if you prefer, and have the lubricated trainer next to you. Start by practising a few lifting and relaxing exercises, feeling the contrast in the pelvic floor muscles. These are the muscles that will surround the trainer and allow it to enter your vagina. Lift and relax, lift and relax. When you’re completely relaxed, begin inserting the smallest trainer into your vagina. Take your time, breathe slowly and deeply, and gently continue inserting the trainer. The PC muscles surround the first third of your vagina so you will feel resistance in this area only and may feel the trainer move easily as it passes beyond the PC muscle. Once you have inserted it, take three big breaths, tighten, let go and draw the trainer out. Remember that when you relax the PC muscle, the trainer will move easily. By feeling your own PC muscle contracting and relaxing in this manner, you will begin to have a sense of control. The next time you have the trainer comfortably inserted, try rolling it around. Then practice lifting it north, south, east, west, before wiggling it around once you have the confidence.

If you have trouble, be sure you are relaxed by breathing deeply. Tighten and relax your muscles and try again.

It’s a good idea to always start with the size smaller than you finished with last time but, once you’ve done that, repeat with the largest trainer you can accept. Once that’s comfortable, try the next larger size. Repeat the above exercise over a period of time as you gradually progress to the trainer that approximates the size of your partner’s penis. Once you have mastered this size, you are ready for the next exercise your therapist will set you.

You could also try a ‘hands-free’ contraction while the trainer is fully inserted, and watch the handle dip. You may find that the trainer just slips out, (more practice helps), but, over time, you will also enjoy the sense of control you can see developing. 8 Psychosexual Services

Progressive muscle relaxation exercise

Most people have times when they find it hard to relax. Often when we think we are relaxed there is still tension in some of our body muscles. When you are not relaxed it is more difficult to appreciate pleasant and enjoyable feelings.

The aim of this exercise is to teach you how to deeply relax your entire body by experiencing the difference between tension and relaxation of the muscles. Make sure you are in a warm, fairly quiet room, where you know you will not be interrupted. Sit in a comfortable chair or lie on the bed, with your legs outstretched and uncrossed and your arms by your sides. You may like to support your head with a pillow or cushion. The next step is to close your eyes and allow yourself to become as relaxed as you can. Now carry out the following series of exercises which will make you even more relaxed.

Start to breathe slowly and deeply, expanding your abdomen first as you breathe IN, then raising your ribcage to let more air in, until your lungs are filled right to the top. Hold your breath for a few seconds and then breathe OUT slowly, allowing your ribcage and stomach to relax, and empty your lungs completely. Do not strain. With practice it will become easier. This slow, deep breathing will continue throughout your relaxation session.

The Exercise

Go through all of the stages of the exercise below in the order they are written. This should take between 15 and 20 minutes.

Both feet and calves/lower legs - Tense both feet by pointing them backwards and upwards as far as possible. Do so by taking a deep IN breath then tensing both feet, hold your breath for at least ten seconds then relax and breathe OUT deeply whilst dropping your feet forward and relaxing them.

Muscles of both thighs - Tense both thighs as tightly as possible while taking a deep breath IN. Hold your breath and the tension for at least ten seconds then relax and breathe OUT deeply whilst relaxing your thighs.

Buttock (bottom) muscles - Tense both buttocks as tightly as possible while taking a deep breath IN. Hold your breath and the tension for at least ten seconds then relax and breathe OUT deeply whilst relaxing your buttocks.

Muscles of your belly and stomach - Tense your belly and stomach muscles as tightly as possible while taking a deep breath IN. Hold your breath and the tension for at least ten seconds then relax and breathe OUT deeply whilst relaxing your belly and stomach muscles. Tackling pain and difficulty with penetrative sex 9

Chest / pectoral muscles - Tense your chest / pectoral muscles while taking a deep breath IN. Hold your breath and the tension for at least ten seconds then relax and breathe OUT deeply whilst relaxing your chest / pectoral muscles.

Muscles of the shoulders - You can tense these by shrugging your shoulders, bringing your shoulders up into your neck as hard as you can. Tense up on an IN breath, hold your breath for ten or more seconds; relax on a deep OUT breath.

Muscles on top of the upper arms (biceps) - To tense these, bend both your arms at the elbow and try to touch your shoulders, then tighten your shoulders on an IN breath. Hold your breath for ten or more seconds; relax on a deep OUT breath.

Muscles of the hands and forearms - To tense these, clench both hands and make fists as tightly as possible. Tense up on an IN breath, hold your breath for at least ten seconds whilst you keep your muscles tense, then relax and breathe OUT at the same time.

Muscles of the face and forehead - You can tense these by EITHER by scrunching your face up tightly, including your eyes, OR by raising your eyebrows as high as they’ll go. Tense up on an IN breath, hold your breath for ten or more seconds; relax on a deep OUT breath.

Continue sitting or lying after the exercise for a few moments to enjoy the full benefit of it. It can help to imagine some pleasant scene or situation where you feel relaxed and at ease, such as lying in the sun or enjoying the peace of the countryside. Imagine the scene as vividly as you can – peaceful, calm – and let it relax you more and more deeply. When you want to finish, tell yourself that when you open your eyes you will be perfectly relaxed, but alert. Count to three and then open your eyes.

Useful Resources

Websites:

• Vulval Pain Society: www.vulvalpainsociety.org/vps/ • British Society for the Study of Vulval Disease: www.bssvd.org/practitioner- portal/

Books:

• When Sex Hurts: A Woman’s Guide to Banishing Sexual Pain. By Andrew Goldstein, Caroline Pukall, Irwin Goldstein • Come as You Are: the bestselling guide to the new science that will transform your sex life. By Emily Nagoski Psychosexual Services

Greater Manchester Mental Health NHS Foundation Trust Rawnsley Building, Manchester Royal Infirmary, Oxford Road M13 9WL

Telephone: 0161 271 0622 Website: www.gmmh.nhs.uk

This information can be provided in different languages, Braille, large print, interpretations, text only, and audio formats on request, please telephone 0161 271 078.

© Greater Manchester Mental Health NHS Foundation Trust

Reference: GMMH000 Published on: 24/06/2020 Author: Gillian Brisk Review date: 24/06/2022