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.