Barbara Davis loved her husband, but she’d begun to dread sex. “The pain was excruciating, recalls Davis, 40, an advertising executive in New York City. She became very timid about wanting to be intimate. “Sometimes, it would hurt so much that we’d have to stop midway.”
At some point in their lives, most women experience at least one episode of painful sex. In most cases, doctors say. the discomfort is transient and doesn’t recur. But for some women, sex is persistently uncomfortable. Although it’s not clear how many are affected, in one study, one third of 324 gynecology patients from the Women Care Center surveyed said that sex was always painful.
Unfortunately. most women don’t volunteer this information to doctors, and doctors rarely ask. Many physicians are uncomfortable delving into sexual matters. says Peter Fagan, Ph.D., director of the sexual behaviors consultation unit at The Johns Hopkins Medical Center in Baltimore.
To further complicate things, many women and some doctors wrongly assume that psychological or emotional problems are to blame. When there are strains in a relationship, a woman can turn off sexually and tense up in bed so that sex becomes uncomfortable, and chronically painful intercourse can lead to emotional problems. However, experts maintain that physical factors are more likely the cause.
A new source for treatment is a pelvic-pain clinic. Although gynecologists or urologists can spot and cure many of the underlying disorders, not all doctors are familiar with less obvious causes. But over the past five years or so, several treatment facilities specializing in pelvic pain have sprung up. These include the Pelvic Pain Center at Ohio State University Hospital in Columbus, the University of California at Los Angeles’s Pelvic Pain Clinic, and the University of Virginia Hospital’s Pelvic Pain Center in Charlottesville. Doctors say although painful sex is increasingly getting the medical attention it deserves, some mysteries remain. But one thing is clear: No woman who finds sex painful should automatically assume that it’s all in her head, or hopeless. Here, what could be wrong and what can be done about it:
Hormonal changes during menopause and breast-feeding are a common cause of painful intercourse. After menopause, declining estrogen levels can make vaginal walls thinner, less elastic, and less capable of lubrication, all of which can make sex uncomfortable. During breast-feeding, the same hormone that promotes milk flow also depresses estrogen levels, causing vaginal dryness. (Estrogen levels return to normal once a woman stops breast-feeding.) Vaginal lubricants can help both groups of women, and if the cause is menopause, estrogen replacement therapy can thicken vaginal tissues and improve lubrication.
Infections usually cause an obvious discharge and odor, or pain with urination. But sometimes the first symptom is discomfort during sex. Vaginal infections can reduce lubrication. leading to soreness during and after intercourse. Yeast infections and trichomonasas (a bacterial infection) are most often responsible. and can also cause pain at the opening of the vagina. Deeper pain may be caused by a bladder infection. That’s because a tender, inflamed bladder may be irritated during intercourse. Infections caused by sexually transmitted diseases (STDs) are another culprit. in fact, abdominal pain during sex may be a symptom of chlamydia. an STD that can linger undetected for as long as five to ten years. Untreated, a chlamydia infection can lead to pelvic inflammatory disease, which causes pelvic inflammation and scarring and can make sex even more painful.
Once diagnosed, most infections are easily treated with antibiotics or — in the case of yeast infections — antifungal creams or pills. Drinking plenty of water, and urinating both before and immediately after sex will reduce the risk of a bladder infection.
Endometriosis, a condition in which tissue from the lining of the uterus (the endometrium) travels into the pelvic cavity, implants itself, and begins to grow, affects an estimated five million American women — and roughly 60 percent of them report that sex is often painful. That’s because the implanted tissue continues to behave like the rest of the uterus (thickening and shedding cyclically), and the resulting inflammation and scarring can cause severe pain. Sometimes, scar tissue pushes the ovaries into a position where they’re repeatedly bumped during intercourse.
“Today, most women with endometriosis can be treated successfully with drugs or surgery,” says Gloria Bachmann, M.D., professor of obstetrics and gynecology at Robert Wood Johnson Medical School in New Brunswick, NJ. Birth control pills can help because they halt ovulation, as can drugs that temporarily suppress estrogen production. Doctors can also surgically remove wayward endometrial tissue through a tiny abdominal incision. (Davis, who found that endometriosis was the cause of her problem, got relief with both medication and surgery.)
Less drastic solutions can often help put the pleasure back in sex. Some endometriosis sufferers find that they’re less likely to have pain during the week or two after menstruation and before ovulation. Positions that avoid deep penetration (such as lying side by side or with the woman on top) can also help.
Vulvodynia, characterized by burning, itching, and irritation in the external genital area (vulva), is one of the most mysterious and misunderstood gynecological conditions. Often, there are no physical abnormalities that can be seen in an examination yet in some cases, the pain is so severe that even inserting a tampon is impossible.
Although vulvodynia isn’t a new disorder, it wasn’t until 1983 that the International Society for the Study of Vulvar Vaginal Disease put a name to what had been described in earlier medical references as exquisite or excessive sensitivity, notes Stanley Marinoff, M.D., medical director of the Center for Vulvovaginal Disorders in Washington, DC. Doctors once thought vulvodynia was extremely rare, but they now suspect otherwise. One survey found that 15 percent of new gynecology patients had symptoms consistent with vulvodynia.
Unfortunately, according to Dr. Marinoff, too few doctors know enough about the condition to properly diagnose and treat it. And when an examination fails to reveal any abnormalities, doctors unfamiliar with the disorder may assume the pain is psychosomatic. As a result, desperate patients may go from one doctor to another in a futile search for help.
The cause of vulvodynia is still unknown. Some cases have been linked to chronic yeast infections. Other possible causes include nerve injuries or irritation, an allergy to environmental irritants, or a reaction to pelvic muscle spasms. Another popular theory holds that vulvodynia is a response to high levels of calcium oxalate crystals, normally excreted in urine. Indeed, studies show that between 20 and 30 percent of women with vulvodynia get relief by switching to a diet that’s low in oxalates (found in coffee, tea, chocolate, tomato sauce, peanuts, spinach, green beans, celery, and sweet potatoes).
Many women get relief by taking very low doses of certain antidepressants, such as amitriptyline (Eelavil), at smaller doses, the drugs block pain. Antihistamines, which treat the inflammation, have also worked for some women, as has applying a little estrogen cream to the vulvar area. “Treatment is often a matter of trial and error,” says Gae Rodke, M.D., an ob-gyn in private practice in New York City, who cautions that whatever the regimen, relief may not kick in for up to six weeks.
Although surgery (to remove areas of tender, inflamed tissue) is also an option, doctors say it should be considered only as a last resort, and then only by a qualified gynecologist.
Interstitial cystitis (IC), a chronic bladder inflammation, causes severe pelvic pain that tends to worsen during sex. It’s often mistaken for a urinary tract infection, because IC also causes a frequent urge to urinate. But unlike a bladder infection, the disorder is difficult to diagnose and treat. And many affected women also have vulvodynia, although doctors don’t know yet whether the two are linked.
It isn’t clear what causes IC, but doctors suspect it when no infection-causing bacteria can be found in the urine. A number of treatments, including the recently approved sodium pentosanpolysulfate (Elmiron), are available, but no single therapy works dependably for all patients. Sufferers often find that intercourse is most comfortable when the woman is on top.
Nerve problems, which can develop after childbirth or pelvic surgery, may cause sexual pain. “One of the nerves that runs from the hip area to the pelvis and pubic bone can be caught accidentally in scar tissue from a surgical incision,” explains Donald C. Manning, M.D., Ph.d., director of the University of Virginia Hospital’s Pelvic Pain Center. Injuries during childbirth or poorly performed episiotomies can also injure nerves and result in pain. Antidepressants or anticonvulsants can often control nerve pain.
An allergy to semen, although rare, is another possible culprit. Jonathan Bemstein, M.D., a Cincinnati allergy specialist, says he’s successfully treated about 30 women with the problem over the last six years. Common symptoms are vaginal pain and burning during sex that can last for several days afterward. Some women also develop hives, wheezing, and shortness of breath that can be life threatening. The simplest solution is to use condoms. For couples who want to conceive, treatment consists of desensitizing women with shots containing small amounts of proteins from their husbands, semen.
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