A banana spooning an eggplant with a light pink background.

A banana spooning an eggplant with a light pink background.Is penetration ever painful for you? Whether it’s with fingers, toys, or penises, you’re not alone: An estimated 50% of menopausal women with sexually active partners experience pain during vaginal penetration. And that’s just women in menopause. (Note: Here’s a Partner’s Guide to Menopause)

Dyspareunia is a very general term for pain with penetration during intimate sexual contact. Deep pelvic pain, or deep dyspareunia, usually emerges because of other existing disorders hidden in the pelvis—either adjacent to or touching the upper portions of the vagina.

There are a few different possible causes for this deep pelvic pain (or deep dyspareunia), which include:

  • fibroid tumors in the uterus
  • cysts in the ovaries
  • tumors on the ovaries
  • endometriosis
  • scarring from pelvic infections or prior surgery

While the disorders that we just listed above are relatively common, the deep pelvic pain that can result from them is not nearly as common. Most people with these disorders won’t have the correlating deep pelvic pain, but if you experience a new onset of deep pain during sex, which can be triggered by a new partner or experience, you should talk with a doctor or other health professional.

More common causes of both superficial and deep pelvic pain include:

  • Vaginal atrophy following menopause (AKA vulvovaginal atrophy, genitourinary syndrome of menopause, or GSM)
  • Vestibulodynia (vulvar vestibulitis)
  • Pelvic floor muscle dysfunction

Regardless of the cause, pain during penetration is not fun, and it certainly isn’t comfortable. To provide additional context, this typically happens when there’s any restriction of movement at the opening of, or at the top of the vagina.

The vagina is meant to slide on its neighboring organs (i.e., ovaries, tubes, uterus, intestines, rectum, etc.). When the top of the vagina (or the vaginal apex) is restricted or bumps up against a tender neighboring organ or disorder, like a fibroid or an ovarian cyst, during penetration, it can cause deep pain.

Other relevant factors include:

  • Depth of penetration
  • Sexual position

Let’s do some quick math—Depending on the length and girth of the fingers, penis, or toy that’s penetrating you + the length of your vaginal canal = deep pelvic pain may only occur intermittently, for example, only with sex in particular positions, with a particular partner, or with a particular partner in a particular position.

If you are experiencing deep pelvic pain from penetration, regular or otherwise, a diagnosis can usually be determined with a vaginal or abdominal ultrasound (sonogram). Vaginal ultrasounds are preferred since the probe that’s inserted into the vagina can be used to reproduce or simulate the pain that’s felt during penetrative sex—quickly demonstrating exactly where and how the pain is initiated.

If endometriosis is the cause, there are a couple of things to note:

  1. Endometriosis often goes undiagnosed for many years.
  2. Endometriosis can be difficult to diagnose.
  3. A complete evaluation may require a careful rectal exam; this is because endometriosis causing deep penetrative pain during sex may best be felt on a rectal exam.

Typically, treatment of deep pelvic pain is focused on any underlying disorder. It may be surgical (i.e., fibroids, ovarian cysts, endometriosis, or scarring) or responsive to medication (i.e., fibroids, ovarian cysts, endometriosis).

When surgery isn’t preferred or necessary, there are medical therapies to shrink the size of fibroid tumors and reduce the heavy menstrual bleeding associated with them, and other medical treatments have been developed to shrink endometriosis, and reduce the associated pain, including deep sexual pain. These treatments include oral contraceptives, and both the injectable GnRH agonists (i.e., Leuprolide, Triptorelin) and the oral GnRH antagonists (i.e., Elagolix, Relugolix, Linzagolix). These GnRH modulating drugs are used to temporarily create a menopausal hormone milieu, because menopause typically shrinks these pathologies and clears the way for unrestricted movement of the upper vagina.

Typically, medical approaches are favored initially, and surgery reserved as a last resort. However, exceptions to this rule are common. For example, if fibroid tumors are causing infertility or recurrent miscarriages and there is related deep pelvic pain during penetration, surgery may be the only choice that can address all three problems: the infertility, pregnancy loss, and deep pelvic pain.

Additional remedies include pelvic floor physical therapy, including treatments like trigger point injections and pelvic floor “Botox,” which can be helpful in reducing the reactive pain, and can help your pelvic muscles to unlearn the guarding they do related to these disorders.

A very simple and non-invasive at-home remedy for pain with deep penetration is reducing the depth of penetration. Testing various positions that shorten penetration can help to achieve this, as can the OhNut, a wearable device that allows you to customize the penetration depth of penises and/or toys.

What else have you found to help? Comment with any thoughts, questions, or concerns. Or you can always give us a call to setup a consult.

 

References:

Yong PJ. Deep Dyspareunia in Endometriosis: A Proposed Framework Based on Pain Mechanisms and Genito-Pelvic Pain Penetration Disorder. Sex Med Rev. 2017 Oct;5(4):495-507. doi: 10.1016/j.sxmr.2017.06.005. Epub 2017 Aug 1. PMID: 28778699.

Donnez J, Stratopoulou CA, Dolmans MM. Uterine Adenomyosis: From Disease Pathogenesis to a New Medical Approach Using GnRH Antagonists. Int J Environ Res Public Health. 2021 Sep 22;18(19):9941. doi: 10.3390/ijerph18199941. PMID: 34639243; PMCID: PMC8508387.

Orr N, Wahl K, Joannou A, Hartmann D, Valle L, Yong P; International Society for the Study of Women’s Sexual Health’s (ISSWSH) Special Interest Group on Sexual Pain. Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities. Sex Med Rev. 2020 Jan;8(1):3-17. doi: 10.1016/j.sxmr.2018.12.007. Epub 2019 Mar 28. PMID: 30928249.

Eid S, Loukas M, Tubbs RS. Clinical anatomy of pelvic pain in women: A Gynecological Perspective. Clin Anat. 2019 Jan;32(1):151-155. doi: 10.1002/ca.23270. Epub 2018 Dec 3. PMID: 30390350.

Sexual empowerment not only applies to equality in the boardroom of the work place, but in the bedroom as well. Equality in comfort and sexual satisfaction, and equality in the types and numbers of treatments available. Women who have had their last menses sometimes say good-bye to their enjoyable sex lives because of pain during sexual activity, due to vulvar or vaginal changes, lack of lubrication, all of which can affect one’s libido. Societal cues, shame, or embarrassment about this lack of sexual equality are not being addressed enough and there are solutions. These physical symptoms are brought on by menopause, whether medically-induced menopause or natural menopause, but because the symptoms may “sneak up” on a woman, the connection to menopause is often lost, and women commonly assume this is just another symptom of getting older, like arthritis. There is certainly nothing natural about a sudden halt in one’s sexual life when pain and dryness interfere. We have answers.

Why the Disconnect?
Many postmenopausal women are relatively unaware of how the symptoms of menopause affect them sexually, and what treatments are available, according to findings presented at the Annual Meeting of the North American Menopause Society.

Results of the Women’s EMPOWER survey reveal that women generally didn’t recognize vulvar and vaginal atrophy symptoms, and were reluctant to discuss them with their healthcare professionals. This second part is most concerning to me. I’m available to discuss, mitigate, and resolve sexual issues. Participants in the survey also reported that they lacked knowledge about therapeutic options to alleviate these bothersome symptoms. When compared with six previously conducted surveys — REVEAL, VIVA US, Healthy Women #1, REVIVE, CLOSER North America and Healthy Women #2 — evaluating knowledge, behaviors and attitudes related to vulvar and vaginal atrophy, EMPOWER demonstrated yet again that women failed to recognize vulvar and vaginal atrophy symptoms, and were reluctant to discuss them. Further, participants reported that they lacked knowledge about therapeutic options to alleviate the symptoms. But, there is no reason to suffer in silence. Speak up!

Experts such as myself, a reproductive endocrinologist, sexual medicine and menopause specialist, and Clinical Professor at George Washington University in Washington, DC, and my colleagues seek to address these issues and have released a study on a new treatment that will enable women to reclaim their sexual vitality.

The REJOICE Trial
TX-004HR is as soft gel capsule containing low-dose, solubilized, natural, bioidentical 17 B-estradiol.  Our team team conducted a phase 3, randomized, double-blind, placebo-controlled, multicenter REJOICE trial that demonstrated this treatment to be safe and effective for treating moderate to severe dyspareunia (painful intercourse) in postmenopausal women with vulvar and vaginal atrophy (VVA). In total, 764 women were eligible to participate in the study, of which 704 (92%) completed the study.

The study used the Female Sexual Function Index (FSFI) as a measurement of the impact of this treatment on sexual function. The FSFI is a self-reporting tool to assess sexual function during the past 4 weeks. It consists of 19 questions categorized into six domains of sexual function (desire, arousal, lubrication, orgasm, satisfaction, and pain).

VVA affects more than 30 million women who go untreated, in part, because of the perceived risks of estrogen, which I have explained in an earlier post,  Estrogen and Breast Cancer Risk: Separating Fact from Fiction.  But this new treatment  aims to alleviate the symptoms without adding any risk by providing a treatment that goes to the source of the issue, the vagina and vulva, with little or no systemic absorption of estrogen. The REJOICE study compared the effects of 12-weeks of treatment with TX-004HR at varied doses with placebo in postmenopausal women (40 to 75 years old) with VVA and moderate to severe dyspareunia (i.e., difficult or painful intercourse).

The Good News
The research team found that TX-004HR improved sexual function in postmenopausal women with moderate to severe VVA and dyspareunia. After 12 weeks, all three TX-004HR doses increased the average total FSFI score.

This treatment shows promise for women who  experience these symptoms and they should talk with their partners and their medical team to address issues as they arise. If these symptoms are affecting your sex life, I encourage you to give our office a call to help develop a plan for a healthy and happier sexual life going forward.

 

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