By Nicole Davis
In 2012, The Journal of Sexual Medicine published an article, What we don’t talk about when we don’t talk about sex: results of a national survey of U.S. obstetrician/gynecologists. The results from the survey revealed that though Ob/gyns routinely (63%) assess their patients’ sexual activities, only 40% of them ask their female patients about sexual problems. Sexual problems may include low desire, difficulty lubricating, pain during intercourse, lack of pleasure or inability to orgasm. Ob/gyn respondents to this survey also reported that they inquired even less frequently about sexual satisfaction, sexual orientation/identity or pleasure with sexual activity.3 Fast forward six years, I would not hesitate to say that these numbers have improved as we at PHRC regularly receive pelvic floor physical therapy referrals from Ob/gyns for sexual dysfunction. Interestingly, the patients that are referred to us from Ob/gyns and other speciality physicians and providers cover across the lifespan – young adults, postpartum, perimenopausal, etc. These women express similar complaints, namely painful intercourse.
Painful intercourse aka dyspareunia is probably one of the most common diagnoses that my colleagues and I treat at PHRC. Oftentimes we find that the pelvic floor muscles of our female patients with dyspareunia are hypertonic and/or filled with myofascial trigger points. Read Shannon’s blog for more specifics on Your Pelvic Floor: What Is It Good For? Manual therapy combined with other physical therapy treatment techniques can successfully address these myofascial findings. Sometimes this is enough to resolve pain during intercourse. Sometimes it is not. Just as frequently as we see tight muscles or knots contributing to a patient’s pain symptoms, we also sometimes discover hormonal and psychological components – meaning the treatment is multifactorial. What does this mean exactly? A brief spiel on hormones: all the vulvovaginal tissues (the clitoris, vestibule, vaginal walls, etc.) are estrogen and testosterone dependent. Disrupting the available hormones to these tissues can create fragility that is aggravated with friction or intercourse. Check out our blogs on how these hormones may be impacted by oral birth control pills, postpartum, or perimenopasual. If a patient presents with vulvovaginal atrophy, using topical hormones can help restore the integrity of these tissues.
And what about the psychological component? Pain is a mind-body experience meaning there are both physical and psychological factors. When I say psychological it does not mean that the pain is in your head. This is never the case. Take a look at the illustration provided by Dr. Andrew Goldstein and referenced in Rachel’s blog here :
Pain during intercourse can create and reinforce this negative psycho-emotional feedback loop. If the women pushes through the pain, the brain can start to associate sex with pain and even just fear or anticipation can increase the pain response. Pavlov. These psycho-emotional components can not be physically manipulated. This is where sex therapy comes in. Sex therapists are licensed providers that have at least a master’s degree in counseling or therapy related field with additional specific sex therapy training. They know their stuff and have become one of my most relied upon referrals for my patients with dyspareunia. They help address some of those aforementioned parts of sexuality that are sometimes missed by other medical providers (i.e. low desire, sexual satisfaction, pleasure, etc.). And those of my patients that have fallen into this pain loop have benefited immensely from working with a sex therapist. Sex therapists can collaborate with patients to help break this pain cycle.
However, their skills and expertise go much beyond this; I have found that some patients have had difficulty transitioning their successes with physical therapy to the sexual relationship. What do I mean by this? At reassessment, their pelvic floor muscle are normal and they can insert their largest dilator on their own comfortably, but when they attempt intercourse they are either still experiencing some discomfort or not experiencing much pleasure. In these cases, sex therapists can work with their patients and partners on restoring the pleasure piece. Including a significant other in the treatment process also makes it it less about fixing her sexual problem and more about developing a healthy partnership and sex life.
Now let’s delve a little into the research which focuses on cognitive behavioral therapy (CBT), which can be delivered by a sex therapist, as a way of reducing fear of pain and reestablishing satisfying sexual functioning. Cognitive behavioral therapy can help bridge the gap between physical therapy and pain reduction in the sexual situation. Modalities may include education and information about how dyspareunia affects desire and arousal; education concerning a multifactorial view of pain; education about sexual anatomy; progressive muscle relaxation; diaphragmatic breathing; vaginal dilation; distraction techniques focusing on sexual imagery; rehearsal of coping self-statements; communication skills training; and cognitive restructuring.4
In a relatively recent randomized clinical trial, researchers assessed how group cognitive behavioral therapy vs. a topical steroid impacted dimensions of dyspareunia in patients with vestibulodynia (pain in the vestibule, a common co-diagnosis). The intervention consisted of either 13 weeks of group CBT that included 10, two-hour group sessions with prescribed home exercises or twice daily application of 1% hydrocortisone cream for 13 weeks. Results revealed that though both groups showed statistically significant reductions in pain during intercourse and improvements in sexual function immediately following interventions and at six-month follow up, the group CBT group showed significantly more pain reduction (via McGill Pain Questionnaire) and improvements in sexual function (via Female Sexual Function Index) at six-month follow up. Similarly, though both groups showed statistically significant reductions in psychological adjustment (via Pain Catastrophizing Scale) the group CBT group had significantly greater reductions in pain catastrophizing post treatment. Additionally, those that received group CBT reported higher treatment satisfaction and self-reported improvements in pain and sexuality.1
Brotto and colleagues took these findings a little bit further in 2015 by researching the impact of a multidisciplinary approach on dyspareunia and sexual functioning in women with provoked vulvodynia (pain in the vulva, another common co-diagnosis). In their study, 116 women were enrolled in a 10-week hospital-based program that integrated psychological skills training, pelvic floor physical therapy and medical management. Participants attended the following courses: an introductory one-hour gynecologist group education seminar discussing the pathophysiology of provoked vestibulodynia and the medical, behavioral and surgical treatment; a one-hour gynecologist or psychologist led educational seminar reviewing the circular sexual response cycle and impact of genitalia pain on sexual desire, arousal and satisfaction; three two-hour counselor or psychologist led sessions that utilized the fear-avoidance model and CBT to illustrate the link between problematic thoughts, feelings, behaviors and pain. The women also attended three individual one-hour pelvic floor physical therapy sessions that focused primarily on providing education about the role of the pelvic floor muscles and their relationship in maintaining pain with provoked vestibulodynia; biofeedback with surface electromyography; pelvic floor muscle relaxation; and use of vaginal dilators. Manual therapy was not performed due to limited treatment time (though I anticipate this would have further strengthened the intervention). Lastly, participants had a final discharge appointment with a gynecologist to discuss their progress during the program, how to use the information and skills acquired during the program once discharged from the program and recommendations for ongoing professional management. Following this protocol, the authors observed strong significant reductions in dyspareunia and sex-related distress as well as improvements in sexual arousal and overall sexual functioning. Modest significant improvements were also observed in sexual desire, lubrication, orgasmic function and sexual satisfaction. All findings were maintained at two to three month follow up.2
Though both of these studies took a group CBT approach and neither specifically included the women’s partners in their interventions, I would 100% of the time recommend sex therapy for patients that have fallen into the pain cycle. The evidence in these studies suggest great benefits and the anecdotal evidence I have seen in the clinic is overwhelming. You can locate a sex therapist in your area here: https://www.aasect.org/referral-directory and many also offer video appointments.
- Bergeron et al. A randomized clinical trial comparing cognitive-behavioral therapy and a topical steroid for women with dyspareunia. Journal of Consulting and Clinical Psychology. 2016; 84(3);259-268.
- Brotto LA et al. Impact of a multidisciplinary Vulvodynia program on sexual functioning and dyspareunia. J Sex Med. 2015;12:238-47.
- Sobecki JN et al. What we don’t talk about when we don’t talk about sex: results of a national survey of U.S. obstetrician/gynecologists. J Sex Med. 2012 May; 9(5):1285-94.
- Ter Kuile MM et al. Cognitive behavioral therapy for sexual dysfunctions in women. Psychiatry Clinic N Am. 2010; 33: 595-610.