Ob/gyns must accept and acknowledge that sexual pain is a physical pain condition, not a sexual dysfunction or a psychological disorder. Some patients have wasted months or longer in sex therapy, when in fact pain was the primary issue, and function could not be helped until pain was recognized and treated. Once this fact is established and a patient is invited to become a partner in caring for this upsetting medical condition, healing can occur. A mental health therapist who is knowledgeable about the physical causes of painful sex may then join the team.
Couples counseling is valuable, as the intimate partner often suffers along with the patient, and may experience sexual dysfunction and mood disorders. Stress reactions often accompany sexual pain, affecting the immune and autonomic nervous systems (ANS), which affects physical healing.11,12 Coping strategies and mind-body therapies such as meditation and yoga mitigate the physical consequences of stress.13-15
The layered approach
When I first began to care for women with sexual pain, organized evaluation methods were unavailable. Not wanting to miss any causes or triggers of pain, I developed for my own benefit a layered approach to evaluating the pelvis that soon became a teaching tool for patients and students. At that time, only 2 layers were recognized as causing sexual pain: the surface (vulva and vagina) and the internal organs (eg, endometriosis). I knew that the structures between those 2 layers needed to be evaluated: the muscles, nerves, connective tissues, bones, and joints of the lumbopelvic region. Working closely with pioneering pelvic physical therapists (PTs) who were steadily gaining an understanding of these “in between” layers, I realized that most sexual pain intimately involved these structures.
The most revealing step in evaluation is obtaining a complete history, which establishes rapport and validates a patient’s pain. Supplement with forms such as the International Pelvic Pain Society’s, which is available at www.pelvicpain.org. Include baseline self-reported pain measures, such as the Visual Analog Scale (VAS), and the Vulvar Pain Functional Questionnaire (VQ).16 The patient should be fully clothed, seated with you in a private consult room, if possible, and given time to detail her history, including childhood symptoms.
What sexual activities, positions, menstrual cycle phase, and other triggers cause or worsen her pain? Is the pain burning, raw, itching, cramping, sharp, or knife-like? Allow her to use her own words. Did it begin after starting combined hormonal contraception or other medications? Is her pain provoked by simply touching the vulvar surface, is it more intermediate in location within the vaginal canal, deeper with full penetration, or a combination of these? Give her a diagram of the vulva to mark and include in her chart for future comparisons.
What are the patient’s short and long-term goals? Specific goals may vary greatly among women. She may want to be able to sit through a whole movie with her partner without severe pain, perform specific sexual activities or positions, use a vibrator or tampon, conceive naturally with intercourse, or avoid days of pain after sex. Clarifying goals early, in writing, can be enlightening to a patient, and periodically reviewing progress during treatment serves as an objective measure of improvement.
Because of the time constraints of most busy ob/gyns, this part of the evaluation often takes up the entire first visit. Prepare the patient for this and reassure her that your full understanding of her pain and previous treatments promotes effective care. Because the physical exam is detailed and cannot be rushed, schedule a second visit in the very near future to perform it. If a patient brings up her chronic sexual pain during a scheduled routine checkup, it may be best to postpone the exam; devote the rest of the allotted time to obtaining the all-important history. Provide the patient with written or online educational materials for self-care between visits.
At the second visit (or the first, if time allows) perform a layer-by-layer exam as described below, and formulate working diagnoses. Schedule testing as needed and formulate a preliminary treatment plan. Be open at all visits for an intimate partner or other support person to be present, take notes, add overlooked items to the history, and help the patient to feel safe, which is especially important for women who have had demoralizing experiences with other healthcare providers. You may be the first person to whom the patient has revealed her pain, and she may be nervous.