8

IT HURTS!

Turn vaginal agony into vaginal ecstasy

You’ve been there . . . a beautiful romantic evening . . . passion and expectation leading to kissing, touching, arousal, and an attempt at intercourse . . . only to find that despite a really great guy and a bucketful of lubricant, the realization that nothing, no how, no way, is going in there . . . or even worse, he enters, but instead of cries of delight there are cries of “Ow, ow, OW, OMG . . . please stop!”

Burning, knifelike, searing, pinching . . . these are the words I have heard my patients use when trying to describe their experience.

For some the agony ends when he withdraws, but other women are in pain for hours, days, or weeks after an attempt at intercourse.

No wonder women decide to go into avoidance mode.

Finding out what is causing pain with intercourse may well be one of the most frustrating things that women must contend with. It’s not unusual for a patient to come to me after seeing three or four other doctors who have said either, “I don’t know why you are having pain,” or worse, “Everything looks fine, just relax!”

Every woman with sexual pain has a story, and I want to hear it. When I ask the following questions, I can begin to understand both the nature of the pain a woman is experiencing and what the cause, or causes, might be.

When did the pain start?

Do you ever have pain-free sex?

What medications are you taking?

Is the pain primarily on the vulva, in the entry of the vagina, or inside the vagina?

Does it hurt immediately on entry or only once he’s inside? Or both?

Does it feel dry?

Does it hurt when you use tampons? When you sit on a bike?

Is there a discharge? Itching? Burning? A rash?

Are there other associated problems, such as incontinence?

Is there pain with bowel movements?

By the time a woman has answered these questions, I generally have a pretty good idea what is going on, but until I take a look and do some testing, nothing is certain.

Dyspareunia: The Name for Pain with Intercourse

The medical word for painful intercourse is “dyspareunia,” which is categorized in two general ways. “Superficial dyspareunia” refers to pain that is limited to the entry and walls of the vagina when there is an attempt at intercourse. In general, superficial dyspareunia is caused by one of the vulvar or vaginal conditions covered in this chapter. “Deep dyspareunia” is the term for when the penis or toy negotiates getting into the vagina just fine, but any thrusting movement causes pain that ranges from achy to sharp to intolerable. The cause may be a gynecologic condition such as endometriosis, a medical condition such as ulcerative colitis, or a side effect of cancer treatment. There are actually more than fifty conditions that may be responsible for deep pelvic pain. Many women experience both kinds of pain: it hurts for him to get in, and then it hurts deep in the pelvis during thrusting.

It’s also not unusual to start with just one kind of pelvic pain—either superficial dyspareunia or deep dyspareunia—but in time end up with both. The reason is simple. If you initially have only superficial dyspareunia, your vagina is not stupid: it is going to try to protect itself from further agony by tightening your pelvic floor muscles to keep the penis out. If you start with deep dyspareunia, the best way for your pelvis to prevent a penis from entering is by not lubricating. In other words, the dryness may not be the initial problem but becomes a protective mechanism to prevent intercourse from occurring. One triggers the other. This is exactly how you get into a vicious cycle of pain.

The body’s protective response to this cycle is often called vaginismus, which refers to the general physical reactions that make intercourse out of the question. The vagina spasms closed, and the slightest touch on the vestibule is excruciating.

An international committee of scientists who met in 2002 defined vaginismus as the “persistent difficulties to allow vaginal entry of a penis/finger/object, despite the woman’s expressed wish to do so. There is a variable involuntary pelvic floor muscle contraction avoidance and anticipation/fear/experience of pain.”

Keep in mind that the anticipation of pain is just as harmful as actual pain, which is why many women are still unable to have intercourse even after the initial physical problem has been eliminated. In other words, vaginismus is not a disease . . . it is a defense mechanism.

Many women respond to this physiological cycle by losing hope. They say to themselves (and sometimes to me), “I will never get better or have pleasurable sex again.” Often they experience persistent anxiety even when they just think about being sexual. A total loss of libido is pretty much inevitable. The only way to break the cycle is to find the cause of the pain, eliminate it, and, if present, treat the vaginismus. This sounds pretty obvious. But in many cases the cause may seem elusive.

Physical Conditions That Can Cause Superficial Dyspareunia

Estrogen deficiency

Vulvovestibulodynias

Lichen sclerosus

Lichen planus

Female genital mutilation

Radiation therapy

Chemotherapy

Graft-versus-host reaction

Congenital malformations

Hypertonic pelvic floor

Dermatologic conditions

Vulvar cancer

Physical Conditions That Can Cause Deep Dyspareunia

Endometriosis

Adhesions

Constipation

Irritable bowel syndrome

Ovarian cysts

Uterine infection

Pelvic organ prolapse

Adenomyosis

Fibroids

Interstitial cystitis

Bladder cancer

Diverticular disease

Fibromyositis

Pelvic infections

Hypertonic pelvic floor

The Exam

The pelvic exam for someone who is having sexual pain goes way beyond the standard annual exam of looking at the vulva, putting in the speculum, and feeling the uterus and ovaries.

First, I do a visual inspection of the skin covering the entire vulva and the vestibule mucosa to check for redness, ulcers, scarring, change in pigmentation, sores, rashes, or dryness.

I then use a cotton swab to touch every part of the vulva and vestibule to detect which parts are painful. Certain conditions affect very specific parts of the vulva and vestibule. Most important is determining whether the pain is inside or outside the Hart’s Line, which is located just inside the labia minora.

Yes, I need to put a speculum in, but if a patient is having severe pain, I use the very smallest speculum possible. In severe cases, I can also use an anesthetic jelly to numb the vaginal opening before inserting the speculum. I then take a careful look at the vaginal tissue to check for any atrophic changes, evidence of infection, or inflammation. Often I check the vaginal pH. If there is an abnormal discharge, I take a sample of the fluid to check for infection.

The speculum exam is followed by the standard bimanual exam (one hand on your belly, with one or two fingers in your vagina) to check your uterus and ovaries for any abnormalities or pain. In addition, I gently push on the bladder to see if there is specific bladder pain consistent with interstitial cystitis. (See chapter 9 regarding pain in the pelvis.) This is followed by a thorough digital exam (applying pressure with a finger inside the vagina) of the pelvic floor to determine which muscle groups are painful or tight. It’s important to differentiate pain from pressure. Sometimes there is a specific trigger point that causes intense pain, as discussed in chapter 6.

“You’re Going to Take a Biopsy from Where?”

In some cases, a sample of tissue from the vulva or vestibule is needed to clinch the diagnosis. This sounds horribly painful, of course, but in reality it’s a minor procedure. Here’s what to expect if your doctor needs to take a biopsy.

After cleaning the area where the biopsy will be taken, your doctor will inject a small amount of local anesthesia, using a tiny needle. You will feel a stick and a burn that will last about three to five seconds. You will feel nothing further other than a little pressure. Your doctor will obtain a tiny sample of tissue (slightly larger than the tip of a match) and then apply either a dissolvable stitch or a drop of medication to stop any bleeding.

After the local anesthesia wears off, you may be a little sore. Usually 400 milligrams of ibuprofen will take care of any discomfort. Do not be alarmed if there is a slight amount of bleeding. You can apply pressure using a pad or tissue. In the rare case of bleeding that is heavy or continuous, you should call your doctor. If the biopsy site burns when you urinate, either gently pat-dry or rinse with warm water. Do not rub the area. Using a blow dryer on a warm setting is soothing if you are sore. Biopsy results generally take three to five days but may take a little longer if the sample is sent to a specialist in interpreting vulvar tissue.

Conditions That Cause Superficial Dyspareunia and Their Fixes

The causes of sexual pain are often complex to diagnose and complex to treat. As much as I wish you could fix anything that’s causing you pain simply by reading this book, that’s not realistic. This is not a cookbook, and my approach is not the only approach. More likely than not, if you suspect that you have one of the following conditions, you will need to see a doctor, not only to get appropriate prescriptions but to confirm the diagnosis. What follows are explanations of the conditions that cause superficial dyspareunia, a general approach to how they are treated, and suggestions on how to facilitate the healing process. Being informed will not only help you when you get to your doctor’s office but calm your fears, I hope, before you get there.

Superficial dyspareunia is generally caused by one of three D’s:

1.  Dynias

2.  Dystrophies

3.  Dryness

The Dynias: Vestibulodynia, Vulvodynia, and Vulvovestibulodynia

When Charlotte on Sex in the City was diagnosed with vulvodynia (aka “the burning vagina syndrome”), awareness of this problem, which affects as many as 15 percent of women, exploded. Dynia is the Greek root for “pain.” Even though the term “vulvodynia” is often used to describe all external genital pain, many women actually have vestibulodynia, also known as vestibulitis. Vestibulodynia is pain confined to the vestibule. This is where pain “mapping” with a cotton swab is important and Hart’s Line (just inside the labia minora) becomes an important landmark. Women with vestibulodynia do not have pain outside Hart’s Line. Vulvovestibulodynia (sometimes called generalized vulvodynia) can affect the entire vulva, including the vestibule. The terminology is confusing, particularly because the same condition may go by various names. I’ve tried to include the most common names to go with the descriptions.

Women with vestibulodynia, no matter what the cause, have severe pain on entry if intercourse is attempted. For some women, the pain and burning associated with vestibulodynia (and vulvodynia) is so severe that it interferes with activities such as riding a bike, wearing jeans, inserting a tampon, or simply sitting and doing nothing. The vestibule may look completely normal, or there may be redness.

Strictly speaking, vestibulodynia is not actually a diagnosis; it is a symptom, essentially “pain in the vestibule.” And just as a pain in the stomach might be gas, it also might be appendicitis. In every case, the burning and pain are due to the proliferation and hypersensitivity of the nerve endings located just outside the vagina. One way to think of it is that women with vestibulodynia have “too many nerve endings.” The result is pain with any physical contact or pressure.

Acquired Vestibulodynia, Inflammatory Vestibulodynia, and Provoked Vestibulodynia

This is the classic “burning vagina” syndrome that women describe as “burning, raw, cutting” pain. Sometimes this condition is a result of chronic inflammation from infections, allergies, or irritants, such as antifungal creams that are used for a presumed infection. There is no end to the possibilities that can cause inflammation to the vestibule—everything from a scented panty liner to that recurrent yeast infection. Any chronic vaginal discharge can cause itching and burning of the vestibule. Allergic reactions also fall into this category. Anything from latex to semen may be the culprit. In many cases there is no identifiable cause.

The Fix

Identify and treat any abnormal vaginal discharge.

Bacterial vaginosis, yeast, desquamative inflammatory vaginitis (see discussion later in this chapter), or even a nasty cervical infection can be the culprit. This is a situation in which you do not want to self-treat a presumed yeast infection.

Eliminate irritants and allergens.

It’s amazing how many everyday products, even those intended for genital use, are loaded with potential irritants. Think of how many products touch your vulva or are applied to your genitals every day—your soap, lubricant, lotion, even your towels if they have been washed in detergent and dried using a fabric softener. Anything with a chemical can be a problem. Take a look at the labels of everyday products and you will be shocked at the number of ingredients you can’t even pronounce, much less would want to intentionally apply to your vulva.

Potential Vaginal Irritants and Allergens

Perfumes

Dyes (as in toilet paper)

Scented soaps

Liquid soaps

Preservatives used in lotions, lubes, and creams

Toilet paper

Sanitary pads

Laundry detergent

Fabric softener

Vaginal lubricants

Antifungal medications

Feminine sprays

Spermicides

Vagisil Feminine Cream

Use medication to “quiet” the nerve endings.

Once irritants are eliminated, the goal of treatment is to desensitize the nerve endings. It can be a frustrating process since a medication that works for one woman may not work for another. Keep the faith. A solution is there, but it might take a little trial and error to figure it out.

Neurologic drugs that “calm nerves” (including vulvar nerve endings!), such as gabapentin and pregabalin (Lyrica), have been successfully used for treatment. If you are prescribed an antidepressant, it is not because your doctor thinks depression is causing your symptoms (even though you may be depressed about them), but because antidepressants that decrease norepinephrine are known to alleviate symptoms. The dosages of the antidepressants prescribed for this purpose are significantly less than those used for depression.

In some cases, an injection of local anesthesia into the painful area or a nerve block injection will “down-regulate” (turn off) sensitized nerves. Capsaicin, an extract from red chili peppers, is an interesting treatment. Initial application causes burning (hardly shocking), but continuous use actually decreases pain since the neurotransmitter that causes the burning sensation gets depleted over time. Don’t expect relief for weeks, but this strategy can work.

Topical Cromolym spray is usually used to treat allergic rhinitis (a runny nose) but can also be sprayed on the vulva. A compounded Cromolym cream is also sometimes prescribed. Antihistamines such as Allegra or Singulair calm the inflammatory response too.

When all else fails, surgical removal of the tender vestibular tissue, a procedure known as vestibulectomy, often solves the problem. It is appropriate as a last resort after every other treatment has been tried, and it is critical that the procedure be performed by a doctor who is very experienced to ensure that you get the best result and also to avoid complications that might make the problem worse.

Congenital Vestibulodynia

About 5 percent of women with vestibulodynia were born with it. So teens who have congenital vestibulodynia don’t use tampons—not because they love wearing pads, but because inserting a tampon is so painful that it’s out of the question. Usually these young women find their way to a gynecologist when they attempt intercourse and experience excruciating pain. Congenital vestibulodynia is one of the most common causes of unconsummated marriages.

The pain associated with this condition is a result of a developmental abnormality that occurs before birth and results not only in vestibular hypersensitivity but also, in 60 percent of cases, umbilical hypersensitivity. So if you are one of those people who hates, hates to have anyone touch inside your belly button, and you also have painful sex, you may have been born with this problem.

The Fix

The same strategies for acquired vestibulodynia are usually the first step in treating the congenital kind. Many experts believe that the only thing that is going to eliminate the pain from congenital vestibulodynia is a vestibulectomy. It sounds radical, but women who have never had pain-free intercourse rarely need to be talked into it.

Atrophic Vestibulodynia, aka Atrophic Vestibulitis or Hormonally Mediated Vestibulodynia

Atrophic vestibulodynia is not the same as vaginal atrophy. With vaginal atrophy, it is specifically the walls of the vagina that are thin and dry. In atrophic vestibulodynia, it is specifically the vestibule, and sometimes the vulva, that is painful from lack of estrogen. In addition to the tissue appearing dry and sometimes thin, there are often bright red patches at the opening of the vagina with this condition. Most women describe the pain on entry during sex as being knifelike. A lack of estrogen is not the only cause of this condition. There are androgen receptors as well as estrogen receptors throughout the vestibule, and these require testosterone, so a lack of testosterone can affect this area as well.

Menopause is the number-one cause of atrophic vestibular issues, which can occur with or without vaginal atrophy. It can also occur in any other condition associated with low estrogen, such as breast-feeding, and with the use of medications that block estrogen pathways, such as certain chemotherapy drugs, tamoxifen, and aromatase inhibitors. Atrophic vestibulodynia is also the number-one cause of sexual pain in young women and is almost always traced back to using a low-dose birth control pill (see chapter 12).

The Fix

Local estrogen treatments, as discussed in the upcoming chapter on menopause, will alleviate the pain, but in addition to a vaginal ring, cream, or tablet, estrogen cream should be applied directly to the vestibule.

A young woman with vestibulodynia who is on hormonal contraception must stop taking the pill and apply estrogen creams to the area. In addition, a topical testosterone cream may also help.

Don’t expect to see any significant improvement for six weeks, since hormone receptors need to be reactivated. It can take up to six months to be 100 percent better.

Posterior Vestibulodynia

The symptom of posterior vestibulodynia is pain that is limited to just the bottom half of the vestibule and does not include the tissue around the urethra. This condition specifically arises from pelvic floor muscles being tight and tender. It really doesn’t make sense that tight, painful muscles would cause pain in the tissue just outside the vagina, but it does. One theory is that since the pelvic floor muscles come together behind the vestibule, there is decreased blood flow and buildup in lactic acid from persistent muscle contraction and chronic inflammation. This can cause not only deep dyspareunia but also vestibular pain and burning as well.

This is why the skin and mucosa look entirely normal with this condition, but the patient experiences excruciating pain at the slightest touch with a cotton swab or finger.

The Fix

As any pelvic physical therapist will tell you, once the pelvic floor muscles are healed (see chapter 6 on pelvic physical therapy), the pain in the vestibular tissue disappears as well. It’s a leap of faith to try pelvic physical therapy, but go with it.

Generalized Vulvodynia

Vulvodynia is, again, not a diagnosis but a description of where the pain is. Many women who are told they have vulvodynia actually have vestibulodynia. Sometimes the condition is referred to as “generalized vulvodynia” to cover all the possible locations for pain—labia, vestibule, clitoris, perineum. In other words, generalized vulvodynia refers to any pain outside the vestibule.

Vulvar pain may be caused by any of the conditions listed earlier that cause vestibulodynia, or it may be caused by one of the following dermatologic, allergic, hormonal, or neurologic conditions. In addition, pelvic floor dysfunction (see Dyspareunia: The Name for Pain with Intercourse earlier in this chapter) can also result in vulvar pain.

The Fix

The key to dealing with any kind of vulvar pain is getting the correct diagnosis and treating the specific condition. You may need one drug, a combination of drugs, and/or pelvic physical therapy. Your doctor may be able to help you, but you may need a consultation with a specialist.

Should Your Vulva Be on a Diet?

A 1991 study suggested that foods high in oxalate (such as peanuts, pecans, and tofu) could cause vulvar burning and pain. While popular for a time, recent studies have shown that a low-oxalate diet is not only almost impossible to maintain but probably doesn’t help with this issue. Some women do find that eliminating certain foods can make a difference. I have one patient whose symptoms disappeared after she eliminated the little red cinnamon candies (sky high in oxalate!) that she was addicted to.

Pudendal Neuralgia

This neurologic syndrome is caused by an inflammation of the pudendal nerve. The pudendal nerve carries sensation from your genitals. The problem occurs if the nerve becomes damaged or entrapped following a coccyx (tailbone) injury or pelvic surgery. Some experts even propose that it can occur from bicycle riding. It is usually one-sided, and the pain extends outside the vestibule to involve the entire vulva and sometimes the clitoris. It is generally at its worst when sitting, but sex is excruciating. Any perineal pressure can cause discomfort, burning, and aching, which is why it is sometimes confused with a vulvodynia. The pain is usually relieved if lying on your stomach or standing.

The Fix

This condition must be treated by a specialist. The pudendal nerve is injected with a local anesthetic, and a medication such as gabapentin or Lyrica is prescribed to desensitize the nerve. Sometimes surgery is required to release an entrapped nerve. Pelvic floor physical therapy is an essential component of treatment.

The Dystrophies

The dystrophies are dermatologic (skin) conditions that are unique to the vulva and vestibule. The majority of women with vulvar dystrophies are peri- or postmenopausal. In the case of dystrophies, the skin does not look normal. There may be discoloration, bleeding, bumps, fissures (splits in the skin), or a rash.

Nearly every one of these conditions can result in chronic itching, discomfort, and scarring if untreated. Scar tissue can even form over the clitoris—and yes, that is painful—and over time the vaginal opening can shrink. This creates a major barrier to entry. While each of these skin conditions has its own characteristic appearance, a biopsy is generally needed to clinch the diagnosis, particularly because constant scratching can make the tissue really inflamed and the condition unrecognizable to the naked eye. A biopsy will also determine whether there is a condition such as eczema, psoriasis, or vulvar cancers or precancers.

Lichen Sclerosus

There is nothing to like about lichen sclerosus (LS). Just about every woman has experienced at least one itchy crotch episode that was so unbearable it culminated in an emergency midnight trip to the drugstore. Over-the-counter remedies will generally do the job if a yeast infection is the culprit, but in the case of lichen sclerosus, no amount of antifungal medication will give relief.

Lichen sclerosus is not an infection or a sexually transmitted disease, but a chronic inflammation of the skin that causes an itching so severe that some women literally scratch until they bleed. One of my patients hadn’t had a decent night’s sleep for months—every time she would drift off she would awaken to find herself scratching furiously. Another patient even confessed to using her hairbrush in a desperate attempt to get some relief.

While LS most commonly affects peri- or postmenopausal women, I have seen it in every age group, including the occasional teen. It’s not clear how or why women get LS, but it is relatively common and affects about one in 70 women. There does seem to be a genetic predisposition, and in many cases it is associated with an immunologic problem such as thyroid disease.

Lichen sclerosus usually occurs on the skin around the clitoris and/or labia, which appears white, thin, and slightly wrinkled. In addition to intense itching, there can be cracks in the skin, bleeding, and pain. Scarring due to this inflammation can cause the labia minora to essentially disappear, and in severe cases the clitoris completely scars over, a condition known as clitoral phimosis.

LS sticks to the vulva and never affects the vagina. However, women with lichen sclerosus have a 4 to 6 percent risk of developing vulvar carcinoma. Lichen sclerosus has been found in more than 60 percent of cases of squamous carcinoma of the vulva. Therefore, treating LS is not optional. A biopsy should be performed, and close follow-up is essential.

Most women know something is amiss because of the itching, the presence of vulvar pain, or the inability to have intercourse. Up to 79 percent of women with lichen sclerosus report chronic vulvar pain. Other women have no symptoms, which is why it is never a good idea to skip your annual gynecologic exam. Someone (other than your sexual partner) should look at your vulva annually even if you don’t need a Pap test!

The Fix

Once the diagnosis is made, relief can be found in the form of Clobetasol, a prescription-strength, high-potency steroid ointment. Clobetasol works best if you take a warm bath first and then massage the cream into the affected area for two to three minutes. A mirror is helpful to ensure that all areas are treated. A follow-up appointment two or three months after initial treatment is important to ensure that all areas have healed. Any areas that have not responded to treatment must be biopsied to ensure that there are no precancerous or cancerous changes to cells.

Once-daily treatment is recommended for the first few weeks, but then is tapered down to once a week. This condition has a high rate of recurrence, so it is important to keep using your medication until cleared by your doctor. While some women are able to eventually stop using the cream and apply it only if symptoms come back, most need to apply the medication on a weekly basis indefinitely to prevent recurrence.

Steroids tend to make the skin thin, so many treatment protocols also require adding a topical estrogen or estrogen/testosterone cream to make the tissue thicker and more elastic. It’s a balancing act: the right combination of steroid and hormone cream does the trick for the majority of women. The hormone cream needs to be applied frequently at first, and then, like the steroid cream, is tapered down to a maintenance dose.

Occasionally a minor surgical procedure may be needed to remove scar tissue, as in the case of a clitoral phimosis.

The most important thing to know is that this is a manageable problem. Virtually every patient with LS is able to restore her sex life and her sanity. So if these symptoms sound familiar, put the hairbrush away and go see your gynecologist.

Lichen Simplex Chronicus, aka Pruritus Vulvae or Hyperplastic Dystrophy

Lichen simplex chronicus is the result of the itch that just doesn’t go away. Basically, some irritant causes an itch. The itch causes scratching, and the scratching causes inflammation and thickening of the skin (known as lichenification) along with the release of histamine. This causes more itching. Sometimes the itching is so bad that the skin starts to bleed or gets infected.

This itch-scratch-itch cycle can be set off by any number of allergens or irritants. In addition, discharge from a vaginal infection may be the root cause of the irritation.

The Fix

Since it is generally impossible to figure out what started the problem, every irritant or allergen must be eliminated to find a root cause. That means no soap, no detergent, and no scented panty liners. Any vulvar or vaginal infection should be treated with oral, not topical, medication if possible. A topical steroid cream such as Clobetasol is then applied once daily. Nighttime scratching can be prevented with a bedtime vulvar ice pack and a low dose of amitriptyline, a tricyclic antidepressant. Unlike other vulvar dystrophies, once treated, lichen simplex chronicus does not return, unless a new irritant is introduced.

Can You Be Allergic to Sex?

It’s pretty obvious that the best way to cope with the average allergy is to simply steer clear of whatever it is you are allergic to. So, while sometimes inconvenient, it is certainly doable to avoid penicillin, shellfish, peanuts, or cats. But what if you are allergic to sex? Yes, there are women who literally break out whenever they have intercourse . . . and abstinence is clearly not a positive solution. Women who are allergic to sex don’t get rash all over their bodies. Typically, their vestibule gets red and swollen after intercourse. There is no pain, discharge, itching, or odor. And unlike most infections, the reaction occurs within minutes after intercourse, as opposed to days later. In most cases, the symptoms spontaneously disappear within a few hours, but on occasion hives and/or trouble breathing can occur.

So what is it exactly that causes the allergic reaction? The problem is actually not the penis or the sperm, but the semen, or more specifically, the proteins that are present in seminal fluid. Before you replace your partner, be aware that once you are allergic to semen, you often react to the proteins in any semen, not just a specific man’s semen. Sometimes, though, the allergens are in certain medications, food, or even cola ingested by the man and then transmitted through the seminal fluid, thus causing an allergic reaction in his partner.

A true semen allergy is a difficult predicament. Using a condom is the simplest way to eliminate the problem. If condoms are not an option, the use of an antihistamine or vaginal cromolym sodium (an allergy medication) will often help, especially if you have a mild case. It’s important to first have your gynecologist make sure that no infection is present. An evaluation by an allergist is the next step to confirm that what you are experiencing is indeed an allergic reaction. In addition to making the diagnosis and prescribing an appropriate medication, allergists can actually “desensitize” a woman to semen using injections similar to allergy shots.

If the problem occurs only after having sex with a condom, keep in mind that a latex allergy is another cause of post-intercourse redness and swelling and can be acquired even after years of successful condom use. In that case, the remedy is to use a lambskin or polyurethane condom. Also, nonlatex condoms break more often than latex condoms, so a spermicide backup is a good idea. The nonlatex female condom (FC2) is also an option. As an aside, if you have a latex allergy, it’s important to inform your gynecologist so that he or she will know to use nonlatex gloves during your examination.

If it’s not his semen and not latex condoms, it could be your vaginal lubricant or spermicide that is eliciting the allergic reaction. So before you give up sex altogether, it’s probably a good idea to try eliminating that strawberry-flavored lube your boyfriend gave you last Valentine’s Day.

Lichen Planus

Lichen planus (LP) is a less common inflammatory autoimmune disease that affects the vulvar skin. It is most commonly found in the soft tissue of the mouth and gums. Approximately 25 percent of women who have oral lichen planus also have genital lesions. Whereas lichen sclerosus is white and looks a little like cigarette paper, lichen planus has bright red shiny patches with lacy borders. Like other vulvar skin conditions, women with lichen planus experience itching, burning, pain, and soreness. Unlike lichen sclerosus, the lesions of lichen planus can also be found on vaginal tissue and can even obliterate the vagina if there is severe scarring.

The Fix

Lichen planus is more challenging to treat than lichen sclerosus. A steroid cream such as Clobetasol, along with a calcineurin inhibitor (a cream usually used to treat psoriasis), is usually successful. Vaginal dilators are usually recommended not only to prevent vaginal adhesions but also to apply steroid cream to the vaginal walls.

Desquamative Inflammatory Vaginitis

Desquamative inflammatory vaginitis (DIV) is a vaginitis that has gotten so out of hand that excessive discharge loaded with white blood cells pours out of the vagina and leaks onto the vulva. Women often describe yellow, sticky, gluelike discharge with this condition. DIV can be initiated by a vaginal infection or by severe inflammation from vaginal atrophy. Women with DIV are the ones who don’t dare go out without a panty liner to protect their underwear. Usually the vaginal pH is elevated with DIV, since the good lactobacilli have vacated the neighborhood.

The Fix

A vaginal antibiotic such as metronidazole or clindamycin, along with a vaginal estrogen, will usually alleviate this problem. Sometimes a vaginal hydrocortisone is used as well. DIV usually clears up quickly (in a week or two) once it is properly treated.

Superficial Dyspareunia and Dryness

Vulvovaginal atrophy—or more simply, dryness—is also a common cause of superficial dyspareunia. As discussed throughout the book, while lack of estrogen from menopause is the most common cause of vaginal dryness, it is not the only cause. Circumstances that reduce natural lubrication in younger woman include:

Postpartum

Hormonal contraception

Chemotherapy or radiation treatment

Stress is also known to have an impact on dryness. I don’t mean stress about being dry, but rather life stress that affects the vagina’s natural ability to lubricate. Add medications such as antihistamines, decongestants, anticholinergics, and tamoxifen to the list, along with cigarette smoking and infrequent intercourse—all of these things can create dryness issues.

No matter the cause of vaginal atrophy, the fixes are available and covered in chapter 13. If the dryness is a reaction to pain from another source, the pain must be eliminated.

Further Tips on Healing

No matter what the condition, your vulva, vagina, and pelvic floor have been traumatized and need to heal. In addition to the specific treatments recommended by your physician, the following tips will help the healing process. Many have already been mentioned but bear repeating:

Avoid Irritants

Avoiding irritants and allergens is critical. Make sure your lubricant is free of preservatives (see chapter 5). Many doctors prescribe an antifungal cream assuming that the pain is from a chronic yeast infection. If yeast has not been diagnosed, chances are that you don’t need this medication and it will be a huge irritant. Find a soap and a detergent that are not loaded with chemicals, or better yet, just wash your body (and your underwear) in warm water.

Keep in mind that urine, because it is acidic, is also an irritant.

No, I’m not going to suggest that you stop urinating, but separate your labia to ensure the urine stream goes straight into the toilet instead of splashing all over your vulva. Toilet paper is also a problem. If you are lucky enough to have a bidet, use it! If not, a bottle with a squirt top is ideal to use in washing the area with warm water before patting it dry with a cotton cloth. Some women also apply zinc oxide ointment or Aquaphor to protect the skin.

Numb the Area

Whether you are attempting intercourse or inserting a dilator, it sometimes helps to numb things up. Keep Cool Water Cone dilators (coolwatercones.com) in the fridge and place in your vagina both pre- and post-intercourse to relieve the burning and pain. Benzocaine, which is the anesthetic in Vagicaine and Vagisil, is often irritating and a common cause of allergic contact dermatitis and should be avoided. Your doctor can give you a prescription for lidocaine gel or ointment to both alleviate pain and short-circuit the nerve impulses. When you first apply the gel, it may be irritating, but if you give it a minute, numbness will set in. Some women apply it right before intercourse and find that it makes an enormous difference. Partner alert: let him know his parts may get a little numb as well.

Neogyn

As previously discussed, Neogyn is marketed as a “vulvar soothing cream.” Although it may well win the prize for worst advertising campaign ever (“Do you suffer from chronic feminine discomfort . . . DOWN THERE?”), it happens to be an excellent product that facilitates healing of any vulvar condition when applied twice weekly. The active ingredient is a cutaneous fibroblast lysate with human cytokines. In English, these are proteins that aid in wound healing.

It has been shown to be effective for pretty much any of the conditions discussed in this chapter to promote healing and decrease pain. In some studies, it is used instead of prescription medications for the treatment of vulvar dystrophies and vulvovestibulodynia. While I wouldn’t recommend that (it’s too early to know if it is effective enough), it is an excellent adjunct to prescribed treatment. Do not expect results for at least six weeks. It can be purchased without a prescription but currently is only available directly from the manufacturer’s website (www.neogyn.us).

When dealing with any kind of pain associated with intercourse, sometimes you are better off avoiding an actual penis until the problem has been solved. Since in severe cases superficial dyspareunia will cause your pelvis to panic and your vagina to contract as a protective mechanism, pelvic physical therapy and/or vaginal dilators may be needed to teach your vagina that putting something in it will not be painful.

Nothing Is Working

I’ve just discussed the most common causes of sexual pain that arise from vulvar and vestibular conditions, but there are other, less common conditions that can be culprits as well. When it comes to pinning down one of these sometimes elusive diagnoses, or if you’ve been treated for one of the conditions I’ve discussed here and it is not getting better, a visit to a vulvar vaginal center (see the resources section) is in order, even if it means getting on an airplane to do so. As one woman I met when I was visiting Dr. Andrew Goldstein’s clinic, the Center for Vulvar Vaginal Disorders in New York, said, “This trip is costing double what my trip to Florida last winter cost, but when I got home from Florida, I still had painful sex. I figure this is a much better use of my money.”

More information about vulvovestibuldynia can be obtained by going to the National Vulvodynia Association website, www.nva.org.

The Small Vagina Issue

Before I close the chapter on superficial dyspareunia, I want to address those women who have a vaginal opening that has become too small and inelastic for the penis in their life. Normal vaginas are able to stretch enough to accommodate a baby’s head and should therefore be able to accommodate a penis of pretty much any size. Sometimes a vaginal opening has shrunk, however, and is no longer elastic owing to scarring, poor blood supply, radiation treatments, lack of estrogen, surgery, or a vulvar dystrophy. There is also such a thing as a vagina that is too tight following reconstructive surgery. Obviously, during a surgical repair of a gaping or scarred vagina, the surgeon has to make a judgment call as to the appropriate size to make the opening. Fortunately, vaginal tissues are elastic and will accommodate pretty much any size penis. Sometimes, though, even with lubrication, intercourse after repair is impossible since the vaginal opening may be too small and has lost elasticity.

All of these scenarios are fixable, but there is no getting around the need for dilators and in some cases additional surgery.

Partners

While sexual pain sometimes comes when a dildo or vibrator is used, most painful entry disorders include a male partner. I would be remiss to not at least address the fact that, unless you are entirely self-sexual, some of what may be causing you pain is the other person involved.

Indeed, studies show that many women, despite severe pain, continue to have sex to please their partner. They do this primarily because they fear the loss of the relationship. I have had more than one woman tell me, “I really feel sorry for him, so I grit my teeth and do my best to get through it.” The guys are generally well aware that the pain is occurring, and sometimes, in a well-meaning way, they make it much worse by saying things like, “This pain is terrible. I’m worried you are never going to get better!” A 2013 study in the Journal of Sexual Medicine showed that this kind of “support” actually makes sexual pain worse.

It’s also not unusual to “protect your pelvis” by intentionally or unintentionally sabotaging your relationship so that he doesn’t even attempt intercourse. In any case, be aware of the profound effect that painful sex has on your relationship, communicate what is going on, and consider couples therapy to fix the emotional and relationship damage that your broken vagina may have caused.