Some sexual pain can be an indicator of a deeper problem
My new patient Valerie was beyond frustrated.
“You’re the fourth doctor I have seen about this. Every other doctor I talk to about painful sex just keeps telling me to use more lube. If I use any more lube, my husband and I are going to both slide off the bed!”
She went on to tell me that she never felt dry, even without the bucketful of slippery stuff she had been advised to use. Her problem was that the slightest little thrust caused excruciating pain. The first doctor Valerie had consulted informed her that her exam was “normal” and told her that she should keep at it. The second ordered an ultrasound and CT of her pelvis. Also normal. The third sent her and her husband for couples therapy. At that point getting a concussion from sliding off an overlubed bed and banging her head seemed infinitely more likely than getting any relief from her pelvic pain.
Distinct from superficial dyspareunia (which you read about in chapter 8), deep dyspareunia can be gynecologic in nature, but it can also be due to gastrointestinal, bladder, musculoskeletal, psychological, or neurologic problems. Fibromyalgia and other pelvic floor muscle disorders have also been identified as culprits.
The cause of deep pelvic pain related to sexual activity is often challenging to diagnose. Your gynecologist may not be thinking about irritable bowel syndrome, your internist may not be thinking about endometriosis, and nobody may be thinking about interstitial cystitis. To make things more complicated, most of these problems are not detectable through blood work, ultrasound, or X-rays. What is required is a high level of suspicion and thinking “outside the box.” It is not unusual for a woman to visit two (or three or four) doctors to get the right diagnosis. In many cases the correct diagnosis isn’t made without a surgical exploration. The purpose of 20 percent of the laparoscopies conducted today is to evaluate chronic or persistent pelvic pain.
Sometimes no identifiable cause for the pain can be found. When this happens, a woman is often told, “It’s all in your head.” This may be true for a very rare few (those suffering from psychiatric conditions, for instance, or from post-traumatic stress due to a history of sexual abuse), but it is not common.
If you are not getting answers to why you experience persistent pelvic pain, it is worth finding one of the gynecologists who specifically deal with chronic and deep pelvic pain. Only when the cause of the pain has been determined can treatment be instituted. What follows is a brief discussion of the conditions that can be responsible for deep dyspareunia. This is not intended to be a complete list, but rather an introduction to the more common conditions to point you in the right direction. More details, including a comprehensive discussion of treatment options, can be found in my book The Essential Guide to Hysterectomy.
Endometriosis
While there are many problems that can cause pelvic discomfort, there is no question that endometriosis is the culprit for the vast majority of women who suffer from the chronic pelvic pain associated with deep dyspareunia. Basically, endometriosis is a condition in which the glandular tissue that normally lines the uterine cavity appears in other places, such as the lining of the pelvis, the fallopian tubes, the ovaries, the bowel, or the bladder, and even in unusual places like the lung. Each month during menstruation, this tissue responds to hormonal changes, just like the tissue that lines the uterine cavity. Since the tissue is not where it’s supposed to be, various problems can ensue, such as inflammation, ovarian cysts, painful intercourse, infertility, adhesions, and excruciatingly painful periods that get worse with time. The degree of pain is not necessarily related to the visible severity of the endometriosis. Women who appear to have minimal endometriosis sometimes suffer the most.
Who Gets Endometriosis?
Any menstruating woman can have endometriosis, but it is most commonly found in women who have no children and who are between the ages of 25 and 40. It is estimated that 7 to 10 percent of premenopausal women have endometriosis. Historically, teenage girls just weren’t supposed to have endometriosis. The monthly pain that would make an otherwise healthy 16-year-old eat ibuprofen like candy, miss school, and crawl into bed on a Saturday was just “bad cramps.” We now know that is not the case. In fact, one study showed that 52 percent of teenage girls with severe chronic pelvic pain had surgically proven endometriosis.
There can also be a genetic predisposition for endometriosis. Women with an affected first-degree relative, such as a mother or sister, are at higher risk than women with no family history of this disorder. Women with shorter intervals between periods and women who bleed eight days or longer are also at increased risk.
How Do You Get Endometriosis?
There are lots of theories for how the endometrial glands get outside the uterus, but no single one explains the disease in everyone. Most researchers in the field feel that there is no one explanation for endometriosis but that many mechanisms are responsible for it. Everyone agrees that it is not infectious or sexually transmitted.
How Do You Know if You Have It?
Endometriosis doesn’t show up on ultrasound or X-rays. Often, it is suspected on the basis of symptoms such as painful periods, pain during intercourse, and infertility. A pelvic exam is sometimes suggestive, but the only way to know definitively if someone has endometriosis is to surgically look inside. Obviously, it’s not appropriate for every woman with severe cramps to have surgery to determine if endometriosis is the cause, but if things are no better despite treatment, a laparoscopy is in order. Many cases of endometriosis are discovered when women have surgery for other issues.
The Fix for Endometriosis
Most conservative treatments for endometriosis do not require definitive diagnosis. If a woman has horrible periods and painful intercourse and endometriosis is suspected, it is perfectly reasonable to seek improvement of symptoms by trying different medical treatments.
It is also reasonable to do nothing in a known case of endometriosis if a woman has minimal or no symptoms, is not interested in conceiving, or is very close to menopause.
Treatment is divided into two categories: medical and surgical. Sometimes medical and surgical treatments are combined. The choice of treatment depends on the age of the patient, the desire for pregnancy, and the severity of the symptoms.
Medical Treatments for Endometriosis
Nonsteroidal Anti-inflammatory Drugs
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen have always been useful to treat the pain associated with endometriosis, but they are usually not adequate for women with severe cases. It helps if the medication is started as soon as there is any pain, or even better, before there is pain. If women who have predictable periods start medication before bleeding starts, they can usually get much better relief than if the pain is well established.
No Period—No Problem
The easiest way to suppress mild to moderate endometriosis is to suppress menstruation, and the best way to do that over the long term is by taking continuous hormonal contraceptives. Some women are uncomfortable with the idea of eliminating their period and worry that there will be a buildup of tissue or some other side effect. In reality, women on the pill have thin uterine linings that do not require monthly shedding, and it is in no way detrimental to long-term health or fertility to not get a period.
There is actually no medical reason for a woman to take a week off and get her period if she is taking hormonal contraceptives. The scientists who developed the pill provided a pill-free week in which a “period” occurs only so that women would be more comfortable taking it. There is also documentation that the early developers of the pill naively thought that the Catholic Church would accept the pill as “natural birth control” and permit its use if it maintained normal menstrual cycles. Some even believe that misguided (male) scientists thought that women taking the pill would still want to get their period—to make them feel young and womanly!
Not only is it okay to fool Mother Nature, but for many women there is a significant medical benefit in not having a period. Menstrual cramps, hormonal migraines, heavy bleeding, and pain from endometriosis are all reduced or eliminated by taking an active pill every day. In truth, estrogen/progestin pills should be known by a name other than “birth control pills” since many women take them solely for the noncontraceptive benefits.
Some women are concerned that it is not “natural” to eliminate a period. That’s true. But it also is not natural to be on the pill. What is natural is to be pregnant or nursing all the time. And then you die.
Traditionally, since insurance companies covered only 12 packs of pills a year, no matter how many polite letters (using small words) they were sent explaining the medical logic, taking continuous pills has been a logistical nightmare. Fortunately, though, many companies are now manufacturing extended-cycle regimens, which make this an easier approach. The development of the birth-control patch and the vaginal ring has also expanded options for the woman who finds it difficult to take a pill every day.
For some women, menstrual suppression is not an option. While most women feel well on hormonal contraception, some women simply don’t tolerate it and despite multiple attempts with multiple varieties continue to have problems with breakthrough bleeding, headaches, depression, or other side effects. Some women can’t take estrogen, such as those with a history of blood clots, smokers older than 35, or women with breast cancer. And of course, there are the women for whom hormonal contraception causes a loss of libido or vaginal/vestibular pain (see chapters 8 and 11). Progestin-only contraception, such as a Mirena IUD, has also been shown to suppress endometriosis and can be used even by women who cannot take estrogen.
GnRH Analogue Injections
Gonadotropin-releasing hormones (GnRH) analogue injections temporarily shut off estrogen production and suppress menses, causing endometrial implants, inflammation, and cysts to become inactive and to regress. GnRH is not recommended for more than six months, since low estrogen levels over a long period of time may result in bone loss. Once GnRH is stopped, endometriosis recurs.
One use of GnRH is to test a woman to determine the source of pain. If it’s not clear whether chronic pelvic pain is from endometriosis or some other cause, a course of GnRH will clarify the diagnosis. Pain from a urologic or gastrointestinal problem will not improve with GnRH. Sometimes a short-term course of GnRH is followed by long-term menstrual suppression with hormonal contraception.
Surgery—Conservative
In conservative surgery, the effects of endometriosis are removed but the uterus and ovaries are preserved.
One of the limitations of conservative surgery is that doctors can only remove what they see. Some endometriotic glands are always present microscopically within tissue, invisible to the naked eye, and therefore go untreated. If pregnancy does not follow surgery, suppression with continuous hormonal contraceptives is usually recommended to delay or prevent recurrence.
Surgery—Definitive
Definitive surgery is hysterectomy and removal of the ovaries. The decision to choose conservative or definitive surgery for endometriosis is made based on the severity of symptoms, age, the desire for pregnancy, and personal preference.
Hysterectomy is appropriate if pregnancy is not desired and if debilitating symptoms persist despite medical treatment. Removal of the ovaries in young women is, of course, controversial. Since endometriotic implants occur outside the uterus and respond to hormones released from the ovaries, removal of the uterus alone will not prevent endometriosis from persisting in the ovaries, pelvic lining, bladder, and other organs if the ovaries remain and continue to cycle. Traditionally, the recommendation for women with severe endometriosis has been to remove the ovaries in order to ensure that no residual endometriotic implants can be stimulated. Post-hysterectomy estrogen therapy is appropriate and has not been shown to cause recurrence of endometriosis symptoms.
Many women, in spite of severe endometriosis, do not want to go into menopause and choose to preserve their ovaries. While removal of the uterus alone will definitely lead to improvement of symptoms, issues related to endometriosis may still occur until the onset of natural menopause. If a woman is made aware of that, preservation of ovaries is an option. The only real “cure” for endometriosis is menopause, either natural or surgically induced.
Adenomyosis
It’s beyond maddening to contend with monthly heavy bleeding, incapacitating cramps, and pain during intercourse, only to be told that it’s not due to fibroids, endometriosis, hormonal problems, or any other identifiable gynecological issue. One diagnosis that is overlooked far too often is adenomyosis, a condition in which the glands that usually line the cavity of the uterus infiltrate deep into the wall of the uterus, resulting in bleeding and pain beyond even the worst of menstrual periods.
Adenomyosis is essentially a cousin to endometriosis. Whereas in endometriosis the glands that line the uterus get outside the uterus, in adenomyosis the uterine glands that usually line the cavity of the uterus burrow into the muscle (the myometrium) of the uterine wall. This condition results in an enlarged, softer than usual, and quite tender uterus. Painful periods and abnormally heavy bleeding are common in women with adenomyosis, but many women feel no symptoms at all and the disorder is discovered only when the uterus is removed for another reason.
Deep dyspareunia is often present with adenomyosis and is triggered when the penis hits the swollen, inflamed uterus. The diagnosis of adenomyosis is rarely made with certainty, since the only way to be certain is to look microscopically at a uterus that has already been removed. Women with adenomyosis often also have a painful hypertonic pelvic floor as a result of chronic pain.
Like endometriosis, adenomyosis doesn’t show up on an ultrasound or X-ray. Since the glands are buried in the wall of the uterus, they can’t be seen during laparoscopy, which inspects only the outside of the uterus, or hysteroscopy, which surgically visualizes the interior cavity of the uterus. An MRI can sometimes be useful in getting to a diagnosis but is not routinely done owing to its high expense.
The Fix
Treatment options for adenomyosis are essentially the same as for endometriosis. A trial of continuous oral contraceptives, or GnRH, may be beneficial. If medical therapy doesn’t result in adequate relief, the definitive therapy continues to be hysterectomy. Unlike endometriosis, removal of the ovaries is not beneficial or necessary with this issue, since the problem only occurs inside the uterus. Symptoms resolve with the onset of menopause, so waiting it out is always an option, though not a very pleasant one.
Adhesions
Adhesions are commonly thought of as “scar tissue” but are not the same thing as scar tissue at all. Scar tissue refers to changes that occur as part of the normal healing process. Adhesions, on the other hand, refer to an abnormal tissue reaction that causes internal organs or structures, such as the small intestines, to adhere or stick to other structures. Adhesions can occur as a result of surgery, infection, endometriosis, or inflammation, or for no apparent reason whatsoever. Prior surgery is generally the biggest culprit, but some types of surgery are more likely to result in adhesion formation than others. In general, laparoscopic or robotic-assisted surgery, as opposed to traditional surgery performed through a large abdominal incision, tends to minimize the likelihood of adhesion formation.
Most women with adhesions have no symptoms and are unaware of their presence. But adhesions can be responsible for a myriad of problems, including bowel obstruction, infertility, and, in some cases, pelvic pain.
For example, structures such as ovaries, tubes, or loops of bowel can adhere to the back of the vagina and be responsible for deep dyspareunia. The pain when the penis hits the ovary is much like the pain a guy experiences when he gets kicked in the testicles.
Interestingly, the way a skin incision heals is not a reflection of the way things heal on the inside. Many women with invisible abdominal scars have terrible intra-abdominal adhesions, yet someone with a thick, raised scar may be perfect inside.
The Fix
Not infrequently, the tissues soften up and the pain dissipates over time and with continued sexual activity (if you are able). Pelvic physical therapists are often able to work with tender trigger points from trapped nerves or adhesions to manipulate tissue and decrease inflammation.
On occasion, however, a surgical procedure is needed. One memorable patient started to have excruciating deep dyspareunia following a very straightforward laparoscopic removal of an ovarian cyst. After months of pain, I did a follow-up laparoscopy and found that a single band of tissue had caused her ovary to attach to the back of her vagina. One snip to cut the adhesion freed the ovary and resulted in pain-free intercourse.
Interstitial Cystitis
The only thing more distressing than having chronic pelvic pain, a constant urge to urinate, and dyspareunia is to have a doctor who has no idea what might be causing this. For women who suffer from interstitial cystitis (IC), also known as bladder pain syndrome, that is all too frequently the case. Recently, however, there has been an increased awareness of this debilitating condition that affects anywhere from 700,000 to 7 million women (depending on whose statistics you believe). Unfortunately, it is still an average of five years from the onset of symptoms until diagnosis and treatment for this condition. One of the reasons diagnosis is so complicated is that IC symptoms are not limited to the bladder. Pain frequently radiates to the back, thighs, or lower abdomen, and yes, this condition can also occur in men.
Usually when doctors talk about cystitis, they are referring to a bacterial bladder infection. IC is not an infection, but an inflammation of the wall of the bladder. Urine cultures are always negative for bacteria, and antibiotics don’t help. Most researchers feel that IC is caused by damage to the inner lining of the bladder, resulting in an elevated pain response to the normal components of urine. Since there is always at least a little urine in the bladder, there is essentially always some degree of pain. Women with mild IC have occasional flares triggered by food, sex, or stress; women with severe IC have chronic, debilitating pelvic pain, urinate as often as 60 times a day (and night!), are unable to have intercourse, and are pretty much nonfunctional.
Diagnosis of IC has always been a challenge, which is why identification of this condition is often delayed. Women who have urinary frequency or urgency should first have a urine culture to make sure there is no infection. A visit to your gynecologist is also in order to eliminate other pelvic problems. Often a urologist is the one to make the IC diagnosis. A few years ago, a questionnaire was developed to help women recognize if they might have IC. The PUF (Pelvic Pain and Urgency/Frequency) patient symptom scale is an eight-question test that measures the presence and severity of IC symptoms and identifies those women who are likely to have IC as opposed to another bladder condition.
Since Antibiotics Don’t Work, What Will?
In the past, the only advice doctors could give patients for dealing with IC was to tell them to avoid foods that were known to irritate the bladder, such as caffeine, alcohol, fruit juices, vinegar, and spicy foods. In 2011 the American Urology Association released guidelines to assist in the diagnosis and treatment of interstitial cystitis. First-line treatments include diet modification, over-the-counter products, and avoidance of activities that trigger pain, such as exercise or certain positions during sexual activity. Second-line treatments include pelvic floor physical therapy and various prescription drugs such as Pentosan polysulfate (Elmiron), an FDA-approved oral medication specifically for the treatment of IC. A number of other treatments are available for the most severe cases, but they are best administered by experts in the IC world.
Additional information about interstitial cystitis, including the details of bladder-friendly foods and available treatments, can be found at www.ic-network.org.
Ovarian Cysts
Ovarian cysts are common. Pain from ovarian cysts, including pain during intercourse, is not. Having said that, very large cysts can sometimes hurt, which is why it’s not unreasonable for a patient with deep pain during intercourse to be sent for an ultrasound in order to eliminate the possibility of a problematic ovarian cyst.
Frequently a tiny one- to two-centimeter cyst is detected and is cited as the cause of the pain. Small cysts do not cause pain, however, and the surgery that some women end up having to remove them is unnecessary.
I had one patient who had a very well-endowed new partner. She experienced deep pelvic pain whenever she had intercourse, and lo and behold she was found to have a large ovarian cyst that turned out to be an early-stage ovarian cancer. We joked about how her new boyfriend’s penis saved her life.
If you are found to have a cyst on ultrasound, keep in mind that only 7 percent of persistent cysts in women under the age of 50 are cancerous. After age 50, up to 30 percent of cysts are cancerous. Size and other characteristics help determine the likelihood of a potential cancer, the likelihood that the cyst is responsible for your pain, and most important, the appropriateness of surgical removal.
Fibroids
Like cysts, fibroids are common, but do not commonly cause severe pelvic pain.
If a woman has sexual pain and is found to have fibroids, it is far more likely that she also has endometriosis or adenomyosis that is causing the problem and that the fibroids are just a red herring.
The official nomenclature for a fibroid tumor is uterine leiomyoma. Also referred to as myomas, fibroids are benign (noncancerous) tumors that arise from the smooth muscle cells of the uterus. They are solid, as opposed to cystic (fluid-filled), and vary widely in size. Often they are microscopic, but they can also grow to the size of a beach ball.
In most cases, fibroids are too small to create symptoms and, if found, can be ignored. It’s not just the size but the position of the fibroid that predicts who is going to have an issue, and what kind of issue. As any good real estate agent knows, it’s all about location, location, location. When it comes to heavy bleeding from fibroids, there’s no worse location than fibroids that grow into the cavity of the uterus. Even small fibroids can cause the “change the tampon every hour” heavy periods that not only are miserable to deal with but also can result in anemia. While heavy bleeding can cause wicked menstrual cramps, small fibroids in the cavity of the uterus do not cause dyspareunia.
The truth is that most fibroids do not cause pain, but there are always exceptions to the rule. Degeneration results if a portion of a large fibroid outgrows its blood supply and dies. The result is pain and a tender uterus. This is more common during pregnancy, when fibroids grow very quickly, but can also happen just because the fibroid is large.
Women with large fibroids that exert pressure on other pelvic structures (known as “bulk symptoms”) are the ones who generally experience discomfort during intercourse. If the fibroid is located on the front of the uterus, the woman knows every bathroom within a five-mile radius of her home and work. There is a constant pressure “down there,” resulting in the feeling of needing to urinate even when her bladder is empty. And when the bladder starts to fill . . . well, there’s not a whole lot of room to spare.
If the fibroid is on the back of the uterus, constipation and rectal pressure may become problematic. Women who have had a baby know that incredible feeling of pressure on the rectum as the baby’s head moves down the vagina right before delivery. Women with large fibroids sitting on their rectum experience that sensation on a regular basis. And really large fibroids can make even the slimmest of women look pregnant. Unlike pregnancy, however, the belly bulge doesn’t disappear after nine months with fibroids, and there is no cute little baby to make you forget all the discomfort. It goes without saying that looking like you are about to deliver, when you’re not, doesn’t do a lot for body image or that sexy feeling.
Any woman can get fibroids, but some women are more likely candidates than others. Fibroids most commonly appear during the years in which women produce estrogen and progesterone—in other words, the reproductive years. Most women develop symptoms from fibroids during their thirties and forties, but some women continue to have problems even after menopause. Many women assume (and bank on the assumption that) their fibroids will disappear after their periods stop. They generally don’t, but they do usually stop growing and eventually shrink over time postmenopause.
As with ovarian cysts, the presence of a fibroid doesn’t always mean the fibroid is causing the problem. Twenty-five percent of women in the reproductive years have fibroids that they are aware of, either because they’ve had symptoms or the fibroids were discovered during a routine gynecologic examination. Small, asymptomatic tumors exist in the uteruses of up to 80 percent of women, most of whom are totally oblivious to their presence until the fibroids are identified serendipitously on an ultrasound done for another reason.
The Fix
We’ve come a long way since your grandmother’s time when the only option for dealing with fibroids was hysterectomy requiring a big abdominal incision and a long recovery. If a hysterectomy is required or desired to treat your symptoms, it can almost always be performed laparoscopically or robotically as an outpatient procedure. But sometimes your uterus doesn’t need to be sacrificed to deal with symptomatic fibroids.
Myomectomy is an alternative to hysterectomy that surgically removes fibroids and leaves the uterus behind. Most women who undergo myomectomy still end up with an abdominal incision and require a six-week recovery even though if the fibroids are in the uterine wall or project outside the uterus, laparoscopic or robotic-assisted removal is often an option.
Hysteroscopic myomectomy is another underutilized minimally invasive uterus-sparing technique that removes problematic fibroids inside the uterine cavity without an incision. This procedure is performed on an outpatient basis, takes less than an hour, and requires essentially no recovery.
Here’s how it works: Most women are familiar with dilatation and curettage (D&C), a procedure in which the cervical opening is made slightly larger in order to put an instrument into the uterine cavity to scrape away the lining of the uterus. It would be nice if a simple D&C could eliminate fibroids, but scraping the lining of the uterus to remove a fibroid is like raking leaves and expecting to remove the boulder in the ground. D&Cs are useful for evaluating bleeding, but are not really meant to treat the bleeding.
When I perform a D&C, it is always accompanied by a hysteroscopy in which I slide a slender scope with a camera and light attached to it through the cervix in order to see what’s going on inside the uterus. If a fibroid is present, I insert a small instrument through the hysteroscope to cut the fibroid into small pieces, a process known as fibroid resection, or morcellation. The small pieces of fibroid then are easily removed. The patient goes home that day, fibroid-free.
Uterine artery embolization is another minimally invasive approach to treat fibroids and involves an interventional radiologist injecting beads (using an MRI for guidance) to reduce the blood supply to the uterus and shrink fibroids.
The details of these and other treatments are covered in The Essential Guide to Hysterectomy.
Dr. Streicher’s SexAbility Survey
From my survey of over 2,000 women about why they decided to ultimately have a hysterectomy:
My uterus was the size of a small loaf of bread because of the fibroid tumors. The bleeding had me soaking through a super-size tampon and extra-heavy pad in an hour. My periods lasted two weeks. It detracted greatly from my quality of life.
I bled 27 days out of 30 and was exhausted for well over two years. I just had enough! I’d tried everything the doctors wanted to try and finally just said, “Enough! I want this nightmare to end. Do the surgery—please!”
Possibly due to birth of 10-pound baby, years later my uterus severely prolapsed so it was very awkward physically and for sex. Also during exercise/sneezing urine came out. At the time I was going through a divorce. Pre-op appt. the doctor asked if I would be having sex later in life. I’m not really sure what that question had to do with the surgery but my sex life is great.
I was finished having children was one of the main factors and I was just tired of the pain that I was having. Intercourse was awful to the point I would make up excuses not to do it.
My husband and I made the decision due to the fact that I was experiencing extremely painful intercourse. My doctor stated it was because my uterus was prolapsed and so was my bladder after multiple pregnancies. Also to reduce my risk of uterine cancer as my mother had uterine cancer.
My story is about making excuses. I made every excuse to not go to the doctor. Until I was able to feel the fibroid tumors in my belly, I put off making the appointments. I had every symptom and still put it off, making excuses about why my period was so heavy. For two years, I told myself it’s just my body changing. It was stupid and I ended up without a choice. For me, it worked out, but it was very scary for me and for my husband. It could have been cancer, it could have ended badly. Take-away here. Go to the doctor for your annual exam. If I had, I would still have my uterus.
Uterine Prolapse
Uterine prolapse is just what it sounds like: the uterus drops down into the vagina, and in severe cases outside the vagina. Weakened pelvic floor connective tissues (as in muscles, ligaments, and fascia) that should support the uterus don’t, gravity wins out, and the uterus descends from its usual position.
Women who have uterine prolapse frequently have other displaced organs due to weak pelvic tissues. A cystocele results when a prolapsed bladder bulges through the front of the vagina; a rectocele occurs when the rectum bulges through the vaginal floor, or back wall of the vagina. The general term used to describe these conditions is POP, as in Pelvic Organ Prolapse, not as in “Yikes, my uterus has popped out.”
Uterine and Pelvic Organ Prolapse Are Associated with Sexual Problems
If the cervix is outside the vaginal opening, there may be bleeding, discharge, and vulvar pain. Let’s not forget the effect of your uterus or bladder hanging outside your vagina on your body image. The urinary or fecal incontinence associated with prolapse is a significant sexual sabotage. (I cover this in greater detail in chapter 15.)
What causes the pelvic pain associated with prolapse is a very weak, dysfunctional pelvic floor (remember chapter 6?). In other words, the weak pelvic floor that contributed to the prolapse also causes pain.
Who Gets a Prolapsed Uterus?
A vaginal delivery, particularly if the labor is long and the baby large, is the greatest risk factor for a uterus that has gone south. It’s not the only risk factor, since most women who deliver vaginally don’t end up with POP, but 75 percent of prolapse can be attributed to pregnancy. Family history is also a major factor. Tissue prone to damage is an inherited tendency, and it’s not unusual for a woman with uterine prolapse to mention that her mother and grandmother had the same problem. Take a genetic predisposition, add a nine-pound baby and three hours of pushing . . . something is going to give. Once the tissue is damaged, it never completely regains its strength and elasticity; the effects of gravity and age then compound the problem.
Obesity is also a significant risk factor. Women with a body mass index over 25 are two times more likely to have prolapse than normal-weight women. Smoking is another culprit. Even though the pelvis is a long way from the lungs, the effects of smoking on tissue are seen throughout the body. It doesn’t help that smokers are often frequent coughers. Chronic constipation is also a risk factor. Pushing is pushing and whether it is a huge baby or repetitive efforts at getting out a bowel movement, tissue will weaken as a result.
While this distressing condition spares no age group, the likelihood of prolapse increases with age, and since women are now living longer, increasing numbers of women are destined to suffer from uterine prolapse.
My new patient was 92 years old and had a uterus that was completely hanging out. I asked her how long that had been the case, and she said, “Oh, I’ve had this since I was 75.” When I asked her why she had never had it taken care of, she replied, “I didn’t think I would get my money’s worth—if I knew then what I know now, I would have had the surgery years ago!”
How Do You Know if You Have a Prolapse?
Symptoms are generally related to the degree of the prolapse—in other words, how far the uterus has dropped. In a first-degree prolapse, the uterus is only slightly lower than its normal position, and most women are totally unaware that something has shifted unless their gynecologist points it out. A further drop creates a second-degree prolapse, which is the point at which some women become aware that something is not quite right. Still, many women with a second-degree prolapse have no symptoms. By the time the uterus drops low enough for the vagina to be completely filled and the cervix reaches the opening of the vagina (third-degree prolapse), most women are definitely aware there is a problem. Even the most oblivious woman notices when her uterus drops outside her vagina (a fourth-degree prolapse), prompting an emergency visit. One woman actually called from her bathtub, appropriately upset, crying, “Something is floating out of my vagina . . . and I think it’s my uterus!”
The most common symptom is the feeling that “something is falling down,” which is not surprising since that is exactly what has happened. Nine times out of ten, a woman correctly diagnoses her own prolapse before any doctor lays eyes on her. Many women, in addition to constant pressure, actually feel a mass or bulge at the vaginal opening. A quick look in the mirror (a hand mirror with a long handle works well) and you can see something pink bulging out. In severe cases, women may be unable to have a bowel movement or urinate.
The Fix
Once the damage is done, what options are available to treat uterine prolapse? Surgery, almost always a hysterectomy, is the ultimate treatment. The first hysterectomy in history, as a matter of fact, in AD 200, was done vaginally for a completely prolapsed uterus. Today vaginal or laparoscopic hysterectomy is the standard treatment for symptomatic uterine prolapse. If surgery is not desired or medically appropriate, a doctor may recommend the placement of a pessary, a device that is placed in the vagina to support the uterus. This will sometimes give relief. Pelvic floor physical therapy is instrumental, with or without surgery.
Sex Post-Hysterectomy
If someone has a hysterectomy to solve a gynecologic problem, a common fear is that the surgery will create a sexual problem. Fortunately, that is rarely the case. Over 500,000 women in the United States undergo hysterectomy each year. One-third of women will lose their uterus by age 60. Virtually every one of those women will have worried about how hysterectomy will affect her sexual function, desire, and desirability. Unfortunately, studies have shown that only half of gynecologists initiate a discussion of sex during pre- or post-op appointments, and few patients (about 13 percent) are willing to bring it up themselves. That means a lot of women who worry about their post-operative sexuality do just that—worry.
A patient of mine had a severe uterine prolapse and was in the pre-op area waiting to have a hysterectomy. The male medical student was eagerly asking her questions about her condition. She finally turned to him and said, “You just have no idea what it’s like to have something hanging between your legs all the time!” Just as she realized what she had said, we rolled her off and mercifully put her to sleep.
Fortunately, studies show that unless ovaries are also removed along with the uterus, inducing menopause, the majority of women do not report adverse effects of hysterectomy on sexual function.
A 1999 study published in the New England Journal of Medicine tracked over 1,000 women during the two years after their surgeries and, unlike many earlier studies, evaluated sexual function both before and after hysterectomy. The results of the study were reassuring and validated what most gynecologists (but not most pre-op patients) knew all along. Seventy-seven percent of the women in the post-operative group were sexually active one year after surgery, in contrast to only 71 percent of the group the year before. This finding is not surprising given that the study also demonstrated that the number of women who experienced pain during sex decreased from 19 percent to 4 percent. The quality and number of orgasms increased, as did overall libido post-op. The bottom line is that frequency of sexual activity consistently increased and sexual dysfunction decreased after hysterectomy.
Even though there was a negative impact on sexual function in about 15 percent of women who took this survey, the improvement in general health evidently trumped the impact on their sex lives.
Dr. Streicher’s SexAbility Survey
My own survey of over 2,000 women post-hysterectomy asked: “Is your sex life better or worse after hysterectomy?”
85 percent said that their sex life was better or unchanged
85 percent said that their orgasms were better or unchanged
92 percent said that they were glad they had the hysterectomy
Women who become menopausal as a result of surgery have an additional set of issues to deal with. If estrogen supplementation is not initiated, it is likely that mood disturbance, vaginal dryness, and a much higher risk of sexual dysfunction overall will ensue. There is no question that estrogen and androgen supplementation will absolutely increase libido, lubrication, and sexual response. Some women are fine without it, but for many women the loss of hormones is a major blow to sexuality. These issues are further explored in chapters 12 and 13.
Pain Post-Hysterectomy
While the overwhelming majority of women have no problems, there are some may experience postsurgical sexual issues.
Once you have had your final post-hysterectomy checkup, most doctors give the go-ahead to resume sexual activity. One big hurdle to overcome is fear. Many women are understandably nervous about having intercourse, thinking that it might create a problem or that they will experience pain. Partners are also sometimes leery, which hardly makes for a wild sexual experience. If your doctor has given you the okay, it really will be fine, but you won’t believe that until you try.
Nevertheless, in spite of waiting the proper amount of time, using appropriate lubrication, and drinking a glass (or two) of chardonnay, things don’t always go well.
New-onset superficial dyspareunia after hysterectomy is usually only an issue if things are dry. If your ovaries were not removed or you were already postmenopause prior to surgery, this should not be the case. If at the time of hysterectomy there were other procedures, like a bladder lift, your first attempt at intercourse may be uncomfortable due to vaginal stitches and healing vaginal or perineal tissue. Use plenty of lube and take it slow, but if things hurt, healing may be incomplete and you may just need a little more time. Once healing is complete, the opening to the vagina occasionally becomes too small or tight. In that case, dilators and local vaginal estrogen may be needed to restore functional anatomy.
Dr. Streicher’s SexAbility Survey
3.7 percent of women surveyed had sex two weeks post-op
11.7 percent had sex four weeks post-op
34.9 percent had sex six weeks post-op
32.5 percent had sex eight weeks post-op
7.2 percent never resumed having intercourse
Deep internal pelvic pain during intercourse after hysterectomy is generally not due to vaginal dryness. Generally, the pain is caused by the penis hitting something at the back of the vagina, or behind the vagina. There are a number of things that could create this problem, all generally solvable.
Infection at the back of the vagina or behind the vagina occurs rarely after hysterectomy, but if it does it can be a cause of discomfort. Usually, a combination of antibiotics, time, and sometimes drainage of a pocket of pus (if there is an abscess) will solve the problem.
Pelvic adhesions are always a possibility, but occasionally there is an adhesion in the vagina where a band of tissue has formed during the healing process. You would have no way of knowing it’s there until a finger or penis pushes on it, creating pain. The pain is usually sharp and occurs without warning. Your gynecologist can easily identify this condition by doing a speculum exam and can easily remedy it, usually in his or her office.
Persistent Pain
It’s not unusual to treat the endometriosis, IC, or adenomyosis, yet still have pain with intercourse. No matter what the initial cause of deep dyspareunia and chronic pelvic pain, there is inevitably some degree of hypertonic pelvic floor dysfunction or a lingering vaginismus, even after the initial cause of the pain has been treated. Your vagina isn’t stupid: it has spent years developing the same kind of protective mechanisms that women with superficial dyspareunia do.
Even if no gynecologic or medical cause of pelvic pain has been identified, in most cases your issues are caused by a pelvic floor dysfunction. I can’t emphasize enough the importance of working with an experienced pelvic floor physical therapist to determine if that is the case. If so, that therapy can change your life.
If deep penetration hurts, one strategy is to make penetration less deep. A Comeclose collision ring (http://www.comeclose.co.uk) placed around the base of your partner’s penis will not detract from his pleasure, but may increase yours since the ring serves as a cushioned “spacer.”