Pelvic Floor: Managing Pain with Intercourse - Podcast Episode #131

Joining us today is Amanda Seymour and Katie Thomas from Hulst Jepsen Physical Therapy.  We discuss the issue of painful intercourse, its causes and the importance of speaking up among those who are impacted.  You can listen to this complete podcast episode on iTunes, Spotify, or SoundCloud.

Welcome.  You’re listening to Ask the Doulas, a podcast where we talk to experts from all over the country about topics related to pregnancy, birth, postpartum, and early parenting.  Let’s chat!

Alyssa:  Hey, ladies.  Good to see your faces!

Amanda:  Hey, Alyssa.  Good to see you.

Katie:  Hi!

Alyssa:  So we’re talking with Amanda and Katie again from Hulst Jepson Physical Therapy, and we’ve done a couple podcasts with them.  I’m excited to do a couple more.  Today we’re going to get into pain with intercourse, which I’m really interested to hear what you have to say about that.  So why don’t you two do another quick, brief introduction in case someone didn’t hear our previous podcasts, and then we’ll get right into it.

Amanda:  Yeah, for sure.  My name is Amanda.  I’m a physical therapist at Hulst Jepson Physical Therapy, our EGR location.  I’ve been a therapist for about five, five and a half years, and kind of delved into the women’s health, pelvic floor rehab world about three and a half years ago, treating patients with pelvic floor disorders.  Also, I treat as well anything from toes to nose, different orthopedic cases.  Just been really enjoying life as a therapist.

Katie:  And I’m Katie Thomas.  I work with Amanda at Hulst Jepson’s East Grand Rapids location.  And I’ve been a therapist for ten years and a pelvic floor therapist for about two.  So it’s definitely really nice to have both of us together in the clinic so we can bounce ideas off of each other and talk about cases if anything gets complicated.

Amanda:  Yeah, it’s been a blast.  And one of those cases, like Alyssa said, is in fact pain with intercourse.  This is common.  We see this a lot coming through our doors at any age, from those younger to older, before having kids, after having kids.  It can show up in anyone.  That’s what we really try to tell people, too.  Hey, you’re not the only one, because it’s kind of a scary thing when there’s pain during what’s supposed to be an enjoyable time.  Obviously, that takes the enjoyment out of it.  I wanted to throw out an interesting stat.  It says about 40-50% of postpartum females actually will experience pain with intercourse, typically three months after labor and delivery.

Alyssa:  So that far along?  I mean, obviously, we – you know, six to nine weeks is a pretty typical recovery period.  We’ll kind of warn our clients ahead of time that, you know, you might not be ready.  There could be some pain.  But even three months after, up to 50% of postpartum women could have pain with intercourse?

Amanda:  Yeah, and that, we’ll dive into, kind of maybe get more into why, because definitely when you think baby delivery – but also, I mean, we have seen it – I’ve seen it with C-section as well.  I think just the pressures from baby, holding baby.  Your pelvic floor has to hold that baby up.

Alyssa:  It’s an important statistic for moms to know, because like you said, this isn’t a topic anyone talks about.  So if you’re three months postpartum and having pain, you know, most moms probably assume, what’s wrong with me?  Nobody else has told me that they’re having this issue.  So I think knowing that 40-50% of moms are experiencing this same thing is really, really critical for them to say, okay, it’s normal in the sense that other people have it, but it shouldn’t be normal.  Like, I can fix it if somebody – hopefully, I can fix it with somebody I can talk to.  So then they can call someone like you.

Amanda:  Yeah, definitely.

Katie:  And I would also bring up, too – I feel like I see a lot of women who say, yeah, I have a little bit of pain, but it’s really not that bad.  Like, it’s what I would expect.  And I would also encourage women to think about the fact that they should be able to have sex without any pain.  Not only should they not have any pain, but it should be pleasurable.  So just being like, oh, it’s not too bad is not enough.  If you’re having any pain or discomfort at all, it’s great to see a pelvic floor physical therapist because there can be some underlying stuff that we can definitely work on.

Alyssa:  I think that’s kind of the mantra of a lot of moms.  Like, there’s a little bit of pain, but I can deal with it.  We just kind of get used to having to deal with stuff that we don’t necessarily need to.  A lot of times, we’re just afraid to ask for help or don’t even know that we can ask for help.  So, yeah.  This is huge.  Let’s keep talking about this because I don’t even know that I’ve had this conversation before.

Amanda:  Yeah, and that’s where we say, yeah, try – if you feel comfortable, come and chat with us and address us, because we also know with this pain with intercourse, it’s surrounded by so many other things, like avoidance of intercourse altogether, which can be tough for relationships.  I mean, just thinking about postpartum and having a baby, alone, is tough for relationships, and then add pain during intercourse.  That adds a whole other element.  And it’s not even always postpartum, though.  Elderly, you know, younger, it’s just the avoidance piece of it.  Or just even kind of that anticipation, that fear, once you get that experience of it being painful.  Obviously, there’s a fear that sets in, anxiety.  And some people, we do say, hey, it’s not a bad idea to just talk to someone about this, too, including us, but also sometimes reaching out to a counselor or sex therapist in that way to be helpful.  The biggest thing as a rehab specialist with physical therapy that we want to teach you guys is to say, hey, this pain is most likely coming from muscle, and they kind of term it to two different pains, I guess.  There’s superficial dyspareunia, which means pain with intercourse, or a deep dyspareunia.  In superficial, kind of as it sounds, right at the front of that vaginal opening, that’s like that insertional pain where it feels like tearing or a really, really strong stretch, ripping sensation.  And I will say postpartum, you want to make sure tissues are healed if you’ve had any stitching and whatnot.  But if it’s past that point, and your OB or gyno is like, yeah, everything is nice and healed, and you’re still having that sensation, that’s what we term more of that superficial dyspareunia because there is muscles right there, like a knuckle in that vaginal opening, that can be too tight.  That deeper pain, that goes more with those deep layers of the pelvic floor muscles, deep layers of muscle.  We kind of say, hey, that’s maybe your second knuckle of your finger into that vaginal opening or all the way to kind of that third knuckle.  And those deep layers can also be just so tight after childbirth or even not after childbirth.  It can just happen.  Stress, I will say, has been a trigger for a lot of females.  When they notice, oh, work is getting really tough, and oh, my goodness, intercourse is quite painful.  Well, we went to Florida.  We felt great.  Intercourse was pain-free.  We have noticed that with females.  So that’s going to be the same as, oh, my word, you know, I have a lot of shoulder tightness, neck tightness, when my work is getting really busy.  Well, guess what, those pelvic floor muscles can respond in that same way.

Katie:  We’ll also see that third layer be really tight and painful with the low back pain and hip pain, as well.  Because those third layer muscles also attach into our hips, if there’s any sort of rotation in your pelvis or misalignment or low back pain, even us taking a look at that, taking a look externally, and working on your back and working on the hips and working on the muscles around it can help a lot internally as well.

Alyssa:  Because one muscle can pull on another which pulls on another?

Katie:  Exactly.  It’s all connected, for better or for worse.

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Katie:  I also wanted to say, too, that sometimes it’s not just intercourse that can be uncomfortable, but also anything superficial, too.  I mean, we’ve seen a lot of women who just had concerns even with their partner touching them externally.  So even if that’s the issue and you haven’t even gotten to intercourse or anything internal and you’re just feeling discomfort or fear or pain externally, we can work with that as well.

Alyssa:  So I have to imagine for women who have pain with this, it’s also – you know, like, I can’t imagine during your period, right?  Like, that time of the month, and you – even like a tampon or a cup, that has to be really painful.  So do you see that women are oftentimes just using pads or something else because they can’t do anything else?

Amanda:  Yeah, definitely.  I would say a lot of even younger females, they’ll tell me, I’ve never – or I should say this.  Older females, when they were younger, say they never could use a tampon because it was so painful, or pap smears were always painful, medical exams always so painful.  And then saying, yeah, intercourse is painful, as well, just because that pelvic floor – you know, it’s kind of like a tunnel, let’s say, and anything that inserts the tunnel, the tunnel isn’t going to want to have pressure to the sides of it because it’s so tight.  It’s going to create that pain.  And that’s something in some kind of diagnoses we do see in regards to that pelvic floor tightness or pain being associated, like endometriosis is one of them where someone will say, yeah, I’ve been diagnosed with that for a while, and the pelvic floor, we find, is quite spasmed because of that, and they’ll often have a history of tampon use being tough.  So, yeah.  They would use pads instead because just to have something in there that long is just too painful.

Alyssa:  So I’m picturing this 18-year-old going in for her first pap smear, sexually active or not, but she doesn’t know if it’s supposed to be painful or not.  You know, so she’s probably not telling her medical team or even her mom when she gets back home that it was really painful – or maybe she did say, oh, that was awful.  It’s really painful.  But then the conversation just kind of stops there.  How do we – again, like we’ve talked about before, just educating people, talking about it is the first step.  But, you know, now that I’m – I know this, right.  When my daughter turns 18, if she says that was really painful, not to just brush that off and say, well, oh, she’s not sexually active yet, so of course it’s painful.  I guess what would your recommendation for – what should that conversation look like after that?

Katie:  Yeah, so I would say that going to the gynecologist and having your first exam can be kind of a scary experience, anyway, and so your muscles – you can just tense them up while that speculum is being inserted and removed.  So if it’s a first-time experience, that might be painful regardless.  So I think some good follow up questions could be, you know, is it painful to insert a tampon?  Is it painful to insert your own finger?  That one’s a really important one because a lot of women, they can insert their own finger because they’re in control.  But then there are some women who are like, I can maybe insert half my finger, but after that, it’s painful.  So following up, I think, with the finger question would be probably the easiest way to know, like, oh, if that isn’t comfortable, or beyond that, if you can insert your finger, can you move that finger north, south, east, and west within your vagina, and if you do, do you have soreness anywhere?  And if you do, that’s not something you should have to experience.  So those could be some kind of red flags, as well.

Amanda:  And I would say, too, like with speculum insertion, is it painful right at the beginning when it’s inserted or deeper, because I don’t think pap smears are ever, I would say, comfortable, comfortable.  But is that pain right away, and then that could be – yeah, I mean, following up with kind of – I think the tampon question, too, is great, because that’s going to be so known for everyone, pretty much, to see if that’s a painful one.  Good question.

Alyssa:  I don’t mind the speculum.  It’s that dang four-foot Q-tip they put in afterward.

Katie:  Never a pleasant experience!

Alyssa:  So I’m assuming, you know, kind of like the other conversations we’ve had about the pelvic floor in general, you would ideally do an internal exam, but it sounds like you can also do an external one.  Let’s look at your hips.  Let’s look at your back.  If someone’s not comfortable – like, I’m totally comfortable having a conversation with my daughter eventually about, hey, put your finger in there.  Tell me how it feels.  But there are a lot of people, parents, who maybe aren’t comfortable having that conversation or even comfortable letting you do an exam like that.  So it’s nice to know, again, there’s a wide array of therapy that you can do and still be effective.

Katie:  Yeah, definitely.  So we do a lot of external work, just like what you said with checking the back, checking the hips.  We can also do some external muscle releases.  Amanda and I were just talking about some of those techniques earlier today where we can do some stretching of the tissues more around your buttocks.  We can do stretching in your groin.  We can give you exercises to stretch those areas.  And by stretching things close to the internal muscles, because they all connect, that can be more comfortable.  We’ve both seen a lot of women who it’s taken weeks or maybe months or maybe never to get comfortable with an internal exam, and there’s still so much that we can do.  And speaking of younger girls, I would say, and Amanda, you’ll have to let me know if you agree or not, but I would say we also don’t do anything internal on young women unless they’ve already had a gynecological visit in their past.

Amanda:  Yep, so they’re familiar with it.  They know it’s medical.  You know, just to kind of get the environment safe for them.  External, I think for sure, is really helpful for younger girls, because yeah, they want to be empowered to be able to do something for themselves at home, too.  Yeah, external tricks work great.  People come from sexual abuse where it’s like, yeah, we’re not even going to go there.  So we’re going to stay all external, and yeah, the releases are effective, and it does feel like you’re getting some of that pelvic floor, even though it’s pressure on the outside.  And, you know, with tightness, we mentioned this before about sometimes muscle that are too tight need to down regulate, we call it.  So relaxation, and that’s where you can have that conversation with a person of, hey, when you know a trigger is coming that creates that tightness and spasms, how are you going to kind of go about that, or what are some relaxation techniques or breathing techniques we had mentioned before of trying to get things to just relax and soften through the pelvic floor.  Or apps, like the Calm app or Headspace.  Just integrate that into your day to really get those muscles to relax, like you would if your neck muscles are getting really sore and tired.  We’ve found that’s really helpful for people.

Alyssa:  I love this aspect of it because we actually teach a course called HypnoBirthing, which is – you know, they learn a lot about the physiology behind what’s happening in your body during pregnancy and what will happen during birth, but it’s also a relaxation technique.  And I think that, paired with teaching yourself how to relax those muscles – you know, not just relaxing your head, but relaxing the muscles in the canal that is actually going to birth your baby, could be really important.  Now, even though talking about – well, let’s give this scenario.  Worst case, right?  Someone who has pain during intercourse is now pregnant.  They have to be so freaking scared to give birth.  Now, if something the size of, you know, a penis hurts, a baby has got to be terrifying.  So do you work with mothers in that regard, of how do we relax to prepare your body for labor and delivery?

Amanda:  Yes, I have had a female come in.  She was pregnant, and probably a couple weeks before birth, yeah, we did some external releases during pregnancy.  And we don’t do any internal pelvic floor releases, just keeping that environment safe.  But external, for sure, and teaching safe stretches will be helpful, but then obviously that breathing, that relaxation piece.  We know – I just had a client come back.  I taught her the breathing, saying, when you inhale, the pelvic floor should relax.  And she used that during intercourse with her husband.  She said, oh my word, that helped so much.  I just used that breath, and it was much more enjoyable.  Obviously, she’s probably focused more on her breath than anything at that point, but it’s just that training to basically teach that body, hey, this is okay.  We can let go and be okay with some of that friction and whatnot.

Alyssa:  Yeah, that’s got to be the first step, right?  Even if she’s focusing on her breath more than the sex, that’s a step in the right direction because she just had sex with less pain.  And then it just has to become a habit.  It gets easier to the point where she can now focus on the sex more and less on her breath.  That’s the goal.

Amanda:  Yes.  And, obviously, with baby, it’s one event during that time, but that too, I think, obviously, is really helpful, just that down regulation piece.

Katie:  Yeah, and I would say your clients who see you and who are working on the hypno-breathing are definitely well prepared for birth and then post-birth with a lot of the things we’re talking about.  And I would go back to your question about seeing women during pregnancy: I think that a lot of women during pregnancy only come and see us if they’re having some hip pain or pubic pain or SI pain.  But we do – often that pain is associated with tightness, and so we do work on a lot of stretching and relaxation techniques.  I think it’s a little bit of a myth or misconstrued that all pregnant women need to be working on their Kegels.  That’s not the case.  Just like any woman, we need to see, are your muscles too weak or too tight?  The same thing can be true for pregnancy.  You might be doing harm by focusing all on Kegels and not focusing on relaxation during pregnancy with that pelvic floor.  So Amanda talked a little bit about some breathing and some apps and stuff like that.  Some other treatments we can do, like sitting on a hot pad or a hot water bottle, can help to relax your pelvic floor while you’re doing some of the breathing or while you’re doing some stretches that we teach you.  We can also use something called biofeedback, which is pretty cool.  We don’t have a unit at our clinic yet, but we’re hoping to get one in the spring, and that’s really nice because it’s not internal.  It’s just some electrode pads that we place externally, and then the patient can see on a screen when they’re relaxing their muscles and when they’re contracting them.  Sometimes it’s really hard for us to know, wait, am I using that muscle?  Am I not?  Am I relaxing?  Am I not?  And so having a visual cue can help.  Sometimes it’s really helpful for some women to actually see, like, oh, I’m relaxing now.  And then once they can see that and associate that feeling with it, it’s easier to relax on their own later while doing their exercises.  And then other exercises, like we talked about, we can stretch.  We can stretch your glutes.  We can stretch your hamstrings, your adductors, so those inner groin muscles, and all that can help relax your pelvic floor, as well.

Amanda:  And our goal is obviously to kind of empower the patient.  So we love doing hands-on and helping, but ultimately, we don’t want the patient to rely on us.  If, let’s say, that pain came back in a year, because sometimes we do have clients who are like, hey, it’s pain-free to have intercourse, and they ask that question, like, oh, what happens if it comes back in a year or whatnot?  So we like to say, hey, these are some things that you can use at home, as well.  And with tight muscles, it doesn’t hurt to get, like, a dilator set.  And, basically, it’s different sizes of a silicone or plastic rod that you gently insert into the vaginal opening, and not everyone is comfortable with this at home, but if a client says, hey, yeah, that is something I can do, and it’s maybe more comfortable than a self-stretch with a finger, but it’s almost like a glorified tampon in a way that you put lubricant on and then gently insert that into the vaginal opening and it allows those tissues just to stretch and allows them just to say, hey, can I hold this dilator in this position for 30 seconds and feel a gentle stretch.  Not that ripping or tearing sensation.  We don’t want to recreate that familiar pain, but just that gentle stretch.  And I found that really effective with patient if they come to therapy once or twice a week and then those other days they’re working on that at home.  There’s also – I think it’s called a therawand.  People may have heard of the theracane, that shepherd’s hook that can get those knots in your shoulders or in your neck.  Well, the therawand, it does not look like the theracane, but it’s smaller and you insert that into the vaginal opening, and you find those areas.  Some people do have just one or two areas within the pelvic floor that are maybe trigger points for spasms, and just hold that pressure.  Just gently; sensitive tissue.  Just hold that pressure on that area.  Yeah, I find that really effective for patients.  So a lot of different options out there, which is really nice.

Katie:  And those dilators, too, can be used not just for stretching, but you can practice relaxing your pelvic floor around them, too.  So we’ll start with a really small size, like maybe the size of a finger, and then you can work up in size so that then you get more comfortable to the size of a tampon or more comfortable to the size of a menstrual cup or more comfortable to the size of a penis.

Amanda:  And I know there’s different companies and stuff you can get them from.  There’s a company, I forget its name, but you can actually custom size a custom size if your partner isn’t perfectly straight or something like that, if anyone has questions on that.  So not everyone’s partner is going to be the same size, either, so, yeah, there’s a lot of options.  And we give education and we have some samples of different lubricants, too.  We know that makes a big difference.  Silicone versus water.  We use Uberlube here.  We’ll give samples of that.  We’ve found good results from that.  In clinic, we use Slippery Stuff.  People seem to tolerate that pretty well.  So, yeah, that makes a big difference, as well.  We try to give education on that, too.

Katie:  Yeah, you’re really looking for a lubricant that has vitamin E in it.  So no KY Jelly.  Don’t use it.  It will make the situation worse because it’s going to dry out those tissues even more that are already sensitive to friction.  So you definitely want something with vitamin E.  We just happen to use Uberlube a lot because we got lots of free samples from them.

Amanda:  And we’ve had good feedback.  So there’s multiple different factors of why there is tightness, and sometimes it can be hormonal, too.  Sometimes if you look at the tissue, if we get the go by the client and look at their tissue of the vaginal area and it’s looking dry or bluish, to say hey, let me call your primary care or your OB or gyno, and maybe you should get estrogen levels checked.  Maybe the tissue is just not as supple as it could be and kind of dried.  That definitely makes a difference, too, of how well intercourse will feel.

Katie:  And sometimes it’s just as simple as your doctor writing you a prescription for an estrogen cream or something like that.  That’s when we definitely work more closely with the gynecologist.

Amanda:  Definitely, and keep that communication between all parties going, for sure.

Alyssa:  I love this conversation.  I honestly don’t think I’ve ever had this with anyone.  I think most women don’t have this conversation with even their friends.  I don’t know that many of them bring it up to their doctors.  So I hope that this at least spurs some conversation in people and maybe makes them think about calling someone and talking about it.

Amanda:  Yeah, we would love that.  Come on in for that 15-minute free consult or set up an evaluation.  I have had couples come together because the husband really wants to learn what he can do.  So we are open to educating as much as we can.  I know we have a sheet even on sexual positions that might be more comfortable for you.  That does make a difference, too.  Every pelvis is shaped differently, so what you see in the movies may not be comfortable for you, and that is 100% okay.

Alyssa:  Awesome.  Well, is there anything else that you want to mention before I ask you to give us contact info?

Katie:  I think the only thing – I think we brought it up before, too, but just emphasizing, too, that we work together with other healthcare professionals.  So it’s great that people are working with you guys pre-birth, during birth, post-birth, and then we’re working closely with a gynecologist, and then it may very well be beneficial to work closely also with a sex therapist, too.  So we just want to remind people that it often takes a team.

Alyssa:  We love that.  We talk about birth and pregnancy teams a lot, too.  Like, who medically, professionally, and personally, who do you need to have on your team to make this as smooth as possible?  So I think a physical therapist, a pelvic floor or women’s health physical therapist, needs to be one of those members on that team, for sure.

Amanda:  We agree!

Alyssa:  So people should look in their area to see if you have a women’s health physical therapist near you.  For those near us in the West Michigan area, how can they reach us?

Amanda:  Definitely.  You can search Hulst Jepson online.  It has a list of our locations.  On the locations page, it will indicate which locations have pelvic floor rehab.  We have about five or six clinics that now offer pelvic floor rehabilitation, and all should be able to take you through the education, treatment, plan, if you’re coming in with pain with intercourse.  That’s definitely a familiar diagnosis we see.  You’re not alone, like we mentioned before.  Katie and I are at the EGR location, and definitely feel free to give us a call.  We’re happy to talk to you, even before you come in over the phone.  We’re happy to just have you sign up for a 15-minute free consult and talk to us in person.  Or definitely we’ll take a referral or a script from a physician.  And you can even come and make an appointment without a referral with certain insurances, so definitely call our front desk and ask them as well.

Alyssa:  Thank you so much for this conversation!  I’m super excited to see what kind of comments people have and what kind of feedback we get and who is now compelled to ask some questions.

Alyssa:  That’s great.  Thank you.

Katie:  Yeah, thank you so much!

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