Dr. Patricia Yarberry Allen is a collaborative physician. She believes in consulting with the best medical minds on issues that require specialization or unique clinical experience. Last week, in Part 1 of this series, she consulted with Evelyn Hecht—a certified athletic trainer and a practicing physical therapist specializing in orthopedics, spine, and pelvic floor health—on a problem her patients frequently bring up: painful intercourse after menopause.
Part 1 covered the causes of painful intercourse after menopause (vaginal dryness because of lack of estrogen, as well as the tension of pelvic-floor muscles, especially after years of celibacy). Last week, Ms. Hecht outlined in detail how a physical therapist diagnoses each patient’s particular problem through history-taking and a physical exam. In today’s article she explains how lengthening of the pelvic-floor muscles can help restore a woman’s ability to have pleasurable, rather than painful, intercourse.
A Note from Dr. Pat:
A woman experiencing painful intercourse after menopause should see a gynecologist for help in compensating for the thinning, drying, and inelasticity of her vaginal tissue caused by the loss of estrogen. Most gynecologists treat this problem effectively with local vaginal estrogen (and in my practice, also large doses of Vitamin D3 for three months). That is the first step. (For more information, see Part 1.) The gynecologist may refer the patient to a licensed physical therapist for assistance in the second step: lengthening and strengthening her pelvic-floor muscles—a step that is especially needed if the woman has been celibate for years.
“Lengthen Before Strengthening”: Physical Therapist Evelyn Hecht Explains
Even after rehabilitation of vaginal tissues, some women still experience pain with intercourse. That is due to the fact that their pelvic-floor muscles are tense. During intercourse, healthy pelvic-floor muscles have the ability to stretch further to allow for the width of the penis. The muscles are also strong and can fully contract to provide more intense orgasms. Unhealthy muscles have knots/fascial restrictions, so that they are stuck in tight position at rest. During attempts at sexual intercourse, these tight muscles cannot accommodate the penis, and so the woman can experience pain.
The pelvic-floor muscles run from the pubic bone in the front of the pelvis to the coccyx [“tailbone”] in the back of the pelvis. They surround the vaginal canal, approximately 1 inch up from the vaginal opening
Location of the pelvic-floor muscles.
How to gain a healthy pelvic floor? Treatment by a physical therapist trained in pelvic-floor dysfunctions is optimum, since a PT can provide tailored manual expertise to release trigger points within muscles, utilize biofeedback therapy, provide visceral mobilization to improve the mobility of organs within the pelvic bowl, teach diaphragmatic breathing and skin-rolling techniques to abolish tight skin of the inner thighs and abdomen, and offer guidance for healing. I have found, in working with thousands of patients dealing with painful intercourse, that those who receive consistent therapy can start to feel better and return to intercourse within two months of treatment.
Please consult your physician or physical therapist before trying my self-help and exercise suggestions below, to be sure you are ready to undertake them without sustaining further discomfort. If any of these suggestions increases your symptoms, please stop and seek professional medical guidance.
How Long Does Physical Therapy Take?
Skin, connective tissue, muscles, and joints that have been in faulty movement patterns for weeks, months, and years (we see many patients with 10 to 20 years of pelvic-floor symptoms) require time to reduce spasm, adhesions, and restrictions and require regular, gentle manual guidance by trained hands to reverse these patterns. It is common for our patients to “clear their busy schedules” to attend PT three times a week for the first two weeks, then decrease frequency to twice a week for the next six to eight weeks. We provide each patient with an individualized home-exercise program on Day One, adding and modifying your program as progress is made.
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wow this is really good information wish i knew about it years ago menopause is over but i still have some pain thanks for sharing this information
When I was first married I started having painful sex. I went to several doctors who didn’t see anything wrong so I was told it must be in my head, or a problem with my relationship, or I needed to relax. None seemed to understand that simply touching my vaginal tissue was painful. Even though they all knew I had polycystic ovaries and did not ovulate and didn’t have menstrual cycles. This was over 30 years ago. When I wanted to get pregnant I had my ovaries cauterized ( slits cut in them by laser) and started ovulating and had regular cycles for the first time in 15 years. And I no longer had painful sex! Had 2 children. So I knew my pain was caused by lack of proper hormones and figured when menopause arrived I would probably go through it again. Had my first hot flash about 12 years ago and about 3 years ago started with the familiar painful intercourse. Started using an vaginal estrogen tablet and cream and these keep the pain away as long as I use them regularly about 2 times a week. I so wish doctors would have tried estrogen cream years ago!!!! Would have saved me alot of physical pain and my wonderful husband a lot of emotional pain as well!!!!!
Thank you for the VERY educational and positive article. It has let me see the light at the end of the tunnel. I started having very painful sex years ago, then stopped having sex all together for the past 7 years. My husband then left me after 23 years of being together. Now with help of a new doctor, she has started me the estrogen cream. It has been amazing. I still haven’t had any intercourse yet,but I feel that I am heading in the right direction. I went through menopause at the age of 40 (never had kids), then I went through Head and Neck Cancer in 2006. I was bedridden for over a year with a feeding tube fighting it. I was very concern about the idea of using estrogen, because of my Cancer history. But my doctor reassured me that the chances of the estrogen causing Cancer was small. So here I am, hopefully on the road to recovery and with the help of your great article I understand the issue a lot better.
Thank you,
Marion