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.

1. Stretch the hip/gluteal muscles. Stretch the large muscles of your hip and buttock region, since they can actively refer pain into the pelvis and cause the pelvic floor muscles to overwork or be strained. When you actively stretch the hip flexors, hip external rotators, inner thigh (adductors), groin, and hamstrings, the pelvic floor is released and can function optimally. Hold each static stretch for 30 seconds. Do this stretch twice, two times a day.
2. Visualize a relaxed pelvic floor. Chronically tight pelvic-floor muscles need many reminders throughout the day to relax. Every time you look at the watch or your mobile phone, ask yourself, “Where is my pelvic floor?”  Think about the area softening, melting, widening. Use any visualization that is calming to you; send a healing color to your pelvis to bring awareness and “let go.”
3. Breathe. Diaphragmatic breathing helps to widen the abdominal and pelvic regions.  Lie on your back, pillow under your knees. Place your hands on your stomach, bent elbows resting by your sides.  Inhale slowly through your nose for a count of 5 seconds.  During your inhalation, allow your stomach to expand into your hands. As your stomach expands, visualize your pelvic floor muscles widening With each inhalation, imagine or visualize the bottom of the pelvic bowl expanding in all directions—front, back, left, right. Slowly exhale for 5 seconds. Repeat 5 times. Do the sets once in the morning and once at night.
4. Keep your pelvis properly aligned. Set up your computer/reading/art workspace to fit your body, instead of making your body adjust to the environment. The chair should be at a comfortable height, so that your feet are supported either on the floor or a raised footrest.  “Good posture” occurs when a neutral spine in maintained.  When you’re sitting, your weight should be in the middle of the pelvis, your lower back resting against a lumbar cushion. The lumbar cushion gently pushes your lower back forward to maintain its natural curve.  You should not slump back to sit on your coccyx bone, nor too far forward on your pubic bone, and don’t sit on one side/hip for hours at a time.  Here is where a PT can really help you gain knowledge about the best position of your body.
5. Self-stretch intravaginally. This is a technique to stretch your intravaginal muscles that lie one inch from the vaginal opening.  Insert your clean left thumb intravaginally up to the level of the first thumb joint. Gently press or sweep your thumb along the right vaginal walls, providing a deep stretch. Do a few sweeps from the midline toward the bottom of the right vaginal wall. Hold areas that feel tight or uncomfortable until they feel softer.  Then insert the right thumb intravaginally and sweep or apply pressure points along the left side of the vaginal wall. Repeat a few times on each side. Do once a day.
6. Dilators. Dilators are also used to help women prepare for intercourse and to apply pressure to tight spots within the vaginal walls to stretch them. Your PT can guide you on how to use them.
7. Strengthen the pelvic-floor muscles.  Once your pelvic floor muscles are lengthened, a basic pelvic floor–strengthening program can begin. Your physical therapist can teach you how to best recruit these muscles without co-contraction of the hip adductors, hip extensors, and breath-holding.  Pelvic-floor strengthening can be done by doing a pelvic-floor contraction and holding it for 10 full seconds, then resting for 20 seconds. Repeat 10 times. This works the slow twitch or endurance muscle fibers. Next, do 10 quick contractions and quick relaxations. Repeat 10 times. This works the fast twitch fibers, which are stimulated during orgasm.
8. Squat. Squatting exercise helps to lengthen the pelvic floor and increase the strength of your hip and buttocks muscles. When you’re performing either a quarter, half, or full squat in good alignment (knees behind toes, weight on heels), this provides great balance of the pelvis and pelvic floor muscle function.
9. An orgasm a day . . . Yes, an orgasm a day keeps all the pelvic muscles happy and healthy.

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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