Medical Mondays 2

 

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. Today, she consults with Evelyn Hecht, a licensed physical therapist in New York City, on a problem her patients frequently bring up—painful intercourse after menopause.

 

 

Dear Dr. Pat:

I am a 57-year-old divorced woman and have not had intercourse for three years. After I began to date a new man seriously, I saw my gynecologist because I had dryness, and even my vibrator caused pain. My gynecologist was very understanding. She explained that after menopause, all of the sexual areas—the labia, the clitoris, and the vagina—are deprived of estrogen, so prolonged contact causes dryness and discomfort. She prescribed an estrogen cream, and after two weeks of using it I was able to have comfortable foreplay with my partner.

However, I have not been able to have intercourse. I use lubrication in the vagina and on the penis, but it is just too painful when he tries to insert the penis. I never had children. I have some arthritis in both hips from engaging in active sports most of my life, according to the orthopedist. What can I do to make intercourse possible, or have I waited too long?

Barbara

 

Dr. Pat Responds:

Dear Barbara:

This is a common story. Women who are postmenopausal do indeed develop thin, dry, inelastic genital tissue. Many women who are not in a sexual relationship choose to use a bit of estrogen locally, just for improved comfort. Others have no symptoms until they want to begin a sexual relationship after a period of celibacy. Women who never had a vaginal delivery often have a tighter vaginal opening. Women who have disorders that affect muscles, tendons, and joints in the hip girdle area often develop painful intercourse.

Your gynecologist did the first thing right. She gave you an estrogen preparation that improved the mucosal tissue: It has become thicker, more elastic, and moist. Certainly the mucosa must be healthy before any further treatment begins; otherwise, the tissue will be unresponsive to manual and other therapies.

The remaining problem often requires some pelvic-floor physical therapy. Since many women live in areas where there is no one who understands this kind of therapy, I have asked Evelyn Hecht, P.T., A.T.C.—a certified athletic trainer and a practicing physical therapist specializing in orthopedics, spine, and pelvic floor health for more than 25 years—to describe how she would evaluate a patient with your history, and what she would suggest that you do.

I have also asked her to describe what she would do for a patient who cannot see a pelvic-floor therapist.

Thanks for the question.

Dr. Pat

 

Evelyn Hecht Responds:

Dear Barbara:

That old motto, “Use it or lose it,” is very applicable here! A menopausal woman loses approximately 70 percent of her estrogen levels, and when she has not had intercourse for three years, this combination causes the pelvic-floor muscles to tighten, making intercourse painful.

Here’s the good news: Painful intercourse in a postmenopausal women who has been celibate for years can be remedied. But the application of estrogen cream is just the first step of the treatment. Strengthening your weakened pelvic-floor muscles will be required—in sessions with a physical therapist or doing exercises at home.

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.

This week’s article is a primer on the muscles affected and a look at the kinds of tests a physical therapist will give. In Part 2, I’ll describe the pelvic-floor-strengthening process.

 

Hecht

Trigger points in the deep hip adductor muscles that can refer pain into the pelvic floor region.

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. During intercourse, the pelvic-floor muscles have to be flexible enough to stretch and accommodate the penis. If there are muscle adhesions, tension, or trigger points, this restricts movement and causes pain during and following intercourse. The pelvic-floor muscles are directly involved in performing four functions of the body: (1) lower back/core stabilization; (2) normal urinary function; (3) good bowel function; and (4) satisfying sexual function.

The History and Examination
Your PT will want to hear your specific complaints of painful intercourse, hip pain, lower-back pain, abdominal pain/bloating, surgeries that may have resulted in increased scar tissue/adhesions, and bladder and bowel symptoms. Questions will be asked about sexual symptoms such as superficial pain or deep-thrust pain during intercourse; whether pain continues post-intercourse; if there is constant perineal pain [pain in the area between the anus and the vulva]; fear of penetration; and difficulty with orgasm.

After the detailed history-taking, your physical therapist will educate you on anatomy of the pelvic bones and muscles, using an anatomical model. This helps you visualize the structures your physical therapist will be examining.

For the physical exam you will be comfortably positioned and draped before your physical therapist visually inspects the perineal/vulva region for skin color and tissue alignment while at rest. After the visual inspection, she will ask you to perform some pelvic-floor movements, such as contracting or tightening your pelvic-floor muscles (sometimes known as “Kegel exercises”). Then she will ask you to relax the pelvic floor, observing the quality of the movement from tension to relaxation. Finally she will ask you to “bear down.”Many patients may not know how to do one or all of these movements—this is a common response, especially when the pelvic-floor muscles are in spasm, or weak or uncoordinated.
Next, your physical therapist will palpate the skin, connective tissues, and muscles of the external hip, thigh, abdomen, and pelvic-floor regions to note any pain, mobility, restrictions, or referred pain to other regions.

After obtaining your informed permission, the internal exam follows. The physical therapist inserts her gloved, lubricated index finger intravaginally, up to the level of the pelvic floor muscles, which are approximately 1 inch from the vaginal opening. She will feel for tissue excursion (that is, whether one side is more flexible than the other side), again noting pain, adhesions, trigger points, and whether her palpation over specific muscles reproduces your symptoms (which is a good sign).

Muscle-strength testing of the pelvic floor follows. with the physical therapist’s index finger remaining internally to feel for quality of your pelvic muscle contraction. She will measure how strong your pelvic floor muscles are, whether your muscle can maintain that strong contraction up to 10 seconds, and whether all this be done up to 10 times.

Biofeedback testing may be next. “Bio” means body and “Feedback” means receiving information about a physiological activity. Biofeedback measures the electrical activity of the muscle and transmits that information to either a range of numbers and/or sounds. The patient sees the numbers and learns how to retrain her pelvic-floor muscles with the guidance of the physical therapist. Your PT inserts a vaginal sensor (the width and length of a female index finger) intravaginally, slowly and with your conscious use of breath. These sensors pick up the electrical activity of your pelvic floor muscles.

Your physical therapist will measure the electric voltage (microvolts) that your pelvic-floor muscles elicit during rest, during slight contraction, during full contraction. She will measure if your muscle returns to complete baseline rest following contractions, whether your muscles have good endurance etc. Biofeedback training is utilized during follow-up physical therapy treatments to help you learn how to properly recruit your pelvic muscles and regain normal function.

All of this careful measuring is a prelude to the instruction you will receive about the exercises you can do to strengthen your muscles so that intercourse is pleasurable, not painful. Part 2 of this series, “Remedies,” will describe the therapies your PT will prescribe.

  • Patricia Yarberry Allen, MD May 15, 2013 at 11:40 am

    Dear Sue,

    Thank you for reading and commenting on the article about management of painful intercourse in a post menopausal woman who had not been in a sexual relationship by choice for three years. Most gynecologists treat this problem effectively with local vaginal estrogen (and in this practice large doses of Vit D 3 for three months) to improve the genital tissue. Then the use of dilators with instruction from the gynecologist may work but often the specialized treatment by a pelvic floor physical therapist is necessary. We do not recommend the use of systemic hormone therapy for this local problem. I do urge you to discuss the issue of your use of systemic hormone therapy with your gynecologist since there is no recommendation for prescribing systemic hormone therapy for a woman your age. The reasons that women are discouraged from using systemic hormone therapy as they age is the natural risk that each of us has for increased stroke, blood clots, heart attack and breast cancer that go along with aging. Hormones are hormones…bio-identical or Premarin…still hormones…still with a risk.

    Dr. Pat

    Reply
  • suetiggers May 14, 2013 at 4:05 pm

    My great GYN is good with homeopathic and Western meds and she helped me with a combo of bio-identical hormone replacement that I get from a pharmacy that does it’s own compounding here in Baltimore and the pain went away and the pleasure came back…hooray…I told her I thanked her and my husband thanked her. I’m 72 and it still feels good, so I expect things to stay good.
    I so appreciate that women’s research team that did the longitudinal study of women and hormones and then concluded that Premarin was especially not the best choice for us older (but not aged) gals. Thanks to the Women’s Health Movement that came out of feminism. I feel so much safer using what I do.

    Reply
  • Caren Gittleman May 13, 2013 at 7:35 am

    when I read this letter I thought it was ME who had written it! I am also 57, married and experience painful intercourse due to menopause.

    I DID go the physical therapy route and guess what? It did NOTHING for me. I am sure it works for many but for me? Nope.
    And…the other problem is even after using Boric Acid I have a vaginal infection that will NOT go away!

    Reply
  • laura May 13, 2013 at 7:28 am

    Thank you so much for this series. In December, my partner and I ended our relationship of three years primarily over the results of this issue with me and his erectile disfunction, which, combined,made our bedroom a battlefield of blame, anger, and grief.

    Reply

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