Many women come to my practice complaining of severe pain with intercourse. Often they are breast cancer survivors who have had a recent mastectomy and reconstruction, and could also be in a chemotherapy-induced menopause. Many may take estrogen-depleting aromatase inhibitors to manage risk factors for recurrence of breast cancer. They are struggling with self-image issues and the unanticipated loss of a previously satisfying sex life.

For many women, the pain associated with sexual intercourse is likely due to a tight and tender pelvic floor. For women who have not had a vaginal delivery and abstained from intercourse for an extended period of time, the vaginal opening will have decreased in diameter and the pelvic floor will have increased tone—in this case, not a good thing—along with decreased flexibility. By addressing this condition with physical therapy, intercourse should be less painful and more satisfying.

During an initial evaluation, the physical therapist performs a comprehensive physical evaluation to assess the musculoskeletal and neuromuscular systems of the spine and hip, and the external and internal musculature of the pelvic floor. If the perineal tissue appears thinner than normal and less elastic, it is probably more sensitive. That means it is probably less able to handle the friction associated with intercourse without tearing. These patients are advised to explore their options for lubrication or other treatment with a gynecologist.

Treatment is tailored to each patient but follows a general pattern.

To address potential discomfort with treatment and to prepare for the eventual resumption of sexual intercourse, patients are taught some basic relaxation techniques and diaphragmatic breathing. They’re encouraged to start a cardio-fitness program to help alleviate anxiety and depression, improve self-image, and increase circulation in the perineal region for better tissue health. Hot baths or moist heat localized to the perineum further increases blood flow to that part of the body.

From the start, patients should learn as much as possible about the anatomy and function of the pelvic floor. Educated patients are more committed to treatment and more likely to follow through with the home exercise program. They almost always make the best progress.

A tight pelvic floor will not stretch without pain, and that makes intercourse painful. One of our goals is to decrease the resting tone of this muscle—in other words, to get it to relax. Internal biofeedback is often used to assess, and then help decrease, pelvic-floor muscle tone. A tampon-sized sensor inserted into the vagina will pick up muscle activity and display the results as a graph on a screen. It is an excellent teaching tool.

To increase flexibility of the pelvic-floor muscle, internal manual techniques are often used, along with dilators of progressively larger diameters, according to patient tolerance. The goal is to achieve enough flexibility to allow comfortable penetration. I advise my patients to wait with penetration until sufficient manual stretching is tolerated.

There is hope out there! Recent studies show that elevated muscle tone is the primary cause of sexual pain disorders. According to one recent publication, after a course of treatment (typically 16 visits, twice a week for eight weeks) 62% of the subjects reported improvement in their sex life. And that can be so helpful to health overall.

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