Chronic sexual pain: a layered guide to evaluation
By Deborah Coady, MD, FACOG
One-third of women at some point in their lives experience painful sexual activity for 3 or more months. Sexual pain may occur during arousal or intimate contact or afterward and may persist for days. Genital and vulvar pain may also exist steadily and independently, with sex heightening its severity. Sexual pain is a feature of chronic pelvic pain (CPP), a condition affecting 30 million women in North America at any one time.1-3 Most women with various types of CPP experience painful sexual activity. For example, 75% of women with interstitial cystitis/painful bladder syndrome (IC/PBS) report sexual pain.4
Sexual intimacy is a fundamental desire of most women. Women suffering from pain disorders consistently report that lack of sexual activity or enjoyment is their main reason for low quality of life.5,6 Secondary depression, anxiety, low libido, and relationship difficulties are understandably common in these individuals.7
Compounding this decline in overall quality of life are feelings of shame, guilt, confusion, and isolation. Despite increasing cultural openness about sexuality, more than one-third of women with sexual pain never seek help from healthcare professionals. When they do, many feel misunderstood or dismissed. Fifty percent are dissatisfied with their encounters with doctors.8,9 Women frequently report being told after cursory pelvic exams that their pain must be “in their head.” Fortunately, women with sexual pain are benefiting from social media, self-education, sharing experiences and resources, and self-care.
Ob/gyns are on the front line of care for women with sexual pain. But because most of them have received little formal training in or practical experience with this common problem, they often feel ill-equipped to evaluate patients who are distressed, skeptical, or hopeless due to previous negative experiences. Ob/gyns also may hold preconceptions that the evaluation of sexual pain is more complex and time-consuming than it really is, and that there are few effective treatments anyway. But many advances have been made in understanding the multi-layered causes of sexual pain, and most women can improve and resume or begin satisfying sexual lives after diagnosis and up-to-date treatment. Postgraduate ob/gyn training on CPP is being updated, through the Committee on Resident Education in Obstetrics and Gynecology’s (CREOG) expanded core competencies, which will improve the future for women with these conditions.10