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When Pleasure Becomes Pain

When Pleasure Becomes Pain

Painful sex is one of the most common conditions I treat in my practice.  This article was written for medical doctors to help them to make the correct diagnosis if you have painful intercourse and more importantly point you and your doctor in the right direction to get treatment that takes the pain away completely.  I hope you or your doctor find it helpful!  You are more than welcome to make an appointment for this assessment and the appropriate treatment.

Please also have a look at our amazing products for the treatment for sexual pain.

Interested in reading more about sexual pain?  The My Sexual Health blog has many articles available on the subject.

Written by Dr Elna Rudolph

Dr Elna Rudolph
Written by Dr Elna Rudolph – Clinical Head of My Sexual Health
011 568 4800
www.DrElnaRudolph.co.za
www.mysexualhealth.co.za
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Botox Injections for Sexual Pain, Vaginismus and Vulvodynia

Botox has been proven to be a safe and effective treatment for sexual pain, vaginismus and more recently also for vulvodynia.   Depending on the diagnosis and cause of the pain, it is used in conjunction with various other medical treatments, physiotherapy, counselling, hypnotherapy and sex therapy.  We do not recommend it as first line therapy for any form of sexual pain, but we have helped many patients by adding Botox to their treatment plan.  I (Dr Elna Rudolph) have presented the results of those patients who needed Botox for the treatment of their sexual pain at the International Conference of Sexual Medicine in Portugal.  My research from our clinic shows that our patients perceive Botox to be a safe and effective treatment for sexual pain, vaginismus and vulvodynia.  I have also found that it works exceptionally well for couples in unconsummated relationships and for people who cannot use tampons.

A few facts about Vaginal Botox:

  • Botox does not take away the sensation around your vagina.
  • Botox does not change the appearance of your vagina or vulva.
  • The procedure we use only relaxes the small muscles around the vaginal opening that makes penetration difficult or irritates the nerves and cause burning and stinging. We only use Botox in the external pelvic floor muscles.  It therefore does not help for deep pelvic pain, only pain on insertion.
  • In eight years of using Botox as treatment, we have never had a patient or partner who complained that the vagina was too big or too relaxed after the procedure, or that it influenced their ability to experience pleasure during foreplay or intercourse. It just makes it less sensitive to pain and to being stretched.
  • Complications such as a leaking bladder or leaking stools have never happened in our clinic and it is extremely unlikely to happen due to the technique we use. We also use real Botox that does not have a tendency to spread to other areas. These are however two of the listed possible complications of Botox.  If either of these complications do occur, it is reversible after three to four months when the Botox begins to work out of your system.
  • The procedure is performed under conscious sedation in our procedure room at the practice.

The Botox will only begin to take effect after ten to fourteen days.  It will then work for three to four months.  If you have established regular intercourse during this time, it is highly unlikely that you will need to repeat the Botox procedure.  Less than 10% of our patients have had to repeat the procedure.

I cannot guarantee that Botox will make your sex completely pain-free or take away your vulvodynia, but if I recommended it to a patient it is because I believe there to be a very good chance that it will make a significant difference.  If I could offer it for free, I would recommend it to 90% of my pain patients.

If you have never been able to insert the number 5 dilator, please talk to me about signing consent for a partial hymenectomy to be performed during the Botox procedure.  In some cases, the hymen may be too tight, and the number 5 dilator cannot be inserted, despite relaxing the muscles completely.  In these cases, it is advisable to make a few small incisions in the hymen.  We do not use any stitches and there is usually minimal bleeding (bleeding as much as during a normal menstrual cycle is nothing to worry about).  The bleeding usually stops within a day or two, but some spotting might occur when the dilator is inserted.  This usually also stops within a week after the procedure.  If you aren’t able to dilate after a partial hymenectomy, the slits may heal with scar tissue formation and the procedure will have to be repeated.

You can also have a Mirena inserted or have a pap smear done during the procedure.  Please discuss this with me before the procedure and remind me about it on the day of your procedure.

What to expect from the procedure:

On arrival, you will be given a local anaesthetic cream to be applied around your vaginal opening.  You should arrive at least 15 minutes prior to your scheduled appointment to allow enough time for the anaesthetic cream to take effect.

If you are having your Botox procedure done by me in Bryanston, you will first meet with Dr Jeanne Aspeling, who will be performing your conscious sedation.  This is a very light form of anaesthesia where you will be partially awake and aware, but you will not have any memory of the event.  It helps you to relax enough to allow me to perform the procedure.

I will then clean the area and inject 10 ml of a long-acting local anaesthetic into your external pelvic floor (around the outside of your vaginal opening).  These injections are somewhat painful.  I will then inject 50 units of Botox, mixed with saline, into the affected muscles. You will receive between 20 and 30 injections in total, so you can expect some bleeding and bruising.  The sensation will come back later during the course of the day when the local anaesthetic wears off, and the Botox will take up to fourteen days to start working.

There will be no pain initially, but as soon as the anaesthetic starts to work out of your system, you may experience pain.  Many patients contact me after the procedure, worried because it feels like the pain is worse than before the procedure.  This is just the body’s reaction to the minor trauma caused by the injections.  The Botox will start working in ten to fourteen days.  Just use the biggest dilator you can insert and take a break for a day if you have to.

Continue to use your Fluconazole weekly to prevent candida infection and contact the practice immediately if you think you have developed an infection or any other complication.

DILATORS:

You have to spend as much time as possible with the largest dilator inside you.  Start as soon as you get home and stay in bed for the rest of the day and night.  Over the weekend you will be able to resume normal activities, but it is still advisable to keep the dilator in for as many hours as possible.  Put a heavy book or other object between your legs to keep it in place if it keeps slipping out.  We suggest that you sleep with the dilators during this two-week period, if you are able to.  If it becomes uncomfortable during the night, you can remove it.  If it becomes too painful to use your dilators, especially if you have pain for an extended period after removing it, take a break for a day before trying again.

You may want to get a stub dilator to make it easier to sleep with your dilator or to walk around with it inside your vagina.  They are the same girth as the normal dilator, but they are shorter, and the outside is oval shaped to make it more comfortable between your legs.  They are available in sizes 3 to 6 and can be purchased at the practice or from www.mysexualhealthSHOP.co.za.

If we have been treated with Botox for vulvodynia, you may be too tender and irritated to keep the dilators in for such long periods.  Just do as much as your body allows you to do.

Please bring your dilators with you on the day of the procedure as I may need to use them during your procedure.

SEX:

The Botox will take at least ten to fourteen days to start working.  Please do not attempt intercourse before then and also not before you are able to insert the number 5 dilator.  If you feel ready, please do attempt intercourse before you see me for your two-week follow-up. Please follow the steps in the “Penetration Programme” initially – you can request the programme to be emailed to you by our staff.

FOLLOW-UP:

I would like to see you again two weeks after your procedure.  Please arrange the follow-up appointment with my staff when you book your Botox appointment to avoid disappointment. The follow-up appointment is included in the cost of the Botox and can be claimed from your medical aid (the amount that your medical aid pays out for a normal GP consultation).

I recommend that you see your physiotherapist shortly before you see me for your follow-up.  It helps to get rid of the tightness around the muscles that may still be pinching the nerves.  Since Botox only helps for superficial pain, you may need to continue seeing the physiotherapist for deeper pain or other problems.

After your two-week follow-up, if you are having pain-free intercourse, I would like to see you again between six weeks and six months, depending on your situation and condition.  I will then evaluate the need to repeat the procedure and confirm that all your sexual problems have been resolved.  Although most of our patients go on to have pain-free or much more comfortable sex after the procedure, up to half of our patients still experience some form of sexual dysfunction a few months or years after the procedure.  Please be aware of this.  You may still need to get additional help for your libido, for instance, or any difficulties with orgasm, any fears around sex or any relationship issues.  Remember that we have a comprehensive team of experts who will be very happy to assist you.  You are welcome to arrange a follow-up appointment with me at any time.

SCHEDULING AN APPOINTMENT FOR YOUR BOTOX PROCEDURE:

The best time for performing the Botox procedure is on a Friday, or any other day which would allow you to keep activity to a minimum for at least two days following the procedure, mostly because we would like you to have as much possible time to dilate.  I will give you a certificate for sick leave if you need it.

Some medical aids pay a portion of the procedure.  You are welcome to contact the practice for a quotation to send to your medical aid.

To make a booking:

  1. Booking your Botox procedure is a sensitive matter, so please call my office on 011 568 4844 to book your appointment. I am usually fully booked a few weeks ahead so book as early as you can.
  2. If you would like to have a Mirena® fitted at the same time, please inform my staff. We do keep the Mirena in stock, and you don’t need a prescription for it.  If you have the Mirena fitted during your Botox procedure, you will only pay extra for the Mirena device – the procedure will be included in the Botox price, making it possible for you to claim more money back from your medical aid.
  3. You will be asked to pay the full amount at least four days prior to your procedure (we do not keep Botox in stock – we order it as soon as your appointment has been confirmed and paid).

Please be sure to arrange for someone to collect you from the procedure room. Under no circumstances will you be allowed to drive during the first 8 hours after receiving the conscious sedation, and you should also not be left unaccompanied for the rest of the day.

If you experience any complications due to the procedure, please email me immediately (elna.rudolph@mysexualhealth.co.za).  Pain, bleeding and bruising are normal for the first few days.  Infection and problems with your bladder or bowel are unexpected problems, so I would definitely want to know about them.

Written by Dr Elna Rudolph

Dr Elna Rudolph
Written by Dr Elna Rudolph – Clinical Head of My Sexual Health
011 568 4800
www.DrElnaRudolph.co.za
www.mysexualhealth.co.za

My Broken Vajayjay

Painful intercourse is one of the most common conditions I treat. Each patient has a unique journey and a special story. Jo was one of those who had a unique story and she was kind enough to share it with us…

Dr Elna Rudolph
Clinical Head of My Sexual Health

Jo’s Story: My Broken Vajayjay

Okay, so how do you start writing a story about your broken va-jay-jay?

Perhaps with that time you had to sheepishly walk into a sex store to ask for a dilator – and walk out with an interchangeable purple dildo or the time you got told to put on hemorrhoid cream on the “affected” area 20 minutes before sex?

My 4-year journey starts with my self-diagnosis of Endometriosis, because when I searched “pain during intercourse” and that was Google’s response.  Keen on a second opinion, my gynecologist at the time didn’t agree – her diagnosis was vaginismus.

Your reaction was my reaction: WTF is vaginismus? Here’s Wikipeadia’s definition today:

Vaginismus: it is a condition that affects a woman’s ability to engage in vaginal penetration, including sexual intercourse, insertion of tampons and gynecological examinations (pap tests).

The offered solution: apply hemorrhoid cream on your “lady flower” before intercourse and this will reduce the pain experienced during penetration. Sounds simple right? Well it wasn’t that simple.

Firstly, who plans on when they are going to get intimate? Secondly, how do you have sex quick enough so that you and your partner’s bits don’t go numb from the local anesthetic you have just applied to your swimsuit area? Lastly, great, neither of us can climax.

I tried this “method” for 3 months, and during this time I tried to educate myself about vaginismus but there really wasn’t much information on it. I became depressed – what was wrong with me, and why couldn’t I please my husband? I mustered up enough courage for what seemed like the next logical step, to visit a psychologist about my broken “taco”.

Her first question during this first session was, “Jo, do you love your husband?” I was shocked. How dare she question my commitment to my husband, especially considering I was trying to solve this issue for us both? On doing some research, she shared a contact number for a physiotherapist specialising in pelvic physiotherapy, pelvic floor functioning and continence. I phoned immediately and took the first available appointment. Twice a week you could find me lying on my back with my legs open while the physiotherapist “massaged” the tense muscles at the vagina opening – this was accompanied by conversations like “Oh wow Jo! You are so much looser than you were last week.”

I had also started seeing a psychiatrist who diagnosed me with anxiety and depression for which I was given a crazy amount of drugs.

Before I got diagnosed with Vaginismus, I was a prude to say the least, I blushed at a sex joke and didn’t even try to talk dirty. I couldn’t even speak to my husband about it, and he wouldn’t even express his frustration. I eventually became so nonchalant about it, “vagina this, p***y that,” I think it was mostly because I was numb from all the emotional and physical probing that I didn’t have any dignity left.

Replaying my most intimate sex scenes to my therapist like a porno and opening my legs to what ended up being 3 different physiotherapists – all this to no avail. No matter what I did, nothing changed.

This went on for a year. Nothing helped. Nothing! I went to a hypnotherapist, an iridologist, a psychic, got a dilator, started to meditate, lost my faith, went to a specialist physician – even discovered I had epilepsy in the process. I had tried everything.

All of this naturally also affected my connection with my husband, my patience and my mind. I was suicidal, wishing a bus would come and smash me into tiny little bloody fleshy bits. I started to go crazy, making up stories to the point where I convinced myself I was raped as a child. Of course I had no memory of it but, “What if I was drugged?” “What if it was so traumatic I forgot it even happened?” I even considered having children just to “stretch out” my vagina. (God knows how I would’ve fallen pregnant…)

I had had enough, breaking down one day in the physiotherapist’s room and told her that I couldn’t cope, there must be something else I can do, I had watched a YouTube video about a surgical procedure that could be done and it was time. She referred me to yet another specialist, Dr. Elna Rudolph, a specialist in Sexual Health.

On our first meeting it was decided that we were going ahead with the Botox programme, which to me was my last and only hope. The procedure was very quick, 30 minutes of conscious sedation. As Botox is injected to relax your frown muscles in your forehead, the same concept applies to the muscles in your vagina. I had 50 units of Botox injected into my vagina, enough for 2 rounds in the face for the average Kugel living in Camps Bay. The Botox wasn’t an instant fix though. You need to include dilation and apply certain creams before you can even start considering having sex.

I followed the programme religiously and a few weeks in, my husband and I were able to have intercourse a few times whilst the Botox lasted (for about 3-6 months). It’s sad how I had started to call sex (such an intimate affair) “intercourse”.

After 6 months my pop-up p***y palace was closed for business.

I had spent stupid amounts of money on this condition, enough for me to go on at least three trips to Europe. My marriage was suffering, we separated a few times before calling our marriage off.

I was damaged goods, with a broken vagina. Would I ever find someone that would want me?

After the divorce was official, I started dating again. In hindsight it was way too soon to even start considering a relationship. But I met a guy and we had instant sexual tension. Being together with the same partner for 11 years, I had forgotten what it was like to feel that intense lust. The problem was, how was I actually going to engage in sexual intercourse with this guy? But, I just went along with the ride as if there was nothing wrong with me. I was as nervous as hell.

We had intercourse. I mean sex. Passionate. Lustful. Sex.

I was so confused, but relieved, but confused. Who knew getting a divorce would fix my vagina?

Yip, as far as I know, it was all in my head. A lot of people don’t realise a big part of vaginisums is psychological. Suddenly the blame I was carrying was lifted off my shoulders.

I simply wasn’t listening to my body, my subconscious got to a point where it was making decisions for me. Looking back, the question from the psychologist was the most valid one. I couldn’t see it then, as I had to go through this whole journey to actually realise it.

Listen, I am not advocating women with vaginismis should get divorced. That’s defintley not my message. Your journey will be a different one. All the methods I tried didn’t work for me because subconsciously, I believe, I didn’t want them to. There are a million other reasons why a woman could have vaginismus – in my case I just didn’t want to accept the reason and thereby let myself down. I didn’t want to be like my parents and the rest of failed society. This was pressure I put on myself to be perfect and to stand by the commitment I made – till death do us part.

My broken vagina was telling me something and I finally listened. And now, through this journey of getting to know each other, we’re not broken anymore.

We’re also having great sex.

You can find this article and other vagina stories on Vaginalogues.

 

Click here if you would like to request a consultation with Dr Elna Rudolph to discuss painful intercourse.

If you would like to connect with Jo or contact her for support, you can send an email to info@mysexualhealth.co.za to request Jo’s email address.

Dr Elna Rudolph
Dr Elna Rudolph – Medical Doctor, Sexologist and Clinical Head of My Sexual Health.
086 7272950
www.DrElnaRudolph.co.za
www.mysexualhealth.co.za
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New MSH Silicone Dilators – a breakthrough in treating painful intercourse

About the new MSH Silicone Dilators

This product is our pride and joy because it has helped so many couples to have pain-free intercourse. They have been custom made here in South Africa, according to the needs of the thousands of individuals and couples that the My Sexual Health (MSH) doctors have treated for vaginismus and other forms of painful intercourse.

Two major advantages are that the silicone dilators have a soft tip and they do not cause infections. We have many patients who have tried plastic or glass dilators in the past, as well as other household items, but they all prefer our silicone dilators now, because of their softness and suppleness. You can also place the silicone dilator in hot water before you use it to retain heat – so much more comfortable than plastic or glass objects that can cause reflex muscle spasm due to being cold.

The highest quality material for its specific purpose has been used in the manufacturing process, and each product is individually casted and sterilised – our products are not mass produced.

We also make a size six (6) and a size seven (7) dilators for women who have a partner with a penis larger than the size five (5). However, the penis of a typical man is between a size four (4) and five (5) dilator. The silicone dilators can be purchased individually should you not need the whole set. We also make “stub dilators” with the same girth as the standard sizes, but they are much shorter and therefore easier to sleep with or keep inside you during the day.

The silicone dilators can be cleaned either with normal fragrance-free soap, or the soap from the FEMAGENE range, and warm water – rinsed and dried thoroughly before storing it in a cool and dry place.

What is the Success Rate of the MSH Dilators?

According to statistics from our MSH doctors, patients progress on average to the number four (4) and five (5) dilator within three (3) to four (4) weeks if they take their medication and see the physiotherapist. Those who do not progress as well, often need Botox or further intensive psychological treatments.

Our dilators have shown work particularly well not only for treating vaginismus but for a host of other conditions too! Pelvic surgery, radiation for genital and rectal cancers, transgender patients with neo-vaginas or any other intersex condition where a vagina had to be constructed or stretched, women who cannot use tampons, women who find intercourse difficult due to a long period of abstinence, menopause setting in or due to skin conditions like lichen sclerosis and lichen planus, after childbirth, and for painful anal intercourse.

How the MSH Treatment Process works

After you have been evaluated by one of our MSH doctors, you will likely get a prescription for a special medicinal cream to address the hormonal and nerve problems you may have, as well as treatment for infections or treatment to prevent infections, muscle relaxants and further medication to help you cope with anxiety when you are dilating or visiting the physiotherapist.

MSH patients see a specialist pelvic function physiotherapist to teach them breathing and positioning techniques, evaluate their pelvic floor muscles, show them how to actively relax their pelvic floor muscles, demonstrate to them how to use the dilators and progress from the different sizes, and help them with trouble shooting when they get stuck. Specialist pelvic function physiotherapists also attempt to find and treat the cause for tight pelvic floor muscles, rather than just addressing the symptoms.

We also recommend that you use the medication for about ten (10) days before visiting the physiotherapist and preferably first see the physiotherapist before you attempt to use the dilators.

Some patients experience painful intercourse due solely to medical reasons. If, however, you expect that there may also be a psychological component (especially if you were victim to childhood sexual abuse or traumatic sexual experiences), we strongly recommend that you also see one of the specialist psychologists or trained hypnotherapists on our team.

If you have not seen one of the MSH doctors and you are struggling with your dilators, please visit one of them as soon as possible. There is usually an untreated medical condition preventing you from progressing, or psychological issues which have not been attended to. Thousands of women around the world have cured their vaginismus and other sexual pain conditions by only using dilators. If you feel comfortable to first try it on your own – go for it! (But please do see a doctor who specialises in pelvic pain if you have any concerns).

How to use your MSH Silicone Dilators step-by-step

  • Select an appropriate time and a warm comfortable place – allow for relaxation and no interruption.
  • Position your body lying down with your legs bent – place pillows or cushions under your turned-out thighs to allow your leg muscles to completely relax.
  • You can warm the dilator before using it – put it in hot water for 5-10 minutes to slightly warm it (avoid it getting too hot).
  • Apply your prescribed cream if you are a MSH patient. Make sure you rub it in around the opening and into the opening, using the tip of your finger, for at least two (2) minutes.
  • Very important: if you are not using these dilators for vaginismus, but for another reason relating to being transgender, intersex or a male, please ask your MSH doctor or physiotherapist if you have any uncertainties.

Step One: Lubrication

You can use any kind of lubrication, however, we recommend that you use Pjur Body Glide Lube or Pjur Med Premium Glide if you struggle with recurrent infections, or if you are very sensitive. If you are being treated by one of the MSH doctors, you can also use the cream they have prescribed as a lubricant. These lubricants can be ordered online from www.MySexualHealthShop.co.za.

Avoid lubricants containing petrochemicals as these can cause pelvic floor tissue irritation and exacerbate pain. Even natural oils can disturb the natural balance of your vagina and contribute to painful intercourse.

Place a small amount of lubricant on the tip of the dilator and around the opening of the vagina.

Step Two: Breathe

Focus on your breathing by using a series of slow, deep breaths. Try to breathe with relaxed, deep breaths so that your belly rises when breathing in and falls when breathing out. This is called diaphragmatic breathing and its purpose is to switch on your parasympathetic nervous system, which makes you feel safe and relaxed, and switch off your fight and flight reaction, which is often over-active in people with vaginismus or painful intercourse.

Count while you are breathing. If you take four (4) counts to inhale, try to take eight (8) counts to exhale. Continue diaphragmatic deep breathing for up to five (5) minutes at the outset of the session.

Step Three – Scanning

Scan your body for any area of muscle tension from head to toes. Notice any muscular tension around your eyes, jaw, throat, shoulders, buttocks and legs. Mentally encourage each area to relax and loosen with each exhalation. As you exhale, let the pelvic area soften with each breath. Visualise or imagine this area in a state of softness, relaxing further with every exhalation.

Step Four: Insert the Dilator

  • Start with the smallest size dilator and gradually progress to a larger size as comfort permits.
  • Rest the narrow end of the dilator against the opening whilst continuing relaxed diaphragmatic breathing.
  • Gently insert the end of the dilator into the entrance when you feel ready to do so.
  • Gradually insert the dilator to a tolerable depth. Keep the level of discomfort minimal – if you feel any discomfort, pause for up to a minute at a time, continuing to breathe and relax your pelvic floor.
  • When discomfort has eased, progress further while stopping at regular intervals to get your body accustomed to the sensation and lengthening of the tissue.
  • Try to keep the dilator in for 30 minutes at a time.
  • If you find that the dilator goes in easily, it is time to progress to the next size. Some people will start the session with a smaller dilator, leave it in for five (5) minutes and then feel ready to progress to a larger dilator.
  • Never force the dilator beyond a level of personal comfort.

Step Five: Dilator Withdrawal

  • After your session, gently withdraw the dilator and allow yourself to rest and recover before getting up.
  • Make sure you are completely relaxed before withdrawing the dilator. The pelvic floor will often contract as a reflex reaction when you start to withdraw. Just give your body time to relax.
  • It is normal to feel a burning sensation after dilating. This is due to the stretched muscles that irritated the nerves. If you are an MSH patient, you can use the cream your doctor prescribed after dilating again. You can also use the FEMAGENE Soothing Gel after dilating.
  • Wash the dilator with warm soapy water thoroughly, dry and store. No need to wash or wipe the cream or lubricant from your genital area – it will only irritate the area more.

Frequency and Timing of Dilator Therapy

  • Aim to use your dilator for 30 minutes during each session. However, when starting out, this time frame may be well reduced.
  • We recommend that you dilate every day for 30 minutes. Many of our patients get comfortable enough to sleep with their dilators a few hours every night (wear leggings to keep it in) or buy the stub dilators and walk around with them during the day.
  • Once you have established pain-free intercourse, we recommend that you maintain the relaxation of the pelvic floor muscles by either dilating, having sex or having physiotherapy three (3) times a week (i.e. if you are having pain-free sex three (3) times a week, there is probably no need to keep on dilating, but if you are getting to sex only once per week, you will need some regular dilating to maintain the relaxation of the pelvic floor.

Additional Dilator Therapy Techniques

These are some of the typical dilator therapy techniques that may be discussed during your visit to the therapist or doctor regarding their suitability for use:

  • Gradually increasing the depth of dilator penetration.
  • Massaging in a circular motion.
  • Moving the dilator diagonally i.e. forwards and backwards, and left to right.
  • Moving the dilator in and out of the vagina while maintaining gentle pressure against the vaginal wall.
  • Maintaining gentle pressure against an area of discomfort for up to 60 seconds.
  • Involving your partner in dilator therapy.

Important Precautions to take while using Dilators

  • Keep discomfort to a minimum – you should not feel physical or psychological discomfort when you are dilating. Of course, you will need to push yourself a little to progress to the next size, but if you feel overly anxious or uncomfortable, first speak to your doctor, your physiotherapist or psychologist about it.
  • Avoid using a dilator with active pelvic infection and see your doctor if you think that you might have an infection.
  • Avoid using a dilator immediately following pelvic surgery – be guided by your specialists’ recommendations regarding all forms of post-operative penetration and dilator use. You also do not want to wait too long either – as soon the sutures have dissolved, you should be able to begin with dilator therapy.
  • Dilating should never lead to bleeding – if you are bleeding, you MUST see a doctor. It may be due to infection or extreme thinning of the outer layer of your vagina.
  • Never use someone else’s dilator.
  • Clean and dry your dilator thoroughly after each use.

How to Progress to Intercourse:

Once you can insert the number five (5) dilator without physical or emotional discomfort, we recommend that you involve your partner in the process. Only when your partner can insert the number five (5) dilator without causing discomfort for you, you can progress to attempt penetration as if your partner is the next size dilator (rather than through a passionate love-making session). We find that it is better if you take the first few attempts at penetration very slowly and then progress to normal intercourse when you are comfortable with penetration.

If you or your partner suffer from painful intercourse, please make an appointment to see one of our specialist health care providers.

To purchase any of our MSH Silicone Dilators, visit the My Sexual Health Shop.
For more information on MSH Silicone Dilators, contact us on 086 7272 950

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LOCALISED PROVOKED VULVAR PAIN (Vestibulodynia)

LOCALISED PROVOKED VULVAR PAIN (Vestibulodynia)

Localised provoked vulvar pain (vestibulodynia) is a term used to describe pain upon penetration of the vagina. There is also tenderness to touch around the vaginal opening (vestibule) during physical examination. It occurs in women of all ages. It is estimated that approximately 15% of women will experience this type of vulvar pain sometime in their lifetime. Other names used in the past to describe this pain included vulvar vestibulitis syndrome, superficial dyspareunia and vulvodynia.

What causes it?

Researchers are studying vestibulodynia to learn more about the cause of the pain. In the last two decades they have shown that the painful tissue of the vestibule has increased nerve endings and inflammation. Although the cause is unknown at this time, there are theories that chronic inflammation from frequent yeast infections, hormonal changes, poor sexual arousal or chronic skin conditions may trigger the pain. It is likely that there is a combination of factors involved in the cause of vestibulodynia.

What are the symptoms?

Pain with vaginal penetration during sexual activity is the most common symptom experienced by most women with vestibulodynia. The pain can be described many different ways including burning, stinging, tearing, throbbing, searing and occasionally itchy. Some women may experience pain for several hours or days after intercourse. Some women may also have pain with tampon insertion or speculum exam during a routine gynaecologic exam. Most women have pain only with touch to the vestibule and are otherwise not bothered by pain.

What do I see?

The appearance of the vulva can vary with each woman. Some women will have redness at the vaginal opening but some will not. For many, the vulva and vestibule look entirely normal.

How is it diagnosed?

Vestibulodynia is a clinical condition which means that there are no laboratory tests or X—ray imaging that are done to secure the diagnosis. However, it is important that you see a practitioner who is experienced in the management of vulvar conditions. By listening to your history and performing a physical examination, your practitioner can be sure there is no other reason for your pain. Your physical examination may include a “Q—tip test” which is when your doctor or practitioner touches the vestibule gently with a Q—tip to determine if you have pain or not. Your health care provider may feel that other tests are necessary and these could include swabs to rule out infections or a biopsy to exclude skin conditions.

How can I help myself?

It is important to minimize irritation to the vulva and vagina. Avoiding soaps, detergents and scented products is ideal. Bland lubricants that are unscented are best for sexual activity. Ask your health care provider for suggestions. White cotton underwear is best and thongs, G strings, synthetic fabrics and tight clothing against the vulva should be avoided. Lidocaine in the form of a liquid, gel or ointment can provide relief when it is applied directly to the vestibule. This can be used for sexual activity as a way to reduce the pain. If you experience such sexual difficulties it may be helpful to see a sexual therapist and it may be best to avoid penetrative intercourse until your symptoms improve.

What do I see?

Many different treatment options have been tried for vestibulodynia. Some women experience a great sense of relief just knowing that the pain they are experiencing is real and has a name. With a supportive team that may include a spouse or partner, gynecologist, physical therapist (physiotherapist), sexologist, pain specialist, and psychologist most women will have improvement of their pain. Often, different treatment options are combined to maximize therapy.

Since research supports that there may be changes in the nerve endings in this condition, some of the treatment options target the nervous system of the vulva. These are sometimes called “neuromodulators” or “chronic pain medicines”. Examples of these medicines include the oral tricyclic medications like amitriptyline, notriptyline, imipramine and desipramine. These medications are used in high doses as an anti—depressant but they do not work in this way when they are used in smaller doses to treat pain problems. In these situations, they are used to try and reduce the hypersensitivity of the nerve endings. Other medicines used for this pain condition include gabapentin, pregabalin, and duloxetine. Recent research has also looked at these same medicines made up as a cream that are then applied directly to the vestibule where the pain is occurring. These medicines include 2—6% gabapentin cream and 2% baclofen—amitriptyline cream.

Other therapies that have been studied for the treatment of vestibulodynia are physical therapy (physiotherapy), sexual therapy, psychological therapy and surgery. Physical therapy means working directly with a therapist that specializes in rehabilitation of the muscles of the pelvis. Many women with vestibulodynia also experience sore, tight muscles of the pelvis which contribute to their distress. Learning how to relax and soften these muscles can often reduce pain but usually requires learning how to work with these muscles. Tools that the physical therapist may use include vaginal massage, heat therapy, biofeedback and dilator work. Each of these will be tailored to the special need of the patient.

There is also good evidence that women who have vestibulodynia often suffer from sexual problems. This can include low desire (poor libido), difficult arousal (poor natural lubrication or wetness) and lack of orgasm. Many couples feel troubled by their sexual problems. Engaging in sexual counselling has been shown not only to help couples with intimacy, but often reduces pain. Finding ways to have sexual activity in a non—painful way is very important towards healing.

Finally, surgery is another option that has been studied for the treatment of vestibulodynia. This outpatient surgery is performed by gynaecologists who specialize in vulvar conditions. The surgery called a vestibulectomy literally involves removing the superficial skin of the vestibule (painful skin) and advancing a piece of non—painful skin over the excised area. Surgical outcomes are best when it is coupled with both physical therapy and sexual therapy.

Vestibulodynia is a challenging and difficult disorder for women and couples to manage. Many vulvar experts believe that there is no single treatment that will cure this disorder. Using a combined approach of treatments is often the most successful in reducing pain. This means that a treatment plan incorporating physical therapy, sexual therapy and direct treatment for the vestibule skin may be suggested. Usually, with this combined therapy plan, most women will have improvement of their pain.

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Sex Q & A with Dr. Elna Rudolph

Sex Q & A with Dr. Elna Rudolph

Dr. Elna Rudolph answers a few questions about sex.

My partner wants to try anal sex more often, but I don’t enjoy it. I’m worried that if I don’t do it, he will feel unfulfilled…

There are certain no-no’s when it comes to sex in relationships and they are different for each couple. The one might never want to have sex unless she first had a shower, the other will never allow oral sex, and another will not do it with the lights on. These taboos should be respected by the partner, but it does not mean that they cannot shift when the reasons behind them are explored and some basic information with specific suggestions are given in the form of sex education or formal therapy.

When it comes to anal sex being one of the taboos, there are usually two reasons: Firstly some people have religious or moral issues with it. These can be quite difficult to shift and should sometimes just be respected. The other reason is that it is just too uncomfortable and therefore really not enjoyable. Guys expect that they will be able to just penetrate their partners as easily as it looks in porn. The reality is that most people have to go through a process to get used to being stimulated first around and then in the anus. Start with some light touch and rubbing and then move to inserting a well lubricated little finger and then progressively go larger from there. If you are really committed to it, you could also practice by yourself to get used to what it takes for the anal sphincter to relax. Like any muscle, it has the ability, but it takes time. If you perceive the attempt at penetration to be threatening and you anticipate the pain, the muscle will just go into spasm and make it more difficult and unpleasant.

How many times a week is it normal to masturbate? I’m in a long-term relationship and masturbate at least once a week, but my partner says he never does.

It depends on many things. If there is so-called “desire discrepancy” in a couple (which is the case in most relationships!) the partner with the higher desire is left frustrated if he or she does not masturbate. Masturbating is also a form of self-loving and soothing. You might get something completely different from masturbating than what you get from sex and therefore remain to have a need for it although you are in a very sexually fulfilling relationship. More than five times a week probably becomes excessive (according to international definitions anyway). It is also normal to never masturbate if you are in steady relationship. Whatever works for you.

I found a stash of lesbian porn on my husband’s computer and watched a video out of curiosity. It really got me off. What does this mean? Am I a closet lesbian?

Not necessarily. Up to 80% of women get turned on by some girl-on-girl action! You are a lesbian (if we have to use such a rigid term) if you would like to build a life with another woman. If lesbian porn excites you, you have just expanded your repertoire of excitement and fantasy.

I sometimes feel like my husband and I are more in the best friend zone than sexually connected. What can I do to get the spark back?

Make sure that you create special experiences when it comes to sex. The longer the relationship, the more difficult it is to create more and more exciting sexual experiences and then you get stuck in a rut.

It is however possible to create a special experience in a different way each time. Take time to make love through sensual massages and external stimulation, do the romantic candle lights and special music thing, make regular dates for love making, increase the oxytocin (bonding hormone) between you by looking each other in the eye, hugging and cuddling – all things to make a concerted effort to say: this is a special relationship with an intimate bond, not merely a friendship.

The more you are like friends, the more difficult these things are, but get started sooner rather than later!

How do I get my partner to go down on me more often?

Ask for it! Make sure you have the hair and hygiene under control and buy some special lubes that taste nice to encourage him. Returning the favor also goes a long way in encouraging him! (His favour might not be oral sex, it might be something else he loves that you are not doing frequently – find out what that is).

My guy doesn’t know how to make me climax – while he’s well-endowed, he’s not an expert at making it work. How do I nudge him in the right direction?

Firstly, you have to be honest about the fact that you are not getting there. Make it about you, not him. Tell him that there is only a specific way that works for you to come and you want to show him how to help you to get there. Show him how you do it and let him get involved in taking over more and more of the stimulation each time.

If he is offended by this and does not want to cooperate, think twice about sorting out a budget or raising kids with him!

How do I tell if he has an STI?

Sometimes you see a discharge, sore, blister, bump or wart in your genital area. It might have a bad smell or burn when you urinate. The reality is that most of the times you won’t even know about it. You will have to get tested.

I’ve just woken up from a night of tantric sex, but I’ve broken out in a nasty rash – I think it might be from the latex condoms we used. Are there any others we could try?

You could get latex-free condoms, but they are very difficult to find. Order them off the internet. It can also be due to oils you used for massaging.

I’m really in love with my partner but I struggle to get turned on by him. What should I do?

Check your hormone levels. Getting turned on is heavily dependent on testosterone. If you are taking an oral contraceptive, it breaks down and block your testosterone and therefore it is difficult to become sexually aroused. Some women just don’t produce enough testosterone. It can be supplemented through the skin, though. Never ever through injections!

My partner is amazing in bed, but he enjoys taking drugs before sex. I sometimes do it with him, but it bothers me that he wants to be high when we’re having sex. How do I tell him?

Be honest about it. tell him that you value the relationship and that you would like to have real intimacy with him and not just a fun, exhilarating experience. Ask him to do it your way every second time.

My partner is always super aroused when we’re in public, and not so much in private. While the thrill of getting caught is sexy, I’m over the riskiness. How do I get him to be as aroused when we’re at home?

It has to do with his sexual arousal template that was probably formed in his brain before the age of nine! He will have to learn that he has a very rigid arousal template and that it can actually be adapted and expanded. He also has to learn that sex is sometimes not that exciting, sometimes it is more special and for the purpose of bonding than for the purpose of that ultimate high. Guys with a rigid arousal template often have problems with real intimacy and if the problem is really severe, it should be addressed in therapy.

I’m very attracted to my partner, but during sex, I get uncomfortable and clamp up. How do I get over this?

That sounds like it could be vaginismus. We are a team of professionals that specialise in helping women deal with this problem. I wish there was a one-liner answer to that one, but unfortunately there isn’t. It’s usually caused by a combination of medical conditions, childhood trauma, religious upbringing with excessive guilt, poor sex education, psychological as well as relationship issues. These all need to be addressed for you to stop clamping up with the man you love.

Help! His penis is too big!

You can use muscle relaxants, better lube, vaginal dilators and even physiotherapy to get over this hurdle! There is also a device from Pure Romance, called Super Stretch Lips, that you can put over his penis to keep a part of it outside of the vagina during intercourse, but it is usually the girth that is the problem. Make sure you have pleeently of foreplay in order for your body to get ready for penetration.

Help! His penis is too small!

Make sure you get satisfied before penetration happens. You can also do kegel exercises and even see a physiotherapist that specialises in the area to help you strengthen your muscles in order to “feel” him better. A device like a We-Vibe also helps to improve the sensation during penetration if you need more than what he ‘has to offer’.

My boyfriend asked me to stick a finger in his bum while we were having sex. At first, I wasn’t keen, but eventually I agreed, and he said he had the most intense orgasm ever. Now he wants to do it all the time. Does this mean he’s gay?

No, not at all! It just means that he has discovered his p-spot. The nerve that supplies sensation this area is the same as the one that supplies your clitoris, so you do the math.

My new boyfriend has marathon-runner stamina in the bedroom. Sex goes on forever. I actually start getting bored and sometimes even chafed. How can I make him come faster?

Ask him to! If he can’t, he has what is called delayed ejaculation. Although it is a difficult condition to treat in sex therapy or sexual medicine, it can be done. Firstly, check if he is not on anti-depressant drugs that may be causing the problem. That can easily be changed to a different type, if it is the case. You can also tell him that you will help him come in another way or he can get himself there (which is usually much quicker) but you are only up for ten minutes of penetration in any one round (the vagina struggles to stay lubricated for longer than that in most women).

I want to do a striptease for my guy but I’m really uncoordinated and I’m worried it’s going to be more comedy than sexy. What’s the best costume to wear that’s easy and sexy to remove?

Probably a man’s shirt, tie and a top hat. Make sure you have the sexy stockings with dispensers and heals that you can still move in to complete the outfit (or at least that is what I’m told by the Carmen Electra Strip Tease DVD that was given by a friend! Not exactly the content covered in a Master’s Degree in Sexual Health!).

I don’t feel pain during sex, but afterwards, I bleed for two to three days, as if I’m having a period. What’s up?

You probably have an infection. See a gynae or doctor who knows something about this as soon as possible! Worst case scenario – it might be a cancer, so don’t wait!

I had my period twice last month. Google says it may be due to stress and my diet. But now I’m feeling some pain below my stomach. What could it be?

Ovarian cysts can cause abnormal bleeding and lower abdominal pain. You need to see a gynae or at least get a pelvic ultrasound done.

What can I do to reduce wetness before and during intercourse?

It may sound a bit strange, but you can just be practical about it and keep a towel handy to remove some of the excess moisture. We also compound a special cream to be applied into the vagina prior to sex to reduce the lubrication. Just also check for an infection. Sometimes the wetness is not lubrication but actually from an infection. Another option is to go onto a low dose estrogen contraceptive. That often causes vaginal dryness which could help in your case.

How do I tighten and strengthen my vaginal muscles?

You can get lots of information about Kegel Exercises on the internet – with different variations and programmes. Many women find it difficult to isolate these muscles and end up squeezing everything but their vaginal muscles. There are physiotherapists who specialise in this area. They will teach you how to do it through biofeedback.

My husband is 63; I’m 31, but he wants sex every day – sometimes twice a day! I can’t keep up. What should I do?

It can be that he just has a very healthy appetite but it can also be that he has a discomfort in his pelvic area that is released through intercourse, something called persistent genital arousal disorder, or it might be that he has an addiction. With professional help, it can be established which one of the three it is. The point however, is that his high desire cannot be your responsibility. You can have sex as many times as you are willing and able to, but the rest of the time, he will have to sort it out himself.

It can also be a hormonal imbalance which can be addressed medically, so get help if you are taking strain.

I lost my brother six months ago, but am still feeling the loss so I have bouts of depression that kill my sex drive to the point where I don’t even want to be touched or kissed, and its taking strain on my marriage. I can’t take anything hormone based as I have a factor 5 laiden disorder. Is there anything I can do or try to help me out my slump?

One the one hand you just have to be patient with yourself and give yourself time to get over this extremely traumatic life experience. It takes time and it is normal to lose your libido when you have depression.

On the other hand, make sure you get professional help. See a psychologist and take an anti-depressant that does not take your libido away. Something that works very well, but only if you are not anxious, is a drug called bupropion. It can actually boost your libido even if you don’t have depression.

My cramps before and during my period are awful! Is there anything I can do to ease them?

You can go onto the pill or have the Mirena inserted. Natural medicine like Premular or Femiscript also helps. Many women find benefit from using Evening Primrose Oil.

My IUD cut my guy during sex. Is something wrong?

Yes, definitely! It is falling out and probably not effective as a contraceptive anymore! Have it removed and replaced immediately. Sometimes when the strings are cut too short, they sting the partner, but if he got a cut, it was from the actual device itself and it should be removed.

My partner and I are both virgins. How can we make our first time really special?

By taking it really slow. Make sure you have covered base one, two and three before you try to have sex. Also make sure he can insert two fingers into your vagina without hurting you. Don’t expect to have orgasms, just enjoy the uncharted waters of really being one for the first time. You can add more movement and stimulation as time goes on.

My friends say they love having their nipples played with. Mine aren’t sensitive so I don’t really enjoy it. Is there something wrong with me?

No, you probably have other areas that get you going, focus on those and make sure you partner knows about them. If they are not very sensitive, normal kissing and sucking might not feel like much to you. Try a bit more pressure that goes towards pain (but not painful) – that could be very intense and pleasurable for women with nipples that are not very sensitive. Vibration also makes a difference.

What does an orgasm feel like?

It is different for every women – some say it feels like sneezing and others like dying! You have to find out for yourself. One thing that all orgasms have in common is a climax (or a few of them) and then a fall. There is a definite point where you can feel that you are experiencing a release. If the release is gradual or the pleasurable sensation just kind of weans off, you did not have an orgasm. You will know if you did.

I keep getting yeast infections, but my guy won’t treat himself at the same time.

Yeast infections love the vaginal pH, they usually don’t survive on a guy’s penis. The fact that you are getting recurrent infections is not due to him not being treated, it is most likely due to you not being sufficiently treated, or it might not a yeast infection but bacterial vaginosis or even an STI. If it is an STI, he will need to be treated as well. Guys get candida only if they have very low immunity like with HIV or diabetes.

Getting rid of yeast infections often require repeated regular dosages of oral anti-fungal medication, restoring the balance of the pH in your vagina and removing triggers for yeast infections like bubble baths and food that is high in sugar.

We often see atypical yeast infections like candida glabrata. You should get a vaginal swab MCS and ask for specific culture and sensitivity for the candida.

 

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VAGINISMUS

VAGINISMUS

What is Vaginismus?

Vaginismus is vaginal tightness causing discomfort, burning, pain, penetration problems, or complete inability to have intercourse.

Depending on the intensity, Vaginismus symptoms range from minor burning sensations with tightness to total closure of the vaginal opening with impossible penetration.

The vaginal tightness results from the involuntary tightening of the pelvic floor, especially the pubococcygeus (PC) muscle group, although the woman may not be aware that this is the cause of her penetration or pain difficulties.

Vaginismus is a common cause of ongoing sexual pain and is also the primary female cause of sexless (unconsummated) marriages. Sexual pain can affect women in all stages of life; even women who have had years of comfortable sex. While temporarily experiencing discomfort during sexual intercourse is not unusual, ongoing problems should be diagnosed and treated.

Common Symptoms of Vaginismus

  • Burning or stinging with tightness during sex
  • Difficult or impossible penetration, entry pain, uncomfortable insertion of penis
  • Unconsummated marriage
  • Ongoing sexual discomfort or pain following childbirth, yeast/urinary infections, STDs, IC, hysterectomy, cancer and surgeries, rape, menopause, or other issues
  • Ongoing sexual pain of unknown origin, with no apparent cause
  • Difficulty inserting tampons or undergoing a pelvic/gynaecological exam
  • Spasms in other body muscle groups (legs, lower back, etc.) and/or halted breathing during attempts at intercourse
  • Avoidance of sex due to pain and/or failure

Examples of the effects of Vaginismus

Left diagram – As the man approaches the woman to attempt intercourse, her PC muscle group (darkly shaded) involuntarily tightens the vaginal entrance making intercourse painfully impossible ‘like bumping into a wall’. This type of Vaginismus makes penetration impossible.

Right diagram – In other cases of Vaginismus, penetration may be possible, but the woman experiences periods of involuntary tightness causing burning, discomfort, or pain.

Vaginismus can be triggered in both younger and older women, in those with no sexual experience and those with years of experience. Not all women experience Vaginismus the same way, and the extensiveness of Vaginismus varies:

  • Some women are unable to insert anything at all.
  • Some women are able to insert a tampon and complete a gynaecological exam, yet are unable to insert a penis.
  • Others are able to partially insert a penis, although the process is very painful.
  • Some are able to fully insert a penis, but tightness and discomfort interrupt the normal progression from arousal through to orgasm and bring pain instead.
  • Some women are able to tolerate years of uncomfortable intercourse with gradually increasing pain and discomfort that eventually interrupts the sexual experience.

Women may also experience years of intermittent difficulty with entry or movement and have to constantly be on their guard to control and relax their pelvic area when it suddenly ‘acts up’.

Vaginismus Symptom Severity Range

  1. Minor discomfort or burning with tightness is experienced with vaginal entry or thrusting but may diminish.
  2. More significant burning and tightness is experienced with vaginal entry or thrusting and tends to persist.
  3. Involuntary tightness of the vaginal muscles makes entry and movement difficult and painful.
  4. Partner is unable to penetrate due to tightly closed vaginal opening. If entry is forced significant pain results.

How does Vaginismus cause problems?

With Vaginismus, the mind and body have developed a conditioned response against penetration. The body has learned to expect or anticipate pain upon penetration, so that the powerful PC muscle ‘flinches’ or contracts to protect against the potential of intercourse pain. This can be equated to automatically blinking one’s eyes and wincing when an object is hurled toward us. It is not something a woman thinks about doing – it just happens (see Causes).

The tightened PC muscles may cause burning or pain with sex or may completely block entry. Instead of preventing pain, the tightening of the PC muscle group ultimately causes pain; although acting as a defence mechanism against pain, the opposite effect results.

Vaginismus has a wide range of manifestations, from impossible penetration, to intercourse with discomfort, pain or burning, all resulting from involuntary pelvic tightness. When a woman has never been able to have pain-free sexual intercourse due to penetration difficulties, it is generally classified as primary Vaginismus. When a woman develops the Vaginismus condition after having previously enjoyed problem-free sex, it is generally classified as secondary Vaginismus. Depending upon the classification, there may be some minor differences in the way in which Vaginismus is treated.

Primary Vaginismus

When a woman has never at any time been able to have pain-free intercourse due to Vaginismus tightness, her condition is known as primary Vaginismus.

Primary Vaginismus refers to the experience of Vaginismus with ‘first-time’ intercourse attempts. Typically, primary Vaginismus will be discovered when a woman attempts to have sex for the very first time. The spouse/partner is unable to achieve penetration and it is like he just bumps into a ‘wall’ where there should be the opening to the vagina. Entry is impossible or extremely difficult. Primary Vaginismus is the common cause of sexless, unconsummated marriages. Some women with primary Vaginismus will also experience problems with tampon insertion or gynaecological exams. The PC muscles constrict and tighten the vaginal opening making it uncomfortable or in many cases virtually impossible to have entry. When tightened, attempts to insert anything into the vagina produce pain or discomfort.

Some women also experience related spasms in other body muscle groups or even halted breathing. Generally, when the attempt to put something in the vagina has ended, the muscles relax and return to normal. For this reason, medical examinations often fail to reveal any apparent problems unless the tightness occurs and is noted during the pelvic exam.

Vaginismus Risk Factors

Vaginismus can strike any woman at any time at any age. Contributing factors could include:

  • Pelvic pain due to a medical condition, infection, physical trauma or assault, age-related changes, or painful physical events such as childbirth.
  • Emotional distress, anxiety, fear, relational difficulties, or other similar emotions that relate to sex, intimacy, past trauma, or relationships.
  • The anticipation pelvic pain due to some past or present condition or situation.
  • Other causes.

Secondary Vaginismus sexual pain can affect women in all stages of life, even women who have had many years of pain-free intercourse.

Secondary Vaginismus refers to the experience of tightness pain or penetration difficulties later in life, after previously being able to have normal, pain-free intercourse. It typically follows or is triggered by temporary pelvic pain or other related problems. It can be triggered by medical conditions, traumatic events, relationship issues, surgery, life-changes (e.g. menopause), or for no apparent reason. Secondary Vaginismus is the common culprit where there is continued, ongoing sexual pain or penetration tightness where there had been no problem before.

Most commonly, secondary Vaginismus strikes women experiencing temporary pelvic pain problems such as urinary or yeast infections, pain from delivering babies, menopause, or surgery. The initial pain problems are addressed medically, healed, and/or managed, yet women continue to experience ongoing sexual pain or penetration difficulties due to Vaginismus. While the initial temporary pain was experienced, their bodies developed a conditioned response resulting in ongoing, involuntary vaginal tightness with attempts at intercourse.

Left untreated, Vaginismus often worsens, because the experience of ongoing sexual pain further increases the duration and intensity of the involuntary PC muscle contraction. The severity of secondary Vaginismus may escalate so that sex or even penetration is no longer possible without great difficulty. Some women will also experience difficulty with gynaecological exams or tampon insertion. Vaginismus can also impede a woman’s ability to experience orgasm during intercourse, as any sudden pangs of pain will abruptly terminate the arousal build-up toward orgasm.

Vaginismus is involuntary – not intentional

It is important to note that Vaginismus is not triggered deliberately or intentionally by women. It happens involuntarily without their intentional control and often without any awareness on their part. Vaginismus has a variety of causes, often in response to a combination of physical or emotional factors. The mystery of the problem can be very frustrating and distressing for both women and their partners. Despite the fact that Vaginismus is involuntary and can strike any woman, many women feel intense shame from being unable to have intercourse and keep their pain private, feeling uncomfortable sharing their secret with anyone.

“It always felt tight and uncomfortable. I never realized it was Vaginismus.”
“I’m still a virgin even though we’ve tried many times – it’s like he hits a wall.”
“Sex was fine until after the baby – now it always hurts.”
“The doctor says there’s nothing wrong with me. So why does it still hurt?”
“Ever since the operation I feel burning pain when I try to get him in.”
“I don’t wear tampons because it is too hard to get them in.”
“There’s no way I’m doing a pelvic exam again – it’s unbearable.”
“I experience burning pain upon penetration attempts.”
“Sex used to be great, but now I close up – it burns and stings.”
“We can’t consummate our marriage – it’s impossible.”
“When he starts to move, it feels uncomfortable and we have to stop.”
“After menopause I began to feel soreness and now I tighten up.”
“I seem to ‘tighten’ up down there even when I really want to have sex.”
“Sex has never been comfortable for me.”

Unconsummated Marriages & Impossible Penetration

With severe cases of Vaginismus where there has never been penetration, is it really possible to overcome? Is there hope for unconsummated couples?

Yes. Fortunately Vaginismus is highly treatable with full restoration of sexual intercourse. Couples completing treatment fully consummate and enjoy normal penetrative sex.

Vaginismus is by far the most common cause of unconsummated marriages (where the problem is due to female issues). Couples often describe their attempts at intercourse as there being a “wall” where the vaginal opening should be. It is baffling to some women as to how this condition originated in them if they had no prior sexual contact or pelvic problems. Intercourse is impossible and painful insertion attempts reinforce the Vaginismus response. The conditioned reflex continues to happen every time there is potential for vaginal penetration. The muscles act rebelliously, refusing to allow entry even though the woman may truly want to consummate and receive her spouse vaginally. This is extremely frustrating. For the aroused man, it is like running into a brick wall. For the woman, it is like her body is no longer under her control.

Sex is an activity involving many complex conditioned responses. Bodies do not start out as skilled reactors to sexual stimulus. Successful intercourse is learned through experience and interaction. The nervous system and musculature discover and remember what feels good, works, and what isn’t comfortable. Normally, the transition to intercourse becomes more pleasurable after the first few experiences. The mind and body allow entry and learn to anticipate intercourse positively. Healthy messages result and they generate arousal in anticipation of intercourse. In a woman with primary Vaginismus, the mind and body never get the chance to be trained through positive intercourse experiences. The process of learning how to have successful intercourse is cut short when the vaginal muscles spasm as a protective device against pain. With the absence of any direct conscious control on the woman’s part, nerves controlling the vaginal muscles react to the anticipation of intercourse as a call to tightly constrict, brace, protect, and guard against the onset of potential penetration pain.

What Causes Vaginismus?

Vaginismus is a unique condition in that it may result from a combination of either physical or non-physical causes or it may seem to have no cause at all.

For many women, Vaginismus comes as a surprise; unexplained tightness, discomfort, pain, and entry problems are unexpectedly experienced during intercourse attempts. The pain results from the tightening of the muscles around the vagina (PC muscles). Since this occurs without the conscious intent or control of the woman, it can be very perplexing.

Usually at the root of Vaginismus is a combination of physical or non-physical triggers that cause the body to anticipate pain. Reacting to the anticipation of pain, the body automatically tightens the vaginal muscles, bracing to protect itself from harm. Sex becomes uncomfortable or painful, and entry may be more difficult or impossible depending upon the severity of this tightened state. With attempts at sex, any resulting discomfort further reinforces the reflex response so that it intensifies more. The body experiences increased pain and reacts by bracing more on an ongoing basis, further entrenching this response and creating a Vaginismus ‘cycle of pain’.

Examples of Non-physical Causes:

Fears: Fear or anticipation of intercourse pain, fear of not being completely physically healed following pelvic trauma, fear of tissue damage (ie. “being torn”), fear of getting pregnant, concern that a pelvic medical problem may reoccur, etc.
Anxiety or stress: General anxiety, performance pressures, previous unpleasant sexual experiences, negativity toward sex, guilt, emotional traumas, or other unhealthy sexual emotions.
Partner issues: Abuse, emotional detachment, fear of commitment, distrust, anxiety about being vulnerable, losing control, etc.
Traumatic events: Past emotional/sexual abuse, witness of violence or abuse, repressed memories.
Childhood experiences: Overly rigid parenting, unbalanced religious teaching (ie.”Sex is BAD”), exposure to shocking sexual imagery, inadequate sex education.
No cause: Sometimes there is no identifiable cause (physical or non-physical).

Addressing Vaginismus Causes

Vaginismus does not always have an obvious cause. Sometimes women with near perfect childhoods, great relationships, strong education, and few anxieties, have trouble finding any plausible explanation for what caused their Vaginismus. Understanding why they had Vaginismus may remain a mystery even after it is fully resolved. Fortunately, though it is helpful to know the causes, full knowledge is not necessary to complete successful treatment.

Examples of Physical Causes:

Medical conditions: Urinary tract infections or urination problems, yeast infections, sexually transmitted disease, endometriosis, genital or pelvic tumors, cysts, cancer, vulvodynia / vestibulodynia, pelvic inflammatory disease, lichen planus, lichen sclerosus, eczema, psoriasis, vaginal prolapse, etc.
Childbirth: Pain from normal or difficult vaginal deliveries and complications, c-sections, miscarriages, etc.
Age-related changes: Menopause and hormonal changes, vaginal dryness / inadequate lubrication, vaginal atrophy.
Temporary discomfort: Temporary pain or discomfort resulting from insufficient foreplay, inadequate vaginal lubrication, etc.
Pelvic trauma: Any type of pelvic surgery, difficult pelvic examinations, or other pelvic trauma.
Abuse: Physical attack, rape, sexual/physical abuse or assault.
Medications: Side-effects may cause pelvic pain.

Since Vaginismus can be triggered by physical events as simple as having inadequate foreplay or lubrication, or non-physical emotions as simple as general anxiety, it is important that it be understood that Vaginismus is not the woman’s fault. Once triggered, the involuntary muscle tightness occurs without conscious direction; the woman has not intentionally ’caused’ or directed her body to tighten and cannot simply make it stop. Women with Vaginismus may initially be sexually responsive and deeply desire to make love but over time this desire may diminish due to pain and feelings of failure and discouragement. It is extremely frustrating to be unable to physically engage in pleasurable sexual intercourse.

Why do these causes trigger Vaginismus in some women but not in others?

Life experiences vary dramatically from person to person. Some women’s bodies react with Vaginismus, while others with nearly identical experiences do not.

The anticipation of pain, emotional anxieties, or unhealthy sexual messages can contribute to and reinforce the symptoms of Vaginismus. Frequently, but not always, there are deep-seated underlying negative feelings of anxiety associated with vaginal penetration. Emotional triggers that result in Vaginismus symptoms are not always readily apparent and require some exploration. It is important that effective treatment processes include addressing any emotional triggers so a full pain-free and pleasurable sexual relationship can be enjoyed upon resolution.

Vaginismus is often a complicating factor in the recovery from other pelvic pain conditions. Vaginismus may co-exist with other medical conditions, possibly triggered by temporary pelvic pain resulting from those conditions. Or, it can be the sole cause of sexual pain remaining after the original medical problems are addressed. When the underlying cause has been resolved or managed and ongoing pain, discomfort or penetration difficulties continue to remain, this is typically due to Vaginismus.

In cases where there is clearly both Vaginismus and another pelvic medical problem existing simultaneously, both problems will need to be treated to ensure full resolution. Without addressing the other medical condition, it will be difficult to resolve the Vaginismus as it may continue to be triggered by pain from the other problem.

The Role of the PC muscle group

How it contributes to sexual pain or penetration problems

The pelvic floor muscles predominant in Vaginismus are called the pubococcygeus (PC) muscle group. The PC muscle group plays a key role in the function of a woman’s reproductive system, urinary tract, and bowels. The muscles enable a woman to urinate, have intercourse, orgasm, complete bowel movements, and deliver babies. Hence, they are also referred to as pelvic floor muscles, vaginal muscles, and love muscles.

With Vaginismus, the mind and body have developed a muscle memory or conditioned response against penetration. The body has learned to expect or anticipate pain upon penetration, so that the powerful PC muscle ‘flinches’ or contracts to protect against the potential of intercourse pain. This can be equated to automatically blinking one’s eyes and wincing when an object is hurled toward us. It is not something a woman thinks about doing – it just happens. Unfortunately, instead of preventing pain, the tightening of the PC muscle group ultimately causes pain; although acting as a defence mechanism against pain, the opposite effect results. The spasms cause burning or pain upon penetration or movement and may even completely block entry.

The PC muscle group is large and very powerful. It encircles the urinary opening, vagina, and anus in a figure-eight pattern with one loop of muscles surrounding the vaginal area and the other loop surrounding the anal area. On each end, the muscles are attached to the skeleton and support and hold in place the abdominal and pelvic organs like a net, forming the pelvic floor.

PC Muscles – The anatomy of the female pelvic floor area highlights the internal muscles called the pubococcygeus or PC muscle group. This is the muscle group that tightens involuntarily when Vaginismus is experienced. The powerful muscle group surrounds both the entire vaginal area and the anus area.

Never fully relaxed, but always partially contracted, the PC muscles are ready to spring into action the moment they sense the need, powerfully tightening even without the woman’s awareness. For example, they enable a woman to retain urine or control her bowel movements until a convenient time without her thinking about it. In Vaginismus, during attempted penetration, the PC muscles tighten involuntarily, without conscious intent (thought), and constrict the vaginal opening. This tightening is what makes intercourse uncomfortable, painful, or unachievable. The pain is often experienced without any awareness of the cause. Frustration is often common as a woman knows that there is something wrong, but is unaware her problem is Vaginismus and treatment is available.

Retraining the Body

Retraining the PC muscle group to respond differently to the anticipation of intercourse is key to the successful treatment of Vaginismus. The process of learning to take conscious control of this muscle group changes the conditioned reflex so involuntary tightness no longer occurs (modifying the muscle memories or conditioned responses). Effective program steps will comprehensively address both body and mind components to resolve all triggers so that when intercourse is attempted involuntary spasms no longer occur and pain is eliminated.

Vaginismus Diagnosis & Tests

Women often suspect they have Vaginismus from their symptoms. Medical diagnosis is typically determined by gynaecological exam to rule out the possibility of other conditions and patient history.

Quick diagnosis chart – common manifestations of Vaginismus

Strong indicators of Vaginismus include any of the following:

·       Difficult penetration or impossible intercourse / unconsummated couples

Female penetration problems and unconsummated marriages are typically due to Vaginismus. Entry tightness and pain are common symptoms of Vaginismus.

·       Ongoing sexual pain after a pelvic problem, medical issue, or surgery

The experience of ongoing sexual pain or tightness after resolving or managing a pelvic medical or pain issue is typically due to Vaginismus (see also dyspareunia).

·       Ongoing sexual pain after childbirth

The experience of ongoing sexual pain or tightness following childbirth (after everything has healed) is typically due to secondary Vaginismus.

·       Ongoing sexual pain and tightness with no discernible physical cause

Vaginismus often occurs only during sex attempts. Physicians may initially be unable to find any problem or cause for the sexual difficulties.

·       Avoidance of sex due to pain and/or failure

When a woman states that she avoids being intimate with her husband because sex does not feel good or has become very painful, Vaginismus should be strongly considered.

Is there a simple medical test I can take that would tell me if I have Vaginismus?

There is no medical test that can be taken to confirm the Vaginismus condition. Vaginismus is diagnosed through patient history and description of problem/pain, and gynaecological examination to rule out the possibility of other conditions.

The medical diagnosis of Vaginismus

Women often suspect they have Vaginismus from their symptoms, but getting medical confirmation can be challenging. Confirming a formal diagnosis of Vaginismus may take some planning and perseverance. No definitive medical test exists for the diagnosis of Vaginismus so it may take a number of visits to several physicians or specialists before a medical diagnosis is obtained. When physicians are initially unable to find any specific medical problem (a common experience of Vaginismus sufferers), no diagnosis or misdiagnosis is a common outcome of initial medical exams. Many physicians are unfamiliar with Vaginismus, so part of the process is simply finding a physician that is knowledgeable about the condition. A successful medical diagnosis of Vaginismus is typically determined through patient history and description of the problem, gynaecological examination and the process of ruling out the possibility of other conditions.

Talking to physicians about sexual problems can be difficult. Embarrassment, shame and anxiety are often present, making it hard to communicate and obtain appropriate care. Women may need to strongly advocate for themselves, insisting on a full diagnosis from a knowledgeable professional to rule out any other medical condition and properly confirm the Vaginismus diagnosis. A medical diagnosis is helpful in removing any doubts or anxiety related to identifying the condition and enables women to have more confidence in moving toward treatment solutions.

Sexual pain disorders like Vaginismus are commonly misdiagnosed or left unaddressed. Women may need to be very courageous in persevering until their concerns are given due attention and a reliable medical diagnosis is reached. In some cases and locations, a solid medical diagnosis is not always available or possible. This is especially true in nations with fewer health care options.

The pelvic exam as part of Vaginismus diagnosis

One of the most important aspects of Vaginismus diagnosis is simply the thorough elimination of other possible physical or medical conditions that may be causing the symptoms – leaving the near-certain likelihood of Vaginismus. The process of elimination is a critical part of Vaginismus diagnosis.

The diagnostic process will typically entail giving a medical and sexual history and undergoing a pelvic or gynaecological exam. The physician will discuss the location and occurrence of pain to help render an accurate Vaginismus diagnosis or may request some other tests to help rule out any other problems besides Vaginismus.

Note that some women feel more comfortable expressing themselves and being examined by female health care specialists. Where this is an issue, we encourage women to seek a referral with a female specialist. Taking a proactive, systematic approach will help a person get better care and treatment outcomes.

Burning, tightness, and difficult penetration symptoms may not be at all noticeable during the pelvic exam. For some women, these symptoms occur only during intercourse attempts. For this reason, diagnosis must involve serious consideration of the woman’s concerns which might be stated vaguely as “I’m having difficulty with sex.” Sometimes, busy health care professionals will fail to recognize the signs of Vaginismus and give standard (but unhelpful) advice to just “use more lubricant”, “try to relax more”, or “drink some wine”. This may be due to a lack of familiarity with Vaginismus or reliance on outdated literature on the condition.

Due to PC muscle tightness, some women with Vaginismus find gynaecological exams to be extremely painful and are unable to tolerate them. If a woman suspects she may have difficulty completing an exam, she should communicate this to her physician. There are adjustments (e.g. body positioning, size of speculum used, and nurse support) that can be made to contribute to a more positive experience. A physician who is familiar with the Vaginismus condition will be more suited to providing a comfortable and sensitive environment.

When there is constant vaginal tightness for the duration of the pelvic exam, it may appear to the physician as though there is an unusually small vagina or a hymen abnormality problem. Instead of recognizing the Vaginismus condition, a physician may falsely believe a woman’s vagina is too small, when/if she is unable to complete a pelvic exam (see diagram below). This combined with the patient’s urgent complaint that she cannot have penetrative sex with her spouse or that sex really hurts, may further lead to the false assumption that the vagina requires corrective surgery to enlarge the opening and allow entry. Though there may be rare exceptions, women with Vaginismus typically have completely normal genitalia. The constriction of the vagina is due solely to the tight involuntary spasm of the pelvic floor muscles. Unfortunately, some physicians continue to press forward with the pelvic exam causing great discomfort and pain for the woman. This traumatic experience in itself can contribute to the Vaginismus condition.

Figure showing constriction during pelvic exam – With Vaginismus, the simple approach of a physician’s hand may have the effect of tightening the pelvic floor muscles and making the vaginal entrance seem very small and tight. Note that not all women with Vaginismus will experience tightness during a medical exam (tightness may only occur during sex attempts).

There are many dangers in being given an improper diagnosis from an uninformed professional. Unnecessary, invasive and potentially harmful surgeries and medications have been suggested for women with Vaginismus who have not been properly diagnosed.

Misdiagnosis and the promotion of invasive or unhelpful surgeries are sometimes the unfortunate result of all this confusion. There is no surgery to cure Vaginismus. It is very important to seek a second opinion if surgery to ‘widen’ the vaginal opening has been recommended as this does not normally resolve the penetration problem, but instead may further complicate the problem. Unnecessary, invasive, and potentially harmful surgeries and medications have been suggested for women with Vaginismus who have not been properly diagnosed. Vaginismus is a highly treatable condition that does not require any invasive procedures.

Many women seeking diagnosis are often simply left undiagnosed and turned away by physicians who fail to find anything physically wrong and feel there is nothing more they can do. They may not consider a diagnosis of Vaginismus due to simple lack of awareness.

To assist women in obtaining reliable diagnosis for their sexual pain, the following sample script includes helpful tips to prepare for a physician visit. The script provides examples related to the Vaginismus condition, however, it can be easily modified to help communicate the details of any sexual or pelvic pain problem:

Sample Script: Self-Guided History of Sexual Pain

1. Introduce the problem:

“I have been having problems with pain during sex and hope you will be able to help me.”

2. Provide a description of the pain (be specific):

  • It happens when …”my husband tries insert his penis in my vagina” or “once he is inside and starts to move I feel burning and tighten up”, etc.
  • The pain is located …”at the entrance to my vagina. My vagina is like a wall; he just cannot get it in.” or “after he is inside I feel burning around the penis just inside the entrance”, etc.
  • The pain lasts …”as long as he keeps trying, especially if we try forcing it in. Once he stops there is no pain.”
  • This has been happening since …”our honeymoon two years ago and has continued to happen every time we try to have sex” (primary Vaginismus) or “my hysterectomy eight months ago”(secondary Vaginismus), etc. [Note: Inform your doctor if you have been able to previously have sexual intercourse without pain.]
  • It feels like …”burning”, “stinging”, “like he’s hitting a wall”, “tightness during/on entry”, etc.
  • I have tried to reduce or eliminate the pain by …”using lubricant, changing sexual positions, relaxing more.”
  • I am able / unable to …”insert a tampon or complete a gynaecological exam.”

3. Mention any past problems:

Have you previously had any sexually transmitted diseases, yeast infections, bladder problems, or any pelvic pain outside of penetration?

4. Mention any past sexual abuse.

5. State what you think the problem is:

“I think it may be Vaginismus. My symptoms are similar to those outlined in an article I read. However, I have read there are other things that can cause pain during sex and would like to have them ruled out.”

Vaginismus Treatment

Vaginismus is considered one of the most successfully treatable female sexual disorders. Many studies have shown treatment success rates approaching nearly 100%. Treatment resolution follows a manageable, step-by-step process.

Successful Vaginismus treatment does not usually require drugs, surgery, hypnosis, nor any other complex invasive technique. Effective treatment approaches combine pelvic floor control exercises, insertion or dilation training, pain elimination techniques, transition steps, and exercises designed to help women identify, express and resolve any contributing emotional components. Treatment steps can often be completed at home, allowing a woman to work at her own pace in privacy, or in cooperation with her health care provider.

  • The sexual pain, tightness and penetration difficulties from Vaginismus are fully treatable and can be completely overcome with no remaining pain or discomfort.
  • Women experiencing sexual tightness/pain, penetration problems, or unconsummated relationships can expect remarkable resolution of their Vaginismus, allowing full, pain-free intercourse.
  • Treatment steps can usually be completed at home using a self-help approach, allowing a woman to work at her own pace in privacy, or in cooperation with her health care provider or specialist.
  • Vaginismus treatment exercises follow a manageable, step-by-step process

The sexual pain, tightness, burning or penetration difficulties caused by Vaginismus are completely treatable, with high success rates for treatment. Couples are often amazed by the sudden life-changing effects of treatment. Those with penetration difficulties, or pain during intercourse, normally transition to pain-free and pleasurable intercourse following a step-by-step approach.

Vaginismus is considered one of the most successfully resolved female sexual disorders. High treatment success rates are typical within reasonable time frames.

Many of the steps to treat Vaginismus are counter-intuitive and not immediately obvious. As failure at any point inhibits recovery (experiencing discomfort tends to intensify Vaginismus) and can cause avoidance or abandonment of progress, it is best to approach Vaginismus with an educated understanding to ensure success in dealing with it.

Sources consulted: www.vaginismus.com

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Love Coach: The Sex Doctor Will See You Now

The Sex Doctor Will See You Now

By Dr. Elna Rudolph, published in Women’s Health Magazine, December 2014.

WH’s resident sex doc shares four of her actual cases with advice so real and raunchy, you’ll want to try it tonight!

Read the full article here.

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Seer Seks

Seer Seks

Die navorsing wys dat soveel as een uit vyf vroue sukkel met pyn tydens seks.  In my praktyk vind ek dat meer en meer vroue daarvan kla en kom aanklop vir hulp.

Ek werk al ‘n geruime tyd saam met Dr. Elna Rudolph en die res van haar multidissiplinere span by haar kliniek, My Sexual Health, waar ons al honderde vroue gehelp het om pynvrye seks te kan geniet – selfs sommige wat in soveel as dertig jaar van getroude lewe nooit seks kon geniet het nie!

Dr. Elna Rudolph is die kliniese hoof van MySexualHealth.co.za en ‘n mediese dokter wat in seksuele gesondheid spesialiseer.  Sy het in Australia, Engeland en Europa verdere opleiding in seksuele gesondheid opgedoen en het ‘n besonderse belangstelling in die hantering van pynlike seks.  Hier is haar siening oor seks wat seer is:

Glo jy dat pyn tydens seks net in vrou se kop is?

Ek het letterlik nog nooit ‘n pasient gesien wie sy pyn tydens seks net in hulle kop is nie.  Daar is altyd ook ‘n fisiese rede vir die pyn – al is dit net die onwillekeurige sametrekking van die bekkenvloer spiere – daar is altyd ‘n rede vir wanneer seks seer is.  As daar ‘n rede is, is daar ook n oplossing!

Die grootste deel van my werk is om die oorsaak van die pyn op te spoor en dan die beste behandelingsplan voor te stel.  Deel van die behandeling sluit meestal ook sessies met jou of ‘n sielkundige in om die emosionele aspekte van die pyn sowel as die impak van die pyn op die verhouding aan te spreek.  Seer seks sit nie in jou kop nie, maar dit lol tog met jou kop en dikwels ook met jou verhouding.

Wat is die mees algemene oorsake van pyn wat jy in jou praktyk sien?

Ek sien meestal wat ons noem “oppervlakkige dispareunie” dit wil sê pyn wat onstaan naby die opening van die vagina waar dit reeds seer is as die man probeer penetreer, of wanneer selfs die gebruik van ‘n tampon seer (of onmoontlik) is.

Mens kry ook “diep dispareunie” wat soms alleen voorkom en soms saam met oppervlakkige dispareunie.  Dit sien ek nie so dikwels nie, want die pasiënte se ginekoloë sorteer hierdie probleem gewoonlik uit voordat hulle by my uitkom.  Die mees algemene oorsake daarvan is endometriose, siste op die eierstokke, prikkelbare derms en hardlywigheid, en dikwels ook die bindweefsel wat vorm as gevolg van herhaaldelike operasies.  Ek hoor dikwels dat dokters vir pasiënte sê dat die oorsaak van hulle pyn hulle baarmoeder is wat “verkeerde kant toe kyk.”  Dit is ‘n baie onwaarskynlike die rede vir hulle pyn – ek dink dit is die moeite werd om ‘n tweede opinie te kry en die saak verder te ondersoek.

Oppervlakkige pyn word gewoonlik veroorsaak deur ‘n kombinasie van probleem met die vel, senuwees en die spiere rondom die vaginale opening.  Hierdie abnormaliteite word veroorsaak deur hormoonwanbalanse (byvoorbeeld die gebruik van die pil, menopouse of swangerskap en borsvoeding), herhaaldelike infeksies, of dit kan ook ‘n genetiese hipersensitiwitiet van die senuwee wees (in so ‘n geval vind ons dikwels dat die pasiënt se naeltjie ook baie sensitief is).

Daar is amper altyd abnormale werking van die bekkenvloerspiere met spasmas, snellerpunte en soms ook swakheid van sekere spiere.  In sommige vroue word hierdie probleme veroorsaak deur die verkeerde postuur, rugprobleme of selfs net spanning en angstigheid.  Sommige vroue het konstante spasma en by ander gaan die spiere net onwillekeurig in spasma wanneer daar ‘n poging is tot penetrasie, en dan kan die vrou dit nie weer willekeurig ontspan nie.

Wat sluit die behandeling van seer seks gewoonlik in?

Dit hang absoluut af van die diagnose.  Dit is gewoonlik ‘n kombinasie van ‘n salf wat spesiaal gemeng word vir die spesifieke diagnose en rondom die vaginale opening aangewend word, dikwels ook medikasie om die senuwees wat betrokke is te herstel en te help vir angstigheid, die behandeling van kroniese infeksies, die herstel van die hormoonbalans, die gebruik van dilators om stelselmatig die weefsel te rek en die brein te leer dat penetrasie iets is wat nie seer is nie en waaroor die vrou beheer het, fisioterapie deur ‘n handjie vol gespesialiseerde fisioterapeute wat die bekkenvloer spiere kan behandel, seksterapie waar die paartjie gehelp word om stelselmatig weer (of vir die eerste keer!) ‘n sensuele verhouding te ontwikkel waar die fokus aanvanklik glad nie op seks is nie, en dan ook dikwels sessies om die sielkundige aspekte van die pyn en die impak op die verhouding aan te spreek, soos wat ek voorheen genoem het.  In sommige gevalle gebruik ons ook Botox of ander inspuitings as die fisioterapie alleen nie help om die spiere laat ontspan nie.

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Eager Beaver

Eager Beaver

By Nichi Hodgson, Originally published in Women’s Health Magazine, 2015. Edited by Dr. Elna Rudolph.

Things we love about vaginas: they have more names than Snoop Dogg. People have written poems, songs and plays about them, and in our overexposed, overtly sexualized world, vaginas still hold the power to appall, enthrall and excite. Oh, and give birth. But it turns out we still have a few tricks to learn…

Oral sex how-to (for him)

A guide you might want to subtly leave on his bedside table…

  1. “While you’re kissing, press a thigh between her legs,” says sex expert Midori, author of Wild Side Sex (like Madonna, she only needs one name). “Now, grind in, moving up and down. It’s the washing-machine-on-spin-cycle principle – the overall vibration has a greater effect than just using a finger or two.” Noted.
  2. “Next, start to nibble through her skirt as a teasing prelude – she should soon start grinding on your face. But before her panties come off completely, try breathing and licking her through them. It’ll make for a truly explosive touchdown when your tongue finally makes direct contact with her clitoris.”
  3. Now to master your technique. “If you want to practice clitoral stimulation, put a Tic Tac in a sandwich bag. Learn to suck the mint between your lips without using your teeth, then keep it there, while using your tongue to tease it.” Well, that’s something they never mentioned in the advert.

Question Time…

Things you never learnt during high school sex ed…

Q. Can my Rabbit give me an STI?

A. If you’ve had one before, yes, you can get it again from your vibrator, says sex educator Kate McCombs. “Toys made from porous material can harbor infections. Choose silicone, glass or stainless steel and clean them in soap and hot water.” Non-electric silicone ones can even go in the dishwasher. Just watch out who unloads it.

Q. Can his cold sore give me genital herpes?

A. In a nutshell: yes. According to Dr Natalie Hinchcliffe, “The HSV 1 type (usually the oral kind) can be passed to your genitals, even if lesions aren’t present.” Cold sores on your cooch? Not ideal. Dr. Elna Rudolph adds that “the notion that HSV1 is an oral infection and HSV2 is a genital infection is no longer true.  You can get “cold sores” on your genitals and genital herpes in your mouth and on your lips.  If he has ever had a fever blister, he can give you genital herpes! The chance is slim, but not zero.  In SA 80% of people have HSV1 in their mouths – it leaves a very small minority that can safely have oral sex!”

Q. Could I become vibrator-dependent?

A. Afraid so, says sex therapist Sarah Berry. “Too much vibrator use can desensitise you. If you’re struggling to orgasm with a partner, cut out the toys until you get used to manual stimulation again.” Turn off to get turned on. “If your brain gets used to reaching orgasm in a specific way, without variations, it becomes learned behavior and deviating from that becomes difficult”, says Rudolph.  “Make sure you love yourself in many different ways to keep your clitoris (and brain!) sensitive to all kinds of stimulation.”

Q. Is it possible to grow a vagina?

A. Actually, yes. US scientists have pioneered a way to lab-grow a vagina from a woman’s own cells. It can then be implanted into her body. The process takes just six weeks and the vagina even has full sexual function. But what do they do with the old one?

Three things your vajayjay would veto

Treat your vagina with kindness and it will return the favour.

1. Smoking

The risk of cervical cancer is about double in smokers,” says Hinchcliffe. “Smoking also puts you at greater risk of certain STIs, including trichomonas – you know, the one that gives you a horrible, foul-smelling discharge.” Stub it out for the sake of your vag. Rudolph adds: “It is much more difficult for your body to fight off the damage cause by HPV infection if you smoke.  Women who already have abnormal pap smears have a much higher chance of it getting worse and worse, even up to the point of cervix cancer, if they smoke.  Some infections like the foul-smelling Trichomonas is also more common in smokers.”

2. Douching

“Your vagina actually cleans itself, so there’s no need to douche it with anything,” explains Hinchcliffe. “In fact, bacterial vaginosis is significantly more common among women who douche, as is general irritability in the area. Your vagina is not meant to smell like a rose, so stop trying to make it.” But if you insist, for gynae’s sake put down the lemon verbena soap on a roap and use a specially formulated wash with the right pH balance. FEMAGENE products won’t upset your beaver’s balance, BUT only if you use it externally.  Never ever use any soap inside your vagina and definitely don’t squirt anything into your vagina. It kills all the good stuff and makes your situation worse in the long run. Bacterial Vaginosis, a condition where one or more of the natural bacteria in your vagina overgrows and cause a smelly discharge, is much more common in women who douche or try to wash inside their vaginas.

3. Penetration-only orgasms

Too many of us still prioritise the hole as the goal – to our sexual detriment. A study by neuroendocrinologist Dr Kim Wallen found that seven percent of women can climax from penetrative sex alone. What’s more, he calculated the “C-V ratio” to show it’s the distance between your clitoris and vagina that likely determines your ability to have a hole-in-one orgasm. The perfect pump-to-pleasure measurement was found to be 2.5cm. If yours is longer than that, don’t let him think it’s only his magic wand that counts.

For when your hoo-haa isn’t feeling hunky dory…

Find out when your lady garden needs some love…

> Symptom: Burnt skin thanks to a bad bikini wax

Unless the skin is blistered, this doesn’t require medical attention. Just treat as you would any other burnL run under cold water, apply cream such as E45, avoid intercourse until healed and, most importantly, get yourself a new beautician, pronto!

> Symptom: Discharge after intercourse

As long as there’s no strange colour or sudden change in consistency, it’s normal. Discharge increases with sexual arousal and the amount varies from woman to woman. And if a guy ejaculates inside you, expect to leak.

> Symptom: Soreness or irritation after exercise

A dragging sensation could indicate vaginal prolapse. Cycling is one of the worst culprits for beaver-bruising, as a study in the BMJ found female cyclists were at particular risk of infections and swelling. Saddle and handlebar positions are important – German scientists found sitting with your upper body at a 30-degree angle to the bike frame can reduce blood flow to your vagina by up to 70 percent. Stand up on your pedals every 10 minutes to avoid this.

> Symptom: Pain during and after sex

One in five women experience pain during intercourse.  There can be various reasons for this from serious gynaecological conditions to hormonal imbalances, infections to muscles spasms and nerve abnormalities.  These need to be excluded and then managed by an experienced multi-disciplinary team that can also address the psychological aspects of suffering from painful intercourse.  Treatment might involve using vaginal dilators, physiotherapy and various creams as well as sorting out any infections and gynae problems.

> Symptom: Bleeding between periods

This warrants some form of medical investigation, as it can be caused by infection, cervical cancer or ectropion (also known as cervical erosion). Ectropion is a normal response to hormones and usually occurs in women of reproductive age, especially those using hormonal contraception. It can be scary, but as long as your smear tests are normal, it’s unlikely to be a long-term worry.

> Symptom: Pain at the top of your pubic bone

Generally means pelvic inflammatory disease (PID), an ovarian cyst or endometriosis. PID symptoms include fever, unusual discharge and bleeding between periods. Cysts cause acute pain on one side, but often go away by themselves. Painful sex, severe period pain and pain going for a number two could be endometriosis, which can be eased with oral or hormonal contraceptives.