Our Bodies, Ourselves (42 page)

Vaginal penetration that you desire typically doesn't hurt, especially if you and your partner take care that you are receiving sufficient sexual stimulation to be fully aroused. Yet there are times when, even with plenty of arousal and added lubrication, you may experience discomfort or pain. If penetration is at all painful, you owe it to yourself to find out what is causing it and do something about it. A gynecologist can help to determine whether there are physical causes and advise you on treatments. While you are seeking help, you can try alternatives, like masturbating or oral sex with a partner, and anything else that brings pleasure. Open communication between you and your partner(s) makes a difference.

The first few times you have intercourse or experience vaginal penetration, you may feel a small to moderate amount of pain at the entrance to the vagina. There can be some bleeding or no bleeding at all—both are normal. The reasons for the pain are not always clear, but it is typically temporary. An unstretched hymen (vaginal corona) has typically been blamed for this pain at first penetration, but new understandings of the hymen
suggest otherwise
.
As Hanne Blank, author of
Virgin: The Untouched History
, comments: “If the hymen is substantial, relatively inflexible, and attached around much of the circumference of the vaginal opening, then yes, it's fair to say that the hymen is at issue. But not all hymens meet these criteria, and women without substantial hymens can also experience painful penetration. The truth is that research has not told us with any particular specificity why it is that this discomfort happens, or why it happens for some women (regardless of hymen type) and not others.”

The following conditions can contribute to or cause pain during intercourse or other forms of penetration.

Insufficient lubrication.
In most women, the wall of the vagina usually responds to arousal by producing a liquid that moistens the vagina and its entrance, making penetration easier. Sometimes there isn't enough lubrication, perhaps because more time is needed for stimulation, or because you may be nervous or tense. Try giving yourself more time to get fully wet.

Insufficient lubrication can also be caused by lowered levels of estrogen, which can make vaginal tissue more fragile and affect the vaginal walls in such a way that less liquid is produced. This affects some women after childbirth (particularly if you're nursing) and women who have to take hormone therapy after breast cancer. Some women also experience this during perimenopause and postmenopause, during which you may need to look for signs other than vaginal wetness to signal arousal (see
Chapter 20
, “Perimenopause and Menopause,” for more discussion). Some women, regardless of their age, simply produce less lubricant. Even if you are not experiencing painful penetration, using a lubricant can dramatically increase sexual comfort, pleasure, and stamina—especially if you use condoms. (
The lubricants
section has more information on the different types of lube.)

Local infection.
Some vaginal infections—like monilia (yeast) or trichomoniasis—can be present in a nonacute, visually unnoticeable form. The friction of a penis, dildo, or finger moving on the vulva or in the vagina might cause the infection to flare up, resulting in stinging and itchiness. A herpes sore on the external genitals can make friction painful.

Local irritation.
The vagina might be irritated by a birth control foam, cream, or jelly. First, try a different brand; however, if the irritation persists, it may be in reaction to the spermicide Nonoxynol-9. Alternative spermicides are extremely hard to find, so you may want to consider another birth control method. Though latex allergy is uncommon, some people are sensitive to latex condoms, diaphragms, and gloves. Alternatives include polyurethane condoms, including female condoms. Vaginal deodorant sprays, douches, scented tampons, and all so-called feminine hygiene products can irritate the vagina or vulva, as can body wash, soaps, bubble bath, and laundry detergents.

Tightness in the vaginal entrance.
In some situations, size matters—if, for example, a male partner has a large penis and your vagina is small. Keep in mind, though, that a woman's body size is
not
related to size of her vagina. One woman notes that orgasms can help.

I have to be enormously aroused to be able to accommodate a man's penis. It takes multiple orgasms usually, so my partner has to be very patient.

Women's difficulty with penetration is sometimes attributed to vaginismus, believed to be a strong, involuntary tightening of the vaginal muscles, a spasm of the outer third of the vagina. Researchers have not always been able to identify these muscle spasms, writes Debby Herbenick, author of
Because It Feels Good: A Woman's Guide to Sexual Pleasure
and Satisfaction
and founder of mysexprofessor.com. “More recently, vaginismus has been described as ‘persistent or recurrent difficulties of the woman to allow vaginal entry of a penis, a finger, or any object, despite the woman's expressed wish to do so.'
4
This is an important distinction because it reinforces the point that penetration should be
consensual and wanted
.”
5

Pain deep in the pelvis.
Sometimes the thrust of penetration hurts way inside. This pain can be caused by tears and scarring (known as adhesions) in the ligaments that support the uterus (caused by obstetrical mismanagement during childbirth, an improperly performed abortion, pelvic surgery, rape, or excessively rough penetration during sex); infections of the cervix, uterus, and tubes (such as pelvic inflammatory disease—the result of untreated sexually transmitted infection in many women); endometriosis; cysts or tumors on the ovaries; a vagina that has shortened with age; or a tilted pelvis. Penetration in these cases is sometimes less painful if you're on top or lying beside a partner. If penetration consistently causes deep pelvic pain, consider consulting with an experienced gynecological practitioner.

Vulvodynia is a catchall term describing chronic vulvar pain, sometimes without an identifiable cause. It can be extremely difficult and time-consuming to find a practitioner who understands vulvar pain and takes the time to determine why the pain exists and how best to address it. Localized vulvodynia, also known as vestibulodynia (or by an older term, vestibulitis), is marked by a painful burning or sharp sensation in and around the opening to the vagina when there is any kind of penetration.

Pelvic floor physical therapy, hormonal creams, and low-dose tricyclic antidepressants may be helpful in reducing or eliminating the pain, which is thought to be caused by an over-growth of nerve endings; surgery is usually a last resort. For more on
vulvodynia
. Self-help tips for dealing with chronic pain are available online at the National Vulvodynia Association (nva.org/self_help_tips.html).

I used to enjoy having sex, but around the time I turned thirty, penetration became more and more painful. I saw at least four gynecologists over the next eight years who either suggested that I needed to relax more during sex (grrr) or completely misdiagnosed the pain. Finally, after I talked with a friend about all this, she pointed me toward a gynecologist who specializes in vulvar pain, and he diagnosed it as localized vulvodynia. It was one of the best days of my life—now that I knew what it was, I could start treatment (in my case, estrogen cream and pelvic floor physical therapy worked the best—the pain connection is unclear, but going through the exercises before sex helps). I'm still frustrated by the number of doctors who made me feel it was “all in my head.” I've since learned that many women go
undiagnosed, which is ridiculous considering how vestibulodynia affects so many aspects of our lives and sexual health.

No matter the underlying cause, when you and your partner are unable to have sex for some time, it can be difficult to start again. Talking with a counselor or sex therapist may be useful. Open communication can sometimes decrease any awkwardness that develops when there's been a physical distance between couples.

Certain medications can affect sexual desire and the likelihood and intensity of orgasms. If you are taking an over-the-counter or prescription drug or herbal supplement and notice a change in your sexual functioning, there may be a connection. For example, antihistamines, which people often take to dry out secretions in the nose, may also cause vaginal dryness. Medications for long-term chronic illnesses and disabilities can affect sexual functioning in a variety of ways (see
“Sex With a Disability or Chronic Illness,”
, for more information).

Keep a record of the drugs you're taking and note how you're feeling sexually. Some package inserts may identify known sexual effects, but your own record may be the best source of information.

Antidepressants are known to affect sexual functioning. Some SSRI antidepressants (selective serotonin reuptake inhibitors), such as Prozac (fluoxetine), Paxil (paroxetine), and Zoloft (sertraline), as well as SNRI antidepressants (serotonin-norepinephrine reuptake inhibitors) such as Effexor (venlafaxine) and Cymbalta (duloxetine) may reduce sexual desire and the ability to orgasm.

Other antidepressants, such as Wellbutrin (bupropion), have been shown to cause less sexual dysfunction than SSRIs or SNRIs (some women even report an increase in sexual desire). Adjustments in drug dosage sometimes affect sexual side effects.

One woman who takes Prozac says:

When I got in a relationship, I found that some of the sexual side effects are more subtle. I found that while I still experienced desire, it has become really difficult to have an orgasm. And when I do, the quality is different. In the old days, I felt a slow buildup that ended with intense, sudden contractions; now I most often feel a wave of excitement that ebbs and flows but never quite peaks in the same way.

Estrogen, progesterone, and testosterone are hormones that affect a woman's sexual desire and functioning. In terms of sexual desire, the most influential hormone is testosterone, sometimes called the libido or male hormone. In fact, testosterone, like estrogen, is present in both men
and
women, though the proportions differ between the sexes. In women, testosterone is produced through the operation of the adrenals (two small glands near the kidneys) and the ovaries.

Hormonal changes and their effects on sexual desire and functioning are not necessarily a problem. Menstrual and menopausal changes, for example, are a normal part of a woman's development. However, if a hormonal change leads to a drop in desire or sexual pleasure, and you feel dissatisfied with this, you may want to explore other options, such as changing or altering
medications or birth control method. Some women who experience vaginal dryness use hormonal supplements, such as estrogen or estrogen/progestin pills and patches, or estrogen cream or rings applied topically in the vagina. (For more about
the harms and benefits of hormonal products used for vaginal dryness
)

Many factors affect hormone levels at any given time.

Menstrual cycle.
Hormone levels fluctuate throughout our cycles. Many women who menstruate have a peak of sexual desire (libido) before and around ovulation, with a second, less intense peak during menstruation. The lowest level of libido is often prior to menstruation, although there is much variation from this pattern.

Postmenopausal women, and many women using hormonal birth control methods, have less variation in sexual desire.

The Pill and other hormonal birth control methods
such as the patch (e.g., Ortho Evra), injectable contraceptives (e.g., Depo-Provera), and the vaginal ring (NuvaRing). Some hormonal birth control methods suppress the usual cyclical nature of hormones and may affect desire and sexual functioning. Some women have more desire, while other women experience less desire, orgasm less easily, and/or experience vaginal dryness. The specific effects of these methods vary greatly among individual women.

Pregnancy.
Estrogen and progesterone levels are higher during pregnancy, and blood flow to the genitals increases. These changes, along with other physical and psychological effects of pregnancy, may lead to increased desire for some women. For others, however, fatigue, nausea, pain, fears, or issues with changing body size and self-image may squelch desire.

Nursing.
Breastfeeding can suppress ovulation for months after birth, as a result of the high levels of the hormone prolactin and reduced levels of estrogen. Many women report a drop in sexual desire while nursing. Some have no libido at all and become nonorgasmic. This is normal; sexual desire usually returns when the baby is weaned or nursing much less. This normal post-partum variation in desire can be stressful to intimate relationships. For more information, see
“Mothers' Health and Well-Being,”