When Sex Hurts: A Diagnostic Algorithm

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Most people know that I am a fan of sexy science. So when I saw that the World Congress on Pelvic Pain (WCAPP) had an entire section dedicated to sexual dysfunction I was pretty stoked. You may already be imagining some very arousing presentations; or you may think listening to a talk on intercourse would induce the same amount of blushing as watching Fifty Shades of Grey with your parents. Instead, the audience is treated to the latest evidence-based medicine related to pelvic pain and sex. Although, since most research, including studies on sexual health, involves the use of rodents, many of the presentations consisted of some pretty steamy rat pornography.


In addition to some randy rats, we had the pleasure of hearing Dr. Andrew Goldstein’s presentation “When Sex Hurts: A Diagnostic Algorithm.” You may remember Dr. Goldstein from a prior post that discussed the relationship between oral contraceptive pills and vulvodynia.


At #WCAPP17, Dr. Goldstein discussed the vicious cycle of pain with sex. In the image below taken from his presentation one can see how dyspareunia (pain with sex) can lead to anxiety surrounding these symptoms, which can lead to pelvic floor dysfunction that can contribute to further sexual dysfunction and relationship dysfunction which can therefore cause more pain with sex. Due to this common cycle developing, Goldstein recommends some form of therapy for any patient that presents with dyspareunia.


Bornstein J, Goldstein AT, Stockdale CK, et al. 2015 ISSVD, ISSWSH, and IPPS consensus terminology and classification of persistent Vulvar pain and Vulvodynia. The Journal of Sexual Medicine. 2016;13(4):607–612. doi:10.1016/j.jsxm.2016.02.167.


While Dr. Goldstein believes most patients benefit from counseling, he acknowledges that treatment for patients with painful sex should not be one size fits all. He emphasized that determining the driver behind the symptoms helps create an individualized treatment plan. His presentation focused on vulvodynia and vestibulodynia as these two conditions are often the cause of painful sex. Often vestibulodynia is a result of multiple factors and his presentation focused on the following three: hormonal, neuroproliferative and musculoskeletal.




As you may recall from prior posts, the vestibule is rich in androgen and estrogen receptors. Testosterone is actually responsible for producing mucin, a component of lubricant. So if a patient presents with pain with initial penetration during sex, or pain in the vaginal opening with any form of penetration as well as vaginal dryness, it would be important to check if there is a hormonal imbalance. Other than doing lab work to assess hormone levels, specifically looking at Sex-hormone binding globulin (SHBG), free testosterone,1 your health care provider may perform a Q-tip test, not to check for ear wax, but to assess sensitivity of the vestibule. Dr. Goldstein reports that if there is allodynia of the entire vestibule that is more indicative that the symptoms are coming from a hormonal imbalance or an inflammatory driver.2 Whereas, if the posterior region of the vestibule is the only area tender upon palpation the driver is most likely overactive pelvic floor muscles, which will be discussed more in-depth shortly. Certain medications such as oral contraceptives, tamoxifen or spironolactone have been shown to cause hormonal imbalances in patients that could potentially cause dyspareunia and/or vulvodynia.2 Dr. Goldstein also discussed research that certain diseases and surgical procedures such as breast Cancer and/or oophorectomy could impact hormone levels and again lead to vulvodynia or sexual dysfunction.3 If a hormonal imbalance is the primary driver for a patient’s symptoms, treatment should focus on trying to improve hormone levels which may consist of stopping a certain medication or using a topical estrogen/testosterone. Again, Goldstein stressed the importance of understanding the pathophysiology behind the symptoms before determining a treatment.




Neuro-what? If I was studying for the SATs I would really hope this word would be on the test because it came up a lot during this presentation. Neuroproliferative basically means too many nerves, and you may be surprised to hear that having too many nerves in the vestibule is a bad thing. Not all nerve fibers are created equal and there are several types in the human body. In patients with proliferative vestibulodynia they may present with an increased amount of a certain type of nerve fiber: C-afferent nociceptors.4 (For a quick review about nerve fibers or to help you prep for going on Jeopardy this site from my alma mater University of Washington breaks it down). To be brief, c-afferent nociceptors communicate pain. As mentioned earlier, if a patient presents with sensitivity around the entire vestibule this can be a sign that an individual’s condition is neuroproliferative in nature. Goldstein points out that neuroproliferation could be congenital or acquired. If a patient also presents with hypersensitivity in the umbilical region it may indicate that a patient has congenital neuroproliferative vestibulodynia due to the fact that the umbilicus and the vestibule are derived from the same tissue during development.5 Patients with congenital neuroproliferative vestibulodynia may have specific subjective reports such as pain with first attempt at intercourse or tampon use. Patients with acquired neuroproliferative vulvodynia may report a history of chronic yeast infections or an onset of symptoms after an allergic reaction.6 These patients may also demonstrate elevated levels of immune mediators such as mast cells,7 and proinflammatory cytokines such as TNF, IL-1b, IL-6 and IL-8.8 The causation of the symptoms and the length of time since symptom onset will determine appropriate treatment which can range from medications such as capsaicin, oral SNRIs, TCAs or topical gabapentin, botox injections or in some cases a vestibulectomy.




Obviously here at The Pelvic Health and Rehabilitation Center, the myofascial cause of sexual dysfunction is what we treat on a daily basis. If you have read prior posts, you may recall that inside the pelvis is a bowl of muscles known as the pelvic floor. If these muscles become restricted or hypertonic it will restrict blood flow to the area. A lack of blood flow means there is a lack of oxygen and a build up of lactic acid which is a perfect storm for: pelvic pain. Dr. Goldstein reports patients with overactive pelvic floor muscles may present with sensitivity at the posterior portion of the vestibule only. Patients with hypertonic pelvic floors will present with tenderness upon palpation of the muscles and may report vaginal fissures in the posterior vestibule post-coitus. An individual may also report a variety of symptoms including: constipation, urinary frequency, urgency and or hesitancy. A provider may check your pelvic floor tone using an EMG, along with an internal examination to assess if hypertonus is present. Pelvic floor physical therapy has been shown to be an effective treatment for patients with musculoskeletal dysfunction as a cause of their symptoms!9 Other treatment may include medications such as diazepam, yoga, hypnosis and cognitive behavioral therapy which can help facilitate relaxation of the pelvic floor.


In conclusion, Dr. Goldstein advocates for a multidisciplinary approach when it comes to treating patients with sexual dysfunction. Most patients require more than one provider and require an individualized treatment plan. It is important to choose a treatment plan based on the cause of a patient’s symptoms, and there may be several factors involved in a patient’s presentation. As always, Goldstein stressed the need for more studies looking at women’s sexual health so that clinicians can provide better evidence-based medicine to their patients.


We thank Dr. Andrew Goldstein for a fantastic lecture!





  1. Burrows LJ, Goldstein AT. The Treatment of Vestibulodynia with Topical Estradiol and Testosterone. Sexual Medicine. 2013;1(1):30-33. doi:10.1002/sm2.4.
  2. Bornstein J, Goldstein AT, Stockdale CK, et al. 2015 ISSVD, ISSWSH, and IPPS consensus terminology and classification of persistent Vulvar pain and Vulvodynia. The Journal of Sexual Medicine. 2016;13(4):607–612. doi:10.1016/j.jsxm.2016.02.167.
  3. Tucker, P. E., Saunders, C., Bulsara, M. K., Tan, J. J. S., Salfinger, S. G., Green, H., & Cohen, P. A. (2016). Sexuality and quality of life in women with a prior diagnosis of breast cancer after risk-reducing salpingo-oophorectomy. Breast, 30, 26-31.
  4. Bohm-Starke N et al. Neurochemical characterization of the vestibular nerves in women with vulvar vestibulitis syndrome. Gynecol Obstet Invest 1999; 48:270.
  5. Burrows LJ, Klingman D, Pukall CF, et al. : Umbilical hypersensitivity in women with primary vestibulodynia. J Reprod Med. 2008;53(6):413–6
  6. Harlow BL, He W, Nguyen R. Allergic Reactions and Risk of Vulvodynia. Annals of epidemiology. 2009;19(11):771-777. doi:10.1016/j.annepidem.2009.06.006.
  7. Bornstein J, Cohen Y, Zarfati D, Sela S, Ophir E. Involvement of heparanase in the pathogenesis of localized vulvodynia. Int J Gynecol Pathol. 2008;27:136–41.
  8. Foster DC, Piekarz KH, Murant TI, et al. Enhanced synthesis of proinflammatory cytokines by vulvar vestibular fibroblasts: Implications for vulvar vestibulitis. Am J Obstet Gynecol 2007;196;346.e1-346.e8.
  9. Morin M, Carroll M-S, Bergeron S. Systematic Review of the Effectiveness of Physical Therapy Modalities in Women With Provoked Vestibulodynia. Sex Med Rev 2017;5:295–322.

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