Healing Painful Sex: Interview with Deborah Coady, MD

Many women in our age group write me that they’re experiencing pain with sex or avoiding sex because of pain. I consulted several experts for their advice in chapter 11 of Naked at Our Age: “When Sex Hurts: Vulvar/Vaginal Pain,” but reading that chapter is just the beginning of solving that problem. You need a diagnosis – vaginal/vulvar pain can be caused by a number of medical issues, and you need to understand why you’re having pain before you can get it treated effectively.  

I was happy to receive a review copy of Healing Painful Sex: A Woman's Guide to Confronting, Diagnosing, and Treating Sexual Painby Deborah Coady, MD and Nancy Fish, MSW, MPH. This book is entirely devoted to sexual pain in women: the myriad possible causes, how to figure out which one or combination is yours, and what to do about it.

The authors are a power team: Deborah Coady is a gynecologist and a pelvic/vulvar pain specialist. Nancy Fish is a therapist with degrees in social work and public health, and she personally experienced chronic pelvic pain until Dr. Coady helped her resolve it.

I asked Dr. Coady if she would answer some questions that women our age often ask me:

Q. Many older women are reluctant to ask their gynecologists about sexual pain because a) they’re embarrassed, b) they think this is part of aging, and c) they fear their doctors will be dismissive. What would you say to these women?

A: These feelings and fears are completely understandable. Unfortunately, the medical profession has until now given too little attention to the sexual concerns of women as we get older. Women often are dismissed or rushed when they bring up their problems. And this is not the fault of the patients: A recent survey of gynecologists by Stacey Lindau, MD of the University of Chicago hints to their discomfort, as well as their lack of experience and formal training in this area of medicine. While 60% responded that they did ask about sexual problems at the first visit, only 14% asked about pleasure with sexual activity. It is often up to women themselves to be pro-active, ask the hard questions, and remember that they are entitled to medical therapy for this medical problem, or referral to an MD who can help.


Q. My readers sometimes report that after a long time without sex (due to lack of a partner or disinterest from a partner), they try to have sex again -- and they can’t: It’s too painful. What should a woman do about this?

A: On average, about 5-6 years after their last menses, most women develop thinning of their vulvar and vaginal tissues, often causing pain with sexual touching or intercourse, or with urination after sexual activity, or itching, burning and even surface bleeding after sex. This can occur even in women taking systemic estrogen therapy. As estrogen levels decline both the surface skin and underlying connective tissues thin, shrink, and lose elasticity. Most pain is actually located at the vaginal opening itself, rather than deep inside the vagina as previously thought. The good news is that since these tissues are exquisitely hormonally sensitive, even small doses of estrogen, with or without testosterone or DHEA, applied to the vaginal opening (the vestibule), can reverse these changes within 2-4 weeks, and then even lower doses can be used to maintain the improvement. Some women with severe loss of elasticity will also be helped by a course of pelvic floor manual physical therapy, to help normalize the connective tissue, and relieve the reflexive muscle spasms that some women develop due to their pain.

Q. I like your questionnaire (107-111) because women often don’t know how to pin down just where and what the pain is that they’re experiencing. I recommend that women scan or photocopy that questionnaire to show their medical professionals. Would it be a good idea to carry a copy of Healing Painful Sex to the appointment, too, in case the doc hasn’t heard of your book?

A: One of our missions in writing the book is that women would have it as a resource to get their gynecologists informed and up to speed on treating sexual pain.  Many patients have done just this, and their MDs have actually been grateful for the introduction to the book.

Q. If a gynecologist says, “You just need lubricant” or – worse! – “Well, at your age, you can expect that,” what should an older woman say to get diagnosis and treatment? I tell women to say, “If you don’t know how to help me, please refer me to someone who does,” but that might seem more confrontational than you would recommend! What would you advise her to say?

A: I would advise her to say exactly that.  We have to advocate for ourselves and we deserve up-to-date treatment for sexual pain.  A healthy sexual life is a basic human right, even defined as so by the World Health Organization!

Q. How can a post-menopausal woman weigh the benefits of HRT vs. the health risks if she’s experiencing vaginal thinning and tearing?

A: There is absolutely no evidence that the small amount of estradiol or estriol available for use at the vaginal opening is absorbed to any degree that would induce breast cancer. The doses are tiny compared to HRT doses that are meant to be systemic, that is, to go to all parts of the body. To help hot flashes the doses need to reach the brain in quantities much much higher than the topical estrogen will ever give. And with the evidence now showing that estrogen alone does not increase the risk of breast cancer anyway, women can be assured that topical therapy, especially if mostly applied to the vaginal opening, is safe. It is also now known that the thicker and more estrogenized the vulvar and vaginal tissues are, the less absorption into the body.  So a stable constant regimen is better than going on and off the topicals, with the tissues thinning again in between.

Q. How do we educate our medical professionals to stop being dismissive and take our sexuality seriously, whether we’re 60, 70, or 80?

A: This is a work in progress, but educational outreach through professional societies like NAMS, the International Pelvic Pain Society (IPPS), and the International Society for the Study Of Vulvovaginal Disorders (ISSVD), as well as patient advocacy organizations, especially the National Vulvodynia Association (NVA) is helping. The websites of these societies all list health professionals by area to help patients find a knowledgeable MD. We also need to devote more time to formal education on sexuality and pain in medical schools and residency programs.


As always, I welcome your comments. If you’re experiencing pain with sex, I hope you’ll read both Naked at Our Age and Healing Painful Sex. Then please carry both books with you to show your doctor!