Sexual Pain: Recognition, Understanding, Treatment

Female sexual pain is a widespread reality, yet it remains invisible today. Endometriosis, vulvodynia, vaginismus, and pelvic floor disorders affect millions of women, but diagnosis often takes 7-10 years. This is an incredibly long time during which suffering is normalized or minimized.

We discussed this in Geen's webinar Sexual Pain: how to manage it in patients with chronic conditions, a valuable discussion with Dr. Valentina Pontello, a gynecologist and clinical sexologist who has been dedicated to raising awareness and treating these conditions for years. She has guided patients through diagnostic and treatment pathways for years, and through her experience as a clinician and educator, she invites us to change our perspective.

Let's talk about diagnostic delays: when does pain become "normal"?

Many women only seek medical help after years of suffering, convinced that "it has always been this way." Often, this is because inadequately trained doctors have dismissed their symptoms with phrases like "relax", "it's normal", "get a new boyfriend". The truth is, pain is never normal. A simple question during an examination – "do you experience pain during intercourse?" – would be enough to identify a problem earlier that affects desire, arousal, lubrication, and pleasure.

One of the main difficulties is that many of the causes are "invisible." Ultrasounds or MRIs don't always show anything, yet the woman continues to suffer. This is where clinical listening is crucial: endometriosis, vulvodynia, or pelvic floor hypertonia are not identified from a report, but from the patient's history. When a doctor finds no objective signs, they risk attributing the pain to psychological factors. But sexual pain is real, and it cannot be dismissed as "imaginary."

Endometriosis: why does the pain remain invisible?

Endometriosis affects at least one in ten women (source: The World Health Organization) and often presents with debilitating menstrual pain which, over time, evolves into pain during intercourse and widespread chronic pain. Despite this, diagnosis is often delayed by years: ultrasounds and MRIs may show no abnormalities, yet the pain remains real. Today, European guidelines emphasize that endometriosis is primarily recognized by listening to symptoms, not just by reading reports. Treatment is never singular: it involves reducing inflammation with hormonal medications, releasing contractions with pelvic physiotherapy, modifying lifestyle and nutritional plans, and incorporating psychological and sexological support. Only an integrated approach can restore quality of life to those living with this silent but disruptive disease.

Vulvodynia

The vulvodynia is chronic vulvar pain that persists for at least three months and can be continuous or intermittent, spontaneous or provoked by touch. It is often described as burning, itching, a pins-and-needles sensation, or "electric shocks." In many cases, the physical examination appears normal: the mucous membranes look healthy, yet the patient suffers.

It affects approximately one in seven women (Graziottin, A., & Murina, F. (2022). Vulvodynia. Springer Italia) and the average diagnostic delay is about five years. The most frequent form (in 80% of cases) is vestibulodynia, which is pain localized at the vaginal entrance, but it can also affect the entire vulva or clitoral area.

The causes are multifactorial: there may be coexisting recurrent candidiasis, endometriosis, painful bladder syndrome, irritable bowel, hypertonicity of the pelvic floor, or neurological and muscular dysfunctions. Treatment requires a personalized and multidisciplinary approach

The pelvic floor is often called "the forgotten muscle." How and why should you take care of this muscle?

There's an often-ignored but crucial player: the pelvic floor. Many young women don't have a problem with muscle weakness, but rather hypertonicity, an involuntary contraction that makes every sexual encounter painful. Specialized physiotherapy is then a turning point: with targeted exercises and body awareness practices, it's possible to release tension and restore freedom to the body and sexuality.

It's not just therapy that matters: language also holds immense power. Terms like "vaginismus" risk stigmatizing, whereas talking about "involuntary muscle tension" helps reduce blame and stigma. Even bad advice can sting like a wound: "relax", "have a glass of wine", "the problem is your partner". Messages like these don't help; in fact, they worsen the suffering. The right ones, however, are simple and revolutionary: “your pain is real, it's not your fault, there are ways to help you”.

The questions women often ask me clearly illustrate the need for answers: “Will I be able to have sex without pain?”, “Will I be able to have children?”, “Will my partner understand?”. These are not just clinical doubts, but existential ones too. The specialist emphasizes that the answer is yes: with timely diagnosis and a multidisciplinary approach, the quality of life can radically change.

Diagnosis always begins with listening: because behind every symptom there is a story that deserves respect and solutions.

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