Let’s End the Silence About Endometriosis

By Dr. Kristina Brown, Adler University

Endometriosis causes physical, sexual and emotional pain. About 190 million people around the globe have endometriosis, including one in 10 American women, but there has historically been a deafening silence about the disease and the pervasive impact it can have on a person’s life.

While endometriosis is a chronic gynecological illness that can affect anyone with a uterus – women, transgender men and nonbinary individuals – it often goes undiagnosed because its symptoms can be attributed to other physical or psychological concerns. Patients presenting with this pain are often told it is “all in your head.”

However, endometriosis is becoming a more visible illness, thanks in part to celebrities such as Lena Dunham, Chrissy Teigen, Amy Schumer, Whoopi Goldberg and others who have begun sharing their stories publicly.

After going undiagnosed for 23 years, Padma Lakshmi, a popular cookbook author, actress and host of the TV show “Top Chef,” founded EndoFund, previously Endometriosis Foundation of America, in 2009 so that others do not have to go through what she did.

I am a couple and family therapy professor, clinician and researcher. My own endometriosis diagnosis at the age of 19 has inspired my work exploring how this illness affects others beyond the physical symptoms.

To better understand the impact of endometriosis on relationships, I interviewed 10 couples about their experiences of diagnosis, treatment and living with this disease. Through their stories of how endometriosis-related pain can affect every aspect of daily life, including their intimate relationships, I provide some specific recommendations. The quotes I have included in this article are from my doctoral dissertation research.

Basics of Endometriosis

When a person has endometriosis, the endometrial cells that line their uterus “implant” in places outside the uterus, such as the ovaries, fallopian tubes and the lining of the abdomen — called the peritoneum. At the end of each menstrual cycle, the uterus sheds its lining, which exits the body via the cervix and vagina. The “misplanted” endometrial cells also shed, but they have no place to go – resulting in internal bleeding, inflammation and pain.

An endometriosis diagnosis is described in stages related to the visual presence of the disease, from minimal, or Stage 1, to severe, or Stage 4. However, there is no connection between the stage and the experience of pain.

One symptom of endometriosis is intense pain during the menstrual cycle. Another is pain with sex. Because pain with menses or sex can be attributed to “normal” pain, a history of sexual abuse or psychiatric reasons such as a dislike of sex, some people with endometriosis wait an average of seven years for diagnosis, which can be visually confirmed only through a procedure called laparoscopy.

In addition to these and other types of severe pain, endometriosis can also cause infertility, and patients who want to have children must often undergo medical or surgical interventions to conceive.

Impact on School, Work and Sex

Physical pain from endometriosis can be debilitating. Adolescents with endometriosis may struggle to keep up with their classes, friends, homework or extracurricular activities when the pain becomes too severe. They may shift to home-schooling or virtual learning to complete their studies.

The pain can also deeply affect a career trajectory. “I almost lost my job because of time off,” one interviewee told me. “In fact, when I had to get my hysterectomy, I walked in to tell my manager and he goes, ‘Well, I hope you’re not going to tell me that you have to have a hysterectomy and have to be out for six weeks!’ And I just broke down in tears.”

All of my participants shared experiences where doctors dismissed complaints of sexual pain – called dyspareunia – from endometriosis. This can delay diagnosis and treatment.

Sex and intimacy often become nonexistent, while some couples shared that they have come to accept that pain is part of sex. One woman shared with me: “I don’t want to be touched or have my naked body seen because I feel bloated and ugly and I’m in horrible pain!”

Partners can also be affected emotionally. “I just feel horrible,” one told me. “There are times when we are having sex that I actually feel guilty that I know that I am hurting her and I know she is going to be in pain and it makes me unhappy.”

These experiences of pain, of not being believed by doctors and professionals, of negative effects on education and career and of intimacy destroyed create a heavy emotional burden on individuals and relationships.

Breaking the Silence

When I was diagnosed with endometriosis, it changed the course of my life. My partner and I learned to expand our definition of intimacy and to redistribute household responsibilities when I was incapacitated. As the risk of infertility only increases without intervention, we started conversations about having children earlier than anticipated. My diagnosis also led me to focus my professional identity as a medical family therapist to help others deal with endometriosis and chronic illnesses.

Based on this experience, here are some ways to break this silence:

• Learn about endometriosis. It directly helps when one’s support systems are educated.

• Separate the person from the disease. When the pain you are experiencing from endometriosis is debilitating, help those around you who are also affected to understand that it is because of your endometriosis and it is not personal.

• Speak from your own experience, saying, “I …” rather than “You …” When we do this, it decreases the other person’s defenses and opens up the communication, making space for connection.

My research participants shared their own recommendations with me, especially the importance of believing that their pain is real; accept that what they are sharing is their very real experience, and let them know that they are believed.

Bestselling author and social work researcher Brené Brown has said, “Empathy fuels connection, sympathy drives disconnection.” Approaching someone with endometriosis from a position of empathy sends a message that you want to work with them collaboratively.

By practicing these important relationship skills, we can break the silence around endometriosis.

Kristina S. Brown, PhD, is a Marriage and Family Therapist, and Professor and Chair of Couple and Family Therapy at Adler University in Chicago. Dr. Brown is the Editor-in-Chief of the Journal of Feminist Family Therapy and also serves as the Director of Mental Health for Floating Doctors.

This article originally appeared in The Conversation and is republished with permission.

Let’s Talk About Chronic Pain and Sex

By Ann Marie Gaudon, PNN Columnist

Do you remember that catchy song from the early 90’s by the hip hop group Salt-N-Pepa called “Let’s Talk About Sex”? I sure do and I still think it’s fun!

For many people, sexual activity and intimacy are incredibly important factors of living well, being happy, and feeling close to one another. But when chronic pain enters a life, those factors may take a big hit. People don’t talk enough – or at all – about living in pain and sexual intimacy.

Let’s talk now baby!

In my many years of being with people in pain, I’ve seen sex become a taboo subject. It can be denied not only to another, but to oneself as well. It gets complicated when the person in pain worries about their physical performance or if they can even engage in sexual activity without increasing their pain.

This most certainly affects self-esteem and confidence in the bedroom. Then we have a situation where everybody stops talking -- when they should be doing just that.

Why does sex matter if you have chronic pain?

It matters and can have a significant impact on your quality of life. Something amazing happens when you are the recipient of wanted sexual touching and intimacy. Your body will release endorphins, which are the body's natural pain reducers. You will feel better and happier, not to mention all those other good feelings you may experience.

The name endorphin comes from “endogenous morphine,” which means they come from inside the body and mimic the effects of morphine. For that reason alone, I tell my clients to have more sex if possible. And if they are single, to get busy masturbating. An orgasm is an orgasm, and your body doesn’t care how it gets there. Just get there.

In 2017 a functional MRI study was conducted measuring brain activity in women during orgasm. “Brain activity gradually increased leading up to orgasm, peaked at orgasm, and then decreased,” researchers found. This activation included many regions of the brain, including those that process rewarding experiences such as food and sex. 

Another study from 2013 shows that orgasm may have the ability to decrease or alleviate headache pain. Want better sleep? Have regular orgasms. Yet another study in 2015 showed the mediating effect of sexual activity on pain and depression for those suffering from low back pain.  

How are you going to have sex if you have back pain?

I found out that the clinical community was in contact regularly with Canadian Dr. Stuart McGill, Chief Scientific Officer for Backfitpro and a distinguished professor emeritus at Waterloo University. McGill is asked repeatedly by clinicians about couples who are celibate because of back pain. Are there any guidelines on sexual technique that can reduce the risk of more pain?

The challenge was on! Professor McGill and graduate student N. Sidorkewicz conducted the only study in the world that took real couples and measured their spine postures and muscle activity while engaged in various sexual positions. This was no small feat, considering the challenges of recruitment, instrumentation and developing an experimental protocol that satisfied the ethics research committee and requests from the medical community. 

The study measured muscle activity and 3D spine and body movements, using the very same technology that was used in the making of Avatar. The object was to create an atlas of sexual positions that did not trigger back pain.

Professor McGill has a short version of a sexual atlas in his book "Back Mechanic," which includes spine-sparing positions that enable sex for people with back problems. The book guides the reader through a self-assessment of their pain triggers. Then, based on the specific trigger, positions and movements are shown to consider and to avoid.

I am super impressed with this work and I only wish that we had guidelines for virtually every source of pain.

Are there other pain conditions that defy sexual activity?

You bet there are! One that comes to mind is pelvic floor dysfunction or PFD. I have known many people with this diagnosis. We all have a pelvic floor, whether you were born with a penis or vagina, and so no one is immune to PFD.

One female patient with this diagnosis -- more specifically “hypertonic pelvic floor muscles” -- told me that just a light touch and/or engorgement from arousal can be enough to create excruciating muscle spasms.

“Spasms beget spasms,” she said. “It is very, very painful and truly sad that we avoid intimacy. I have a Pavlovian response developed over many years of severe pain and flares that lasted for days.”

The forceful, rhythmic contractions that occur for anyone having an orgasm can set off a cascade of painful symptoms. Here are links two simple videos to explain male and female pelvic pain.

PFD is currently treated by specialized physical therapists and yes – there are success stories, thankfully.

How do I get busy?

As a person with any type of pain, you may need to get creative. You may need to adjust positions for yourself or your partner, as well as the time, day and even the environment. If you require minimum body movement, consider self-stimulation while lying beside your partner. Sex toys and lubricants also work wonders, whether you have a partner or are alone.

If being spontaneous is not in the plan, consider making intimate dates either with a partner or yourself. Above all, keep the communication open with your partner. It’s crucial that you understand each other and have realistic expectations without judgment.

If you’re wondering if you can share intimacy without the orgasm, the answer is yes! Orgasm is only one aspect of sexual intimacy, and you can connect and feel great in plenty of other ways.

There comes a time in many couple relationships when sexual intercourse isn’t an option, due to physical, emotional or mental health. When this occurs, there are many alternatives to consider. Make a list for yourself, considering your unique needs, which will support and care for your pained body no matter what stage in life you are in. 

Ann Marie Gaudon is a registered social worker and psychotherapist in the Waterloo region of Ontario, Canada with a specialty in chronic pain management.  She has been a chronic pain patient for over 30 years and works part-time as her health allows. For more information about Ann Marie's counseling services, visit her website. 

Rare Disease Spotlight: Vulvodynia

By Barby Ingle, PNN Columnist

This month in our Rare Disease Spotlight we’ll look at vulvodynia, which causes chronic pain and discomfort around the vulva, the opening of the vagina. About 15 percent of women will have vulvar pain at some point in their lives.  

I first learned about vulvodynia a few years ago at a medical conference. It was described to me by a woman who has it as the feeling of a chain saw cutting into her private parts. Quite the visual description. It made me stop to pay attention.  

There are many causes for vaginal pain. These range from hormonal changes, nerve conditions, eczema, psoriasis, endometriosis, anxiety, depression, vaginal atrophy and vaginal dryness. Often, multiple causes contribute to vaginal pain. 

There are two main types of vulvodundia: generalized vulvodundia and localized vulvodunia. The latter is also known as vestibulodynia, which occurs when there is any kind of touch or pressure near the vaginal opening that causes irritation. Burning, stinging or itching can be triggered by tampons, cotton swabs, tight clothing, toilet paper and sexual contact.  

For women with generalized vulvodynia, the pain occurs spontaneously and has no known cause. Often we focus on women when we look at pelvic pain. But men can also experience pelvic pain and conditions. A similar disorder to vulvodynia is known as male genital dysaesthesia.

Vulvodynia can resolve within months or become chronic. It can be so painful that some activities feel unbearable, such as sitting for long periods, riding a bike or having sex. If you experience pelvic pain, you should avoid those activities until you see an OB/GYN doctor, physical therapist or primary care provider.  

Some of the symptoms of vulvodynia include vaginal dryness, itching, or inflammation. These can appear with pain in the vagina or pelvis. Pain can increase during sexual intercourse. It may also cause sexual dysfunction, uncomfortable tingling and burning pain.  

Fortunately, there are some potentially helpful treatments. These options include acupuncture, biofeedback, cognitive behavioral therapy, nerve blocks, nerve pain medication, and oral and topical analgesics. You can also try a pelvic floor therapy to strengthen and desensitize the pelvic region. Avoiding irritants and practicing good hygiene may also help. 

There are some new medications being developed in clinical trials for vulvodynia, but they could take years before they are available. In the meantime, physicians may provide patients with vaginal estrogen in low doses, as well as lidocaine. Systemic hormone therapy is associated with an increased risk of heart attack, stroke, blood clots and other complications. Be sure to talk to your provider about the risks involved with vaginal estrogen treatment before starting hormone therapy.

If you have vulvodynia, there are some private Facebook groups where you can get support, such as Vulvodynia Support and Vulvar Vestibulitis Syndrome (VVS) & Vestibulodynia & Vulvodynia Awareness. The National Vulvodynia Association is also a good resource.

So much emphasis in our society is put on sexual health, especially for men. Having lived through endometriosis myself, I know pelvic health is important. Women deserve good sexual health too.

Barby Ingle lives with reflex sympathetic dystrophy (RSD), migralepsy and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the International Pain Foundation. She is also a motivational speaker and best-selling author on pain topics. More information about Barby can be found at her website.

How to Rekindle Romance While Living with Chronic Illness

By Barby Ingle, PNN Columnist  

Living with chronic illness can put a strain on any relationship, particularly marriages. To help other couples, my husband Ken and I have I decided to share our learned wisdom on how to rekindle romance in a chronically ill partnership.   

My first suggestion is to keep track in your pain diary so that you can remember the details. Record at what point during sexual intimacy that pain occurred or increased, and what the circumstances were when your pain subsided. Putting your thoughts on paper can help you understand the underlying issues and complications, and regain control of your intimacy.

Although Ken and I did not use a therapist, there are techniques that a therapist will suggest that can help a chronically ill person normalize their symptoms, which boosts self-esteem and lowers feelings of isolation. Improved self-esteem can enhance virtually every aspect of your life, including strengthening your relationships.

A life change due to health problems can be a common trigger for lowering how you perceive yourself. The challenge is to identify that this is going on and create an intimate connection with your partner at the same time.  

Take a look at what you are doing. Are you alienating yourself or your partner? If so, why? Think about your behaviors and beliefs. Are they holding you back from intimacy?

Consciously thinking positive thoughts can boost self-esteem, but it takes practice. How you approach it can make all of the difference. Start with simple words and reminders to yourself. Then reconnecting with your partner will become easier. 

Rekindling romance could be as simple as a few words, a gesture, or a look or touch that will let the other person know you are okay. Be conscious of this each day, so that not a day goes by without a kind word or gesture, even if you are not having sex daily. And really, who does that when they’re in constant pain?

Try this the next time you are washing your hands at the bathroom sink: Write “I love you” on the mirror with a soapy finger or lipstick. This can help create an intimate moment.  

Be the one to take control if your partner is afraid that they will hurt you further because of your current pain level. Be sure to reach out and let them know you would like to have a sexual experience. Say, “Do you want to have sex right now?” or whatever cute, sexy or clever way feels natural to you.  Lead the experience to relieve their worry.

Spouses often have different sexual desires. Turning your desire totally off just because of pain can cause harm to your relationship. Your partner probably married you expecting a healthy sexual relationship. Holding back on intimacy can lead to the end of a marriage or even infidelity.

The last thing a chronic pain patient needs is more discomfort. But when intimacy increases pain and leads to avoiding sex or even cuddling, the relationship suffers. Don’t let this be the beginning of a vicious cycle of no sex.  

What can you do to increase the connection, romance and sex that you have with your partner? When you are talking, try to share your struggles about staying close. You can also share positive thoughts, such as sex helping you cope with chronic pain. 

I hope that these tips can help you rekindle any lost sparks with your partner. All those things you don’t say could be keeping you and your partner on different pages. Turn on the power of romance and make your relationship stronger.

Believe me, I understand how difficult it can be to push yourself to be romantic when all you want to do is sleep or cry from the pain. Having a close relationship physically with your partner can make a huge difference in many areas of your life.

Barby Ingle lives with reflex sympathetic dystrophy (RSD), migralepsy and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the International Pain Foundation. She is also a motivational speaker and best-selling author on pain topics. More information about Barby can be found at her website. 

Chronic Pain and Opioids Impact Sexual Health

By Pat Anson, Editor

What’s more important to you?  Pain relief or an active sex life?

The question is not as frivolous as it sounds. According to a recent study published in Pain Medicine, chronic pain patients who take opioid medication are significantly more likely to experience a lack of desire and to be less satisfied with their sex lives, especially if they take opioids long-term.

Of course, anyone with a chronic illness is more likely to have sexual health issues – whether its desire, function or attracting another partner.  But the issues seem more pronounced with those who take opioids.  

Danish researchers surveyed over 11,500 randomly chosen adults. Slightly more than half the women and a little less than half the men said they suffered from chronic non-cancer pain.

Pain sufferers who did not use opioids were 38% more likely to be unhappy with their sex lives and 46% more likely to report a lack of desire than people who were pain free. So just being in pain is a big factor by itself.

But long-term opioid users were 69% more likely to report dissatisfaction with their sex lives and were twice as likely to experience low or no sexual desire.

Short-term opioid users were 35% more likely to be unhappy with their sex life and 82% more likely to have less desire.

“Patients suffering from chronic non-cancer pain should be aware that it can have a negative impact on their sexual desire and satisfaction with sex life, and that using opioids, especially long-term, can add an additional negative impact on their sex life,” lead author Hanne Birke, an oncology researcher at Rigshospitalet (Copenhagen University Hospital) told Reuters.

Only 57 percent of people on long-term opioids reported having sex during the past year.  That compares to 62% of pain patients on short-term opioids, 68% of pain sufferers not taking opioids and 77% of people who were pain free.  

Short-term opioid use was defined as having one prescription filled in the previous year, while long-term use was having opioid prescriptions dispensed in at least six months during the previous year.

Chronic pain and opioid use has long been linked to sexual health problems.

“Chronic pain ‘highjacks’ sensory nerve fibers, thereby making it harder or impossible for pleasurable stimuli to elicit a response,” said Anne Murphy, a researcher at Georgia State University in Atlanta, who wasn’t involved in the study. “On top of that, opiates suppress the activation of sensory nerve fibers which would have an obvious impact on sexual pleasure.”

But many people who were pain free also reported sexual health issues. About 19% of men and 14% of women without chronic pain were unhappy with their sex lives. And 7% of men and 19% of women without pain reported a lack of sexual desire.

Can Marijuana Improve Your Sex Life?

By Roger Chriss, Columnist

A new study by researchers at Stanford University, published in the Journal of Sexual Medicine, shows that marijuana use is associated with greater sexual frequency in both men and women. There has been a lot of enthusiasm about the findings, but relatively little understanding of what the research actually says.

Marijuana has intriguing medical potential, from symptom relief in terminal cancer patients to pain management in chronic conditions. And the possibility that it may improve sexual function is enticing in particular for people with health problems. Thus, it’s important to understand what any new results are really saying. So let’s use this paper as a case study on how to read a research paper.

We start with the study methodology. Because the gold-standard of a double-blind placebo-controlled randomized prospective trial is not possible with marijuana, the authors had to engage in data mining, the process of using an existing data set to ask new questions.

For a data source, the study uses the National Survey of Family Growth (NSFG), a large database assembled by the CDC. The study results were drawn from an analysis of 28,176 women (average age = 29.9 years) and 22,943 men (average age = 29.5).

It is important not to be impressed by these large numbers. Increasing a sample size beyond a certain point offers no additional reliability, and it may create more problems with confounding variables and hidden biases. Because the authors did not assemble this data themselves, there was no way for them to address these issues.

A sanity check of the data is the next step. This study looks at sexual frequency at various levels of marijuana use. A check of the International Encyclopedia of Human Sexuality shows that “on average, men and women engage in sexual intercourse approximately six times per month.”

This is consistent with the Stanford study findings, but with a caveat: recall of the previous month’s sexual activity or marijuana use may be imperfect. Some researchers try to get around this problem by having participants keep written logs or by using apps, but this study did not.

It is also important to keep in mind that the study variable of sexual frequency is an imperfect number. You cannot have sex 0.73 times!  Any change in sexual frequency has to occur in increments of one per unit time. In this study, the unit time is a 4-week period. The increase reported in the study represents the smallest possible increase, or one additional sexual event. The authors found that regular marijuana use was associated with one more sexual event every four weeks.

The study mentions the use of the NSFG data as a limitation. The authors note that “survey responses were self-reported and represent participants only at a specific point in time.” But there is a deeper issue here. As noted above, the data set may contain flaws, biases, or other issues beyond the control or even the awareness of the authors. Formally speaking, randomness is lost. In election polls, for instance, pollsters follow strict protocols to ensure randomness because doing so makes for more reliable results.

In practice, large data sets often contain many associations because life is complicated and even seemingly simple activities like sex are subject to a variety of influences. So posing questions to large data sets requires caution, or as statisticians sometimes say, “give me a large enough data set and I can prove anything.”

The Stanford study’s conclusion is that a “positive association between marijuana use and sexual frequency is seen in men and women across all demographic groups.”

But in an interview with The Washington Post, the authors qualify that by noting that the study “doesn't say if you smoke more marijuana, you'll have more sex,” appropriately warning that correlation is not causation.

Spurious Correlations

But the mantra of “correlation does not imply causation” is simplistic. In reality, association does not even imply direction. It is equally reasonable here to say that greater sexual frequency is associated with increased marijuana use. But changing the word order alters the implication.

The second problem is that the association may be meaningless, an artifact of our data-rich world. Such spurious correlations can even be a source of entertainment. For instance, coital frequency may be correlated with living in an even-numbered zip code or marijuana use may be associated with banana slug activity.

Not to make light of overdoses, but there is even a spurious correlation between deaths caused by opioids and the price of potato chips:

SOURCE: TYLERVIGEN.COM

These associations could be tested, but a positive result would probably not get the kind of media attention the Stanford study is receiving.

Moreover, sexual activity is influenced by a wide range of factors. It is possible that regular marijuana users have a lifestyle more conducive to sex, making lifestyle a lurking variable that affects both sexual frequency and marijuana use. Or it may be that daily marijuana users have more disposable income, more time to enjoy the effects of marijuana, and a more drug-tolerant work situation. In this case, marijuana use would act as a proxy for other potentially causal factors that influence coital frequency.

Because these issues are always found in large data sets, the potential for finding meaningless associations is ever-present. Or as statisticians say, “if you torture the data enough, you can get it to confess to anything.”

Thus, a study of this nature has inherent limitations that mean its results must be interpreted with caution. As the authors note in their conclusion, “the effects of marijuana use on sexual function warrant further study.”

So our final task is to consider what would constitute further study. Obviously, this result needs to be confirmed, ideally with a prospective study that controls for confounders. If the result is reproduced, then the hard work of identifying the causes begins. Once identified and confirmed through human testing, then and only then can we say that marijuana increases sexual frequency. For now the best we can do is read such studies with care and caution.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society.

Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Let’s Talk About Sex, Baby — and Chronic Pain

By Crystal Lindell, Columnist

The thing that nobody tells you about Cymbalta is that it takes a machine gun to your sex drive. Seriously. When I was on it, I was so repulsed by sex that I started to think maybe I was legitimately asexual. 

I mean, when the doctor hands you the prescription, it would be nice if they threw in something like, “BTW, you’re never going to want to make passionate love while you’re on this medicine.”

But of course, doctors never tell you stuff like that. And God forbid they give you a handout of some sort that maybe mentions it. No, they just leave you to Google “asexual” at 1 a.m. on a Tuesday night when you realize you’re identifying a little too much with Sheldon on the Big Bang Theory.

Don’t get me wrong, I have definitely been in such tragic levels of pain, that if someone had asked me if I wanted to give up sex so I could feel better, I wouldn’t have even thought twice about cutting off my own vagina and handing it over. 

But the thing is nobody asked me. They didn’t tell me I might have to make that sacrifice when they put me on Cymbalta. So I didn’t even know it was happening. And that’s when you get to some pretty dark places. 

Thankfully, I’ve since gone off Cymbalta, and my sex drive came back like a freight train. 

But that doesn’t mean there aren’t other issues related to sex and chronic pain.

Like when you have stabbing rib pain on your right side, so you can only tolerate sports bras, and then he goes to unhook the back, and it kills the mood because there is no hook in the back of a sports bra. And he’s mad that you’re dressed like someone planning to run a 5K, and then you’re mad that he’s mad that you’re dressed like someone planning to run a 5K, and so you just leave.

Or when he wants to cuddle, and you have to explain that, “Sorry, I can’t lay on my right side because when I do it feels like someone is jack hammering into my bones through the mattress. Hope that’s not a deal breaker!”

Not to mention the fact that when you’re in physical pain, the last thing you feel is sexy. And you most certainly don’t feel like having anyone touch you ever. 

First, there’s just the literal pain that can come from someone passionately throwing you against the wall, or even a pillow top mattress for that matter. When you feel like you always have a broken rib, even passionate love making can make you wince. 

Then, there’s the fact that the pain probably keeps you from showering as often as most Americans believe is normal, which means you probably smell, which means you’re probably not feeling very romantic. 

And of course, there’s the side effects from the medications, which make you gain weight, sleep all day, and zone out in front of YouTube videos about makeup while you simultaneously lose the ability to actually wear makeup. 

Not to mention the fact that it’s just really hard to make love to someone, while you yell things like, “OH GOD! OH GOD! OH GOD!  IF YOU TOUCH MY RIGHT SIDE AGAIN I’M GOING TO STAB YOU TO DEATH!’ or “YES! YES! YES! I NEED YOU TO AVOID MY CHEST AREA AT ALL COSTS!”

That’s the kind of stuff that can turn an evening of “Netflix and Chill” into an evening where you actually watch Netflix and chill. 

But even with so many things working against the sex lives of those with chronic pain, that doesn’t mean people should give up. 

For one, that old saying about how, “You can have great sex without having a great relationship, but you can’t have a great relationship without great sex,” is actually pretty true in my experience. Having sex is an important part of being a healthy couple. Of course, that doesn’t mean partners shouldn’t be understanding of the situation, and our pain levels. What it does mean is that avoiding sex, regardless of how legitimate the reasons for doing so are, will likely put a strain on your love life. 

Also, sex is just a good thing to have in general. It helps your mood, it can be a great pain reliever and stress reducer. And, you know, it’s fun.

So I don’t think patients should just resign themselves to the idea that having chronic pain means giving up good sex for the rest of their lives.

Unfortunately, I don’t have magical solutions to offer people with chronic pain struggling to work sex back into their daily life. But there are a couple things you can at least try.

Frist, there’s always the obvious “talk to your doctor” advice. Yes, I know that conversation can be awkward — both for the patient and the physician. If you’re up for the conversation though, I definitely recommend it. Your doctor might be able to recommend other medications that don’t kill your sex drive, some less painful positions or other techniques to help you out.

In the end though, I honestly think the best thing you can do is be open about the issues without whomever you’re making love to. Just like with anything, talking about what’s going on usually does the most good.

And if you both decide that maybe you can try to get a wire-free bra with a hook in that back because that’s what he’s into, as long as he promises to never touch your right boob, then great! Or, if you decide that having sex just isn’t worth the pain, then that’s great too.

After all, there’s always Better-than-Sex cake in a pinch.

Crystal Lindell is a journalist who lives in Illinois. She loves Taco Bell, watching "Burn Notice" episodes on Netflix and Snicker's Bites. She has had intercostal neuralgia since February 2013.

Crystal writes about it on her blog, “The Only Certainty is Bad Grammar.”

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.