What They Didn’t Tell You: From Core to Floor

Painful Sex & Other Things Your PT Wishes You’d Ask Sooner

• Millie Schweky • Season 1 • Episode 4

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In this episode:
Dr. Millie and sex coach Galya tackle a listener's heartfelt question: "Who do I see first: pelvic floor PT or a sex therapist, when sex is painful?" Their answer? It depends... and you deserve to know why.

You'll learn:

  • What vaginismus is (and why it’s more common than you think).
  • How to differentiate between muscle-related vs. emotional/psychological pain during intimacy.
  • The truth about postpartum pain and the myth of the "loose" pelvic floor.
  • Why even C-section mamas shouldn’t skip out on pelvic floor care.
  • The game-changing role of communication, lubrication, and gentle guidance.

Whether you're prepping for marriage, navigating postpartum intimacy, or revisiting pain you’ve pushed aside for too long, this episode will leave you feeling informed, supported, and a little more in control of your story.

Resources & Links:

[Dr. Millie Schweky]

Okay, so we have another question from the audience. Someone asks, Galya, I have painful sex. How do I know if I need to see a pelvic floor PT or if I should see a sex therapist or a sex coach? Which one should I see first? 

[Galya Falkson]

This is a great question because this is often something that people get confused about.

So I would say that the most important thing is to determine what is the thing that you need help with. So if you're experiencing anything that muscle related, in other words, there's pain during sex or you have tension or there's tightness or a burning or spasming, that's when your PT is going to be your first step because they're going to be able to look at what's going on with those muscles, what's going on with those nerves, et cetera, and give you a really helpful plan to implement and to take forward into fixing that difficulty. Whereas a sex therapist or coach is going to help you with the emotional, relational, and psychological aspects.

So if you're experiencing fear or anxiety or if you've got past trauma or if there's things that you're not necessarily sure about or you don't know how to communicate with your partner or if you're experiencing lack of arousal or anything that's related to the relationship or the sex side of things. The actual muscular side of things is where your pelvic floor PT is going to come in and oftentimes I'll work alongside a pelvic floor PT because they'll be dealing with the muscles and all the structural issues, whereas I'll then deal with the fear or the anxiety that may also be causing those structural issues. So sometimes we work together and sometimes you don't need both.

So depending on your experience is dependent on who you're going to go to first. If you're not sure, you're always welcome. Yeah, sorry.

If you're not sure, you're always welcome just to reach out to myself or me and ask them, okay, this is my symptoms. Who do I go see first? 

[Dr. Millie Schweky]

I couldn't agree more. There are so many cases where people are coming to me and they're like, oh, is this like a sex therapy issue? And usually it's like inability to orgasm or pain, like kind of like what we would call in the clinic vaginismus, where they're clenching up before intimacy occurs.

So for anyone that doesn't know what vaginismus is, it's the involuntary contraction of muscles of the pelvic floor upon anything penetrating, whether that's like a speculum, a finger, a penis, like literally anything. So sometimes they're like, oh, should I be in sex therapy? And like a lot of the times my answer is yes, this too, but sex therapy or sex coaching as well. And it's honestly like challenging for me because as I've heard you say, our brain is our largest sex organ.

And when there's something going on, a stress, a trigger, a trauma, it's really hard to see results physically when that's not being addressed. I take a holistic approach where I'm able to address it, but it's out of my scope of practice once we get to a certain line. And that's where I love referring to sex therapy.

So I really couldn't agree more. 

[Galya Falkson]

Yeah, 100%. There was another question that actually came in for you, which was how long after birth will sex hurt or feel uncomfortable?

[Dr. Millie Schweky]

So let's bust a myth first.

I always love a myth buster. I think a lot of women that had C-sections are going to say I am exempt from this category, but you're not. I see a lot of you in the clinic and when they make the incision, the nerves that they're cutting through happen to overlap with the pelvic floor, not to mention that the whole entire area of fascia and muscles being cut through is connected to the pelvic floor as well.

So C-section mamas, don't skip this question if you're listening, all right? So really, sex shouldn't hurt, but what I do see super common, and I'm kind of like okay with it, is it hurting the first one to two times postpartum, but you're seeing from that first time to the second time that there's a significant degree of improvement. And by the third time, if there's still pain, I would say go see PT. I actually, just from my clinical experience and speaking to patients, they're like, I was so scared the first time.

 And that really could be a contributing factor to the pain, which I think there's a degree of normalcy to that. No matter how amazing your birth was, if it was like a magical unicorn rainbow birth, like it's still a trauma to the body. So there is going to be like some degree of muscular tightness after birth, which I think a lot of women think the contrary would be true where, oh, like I was just stretched out, everything's going to be so loose and floppy down there, but it's a stress to the body.

Even nine months of pregnancy is a stress to the body. So to go ahead and meet intimacy after that rapid shift in hormones post birth, things are going to change, things are going to change. So in short, to recap my answer, it's okay if it's hurting one to two times and gradually getting better, but if you're still experiencing pain by the third time, I would seek help because you don't want to get trapped in that cycle of anticipating the pain and then actually hurting, and then your body actually remembers that.

So then the next time you're exposed to the painful stimulus, your body already is like red flagging it, and then you're more likely to have pain again. Yeah,

 [Galya Falkson]

A hundred percent. And I think that totally like even relates to the fact that the fear is coming from everyone else's experiences, everyone else telling you something, or maybe you've had, this is your second child, so you know that the first time is a little bit uncomfortable, but in the end of the day, there are ways to manage that discomfort so that it shouldn't be very painful.

So it's important to also just like make sure you're using lots of lubricant and make sure that you're going super slow and that you're not just rushing into where we were doing all these crazy things and positions and fun experiences before, so we're just going to jump back into that. I mean, most moms aren't exactly jumping back into that, but the point is is that just kind of don't assume, like go slow and see where your body's at before. And this is actually kind of related to another question that came in as well for you, which is how long after getting married is sex supposed to stop hurting? And like when is that concerning? So after birth, you said on the third time, this is when you should seek help.

Is that the same with having sex for the first time?

[Dr. Millie Schweky]

It's a great question. So I like that we like kind of put these two together because it's a similar question, but I have like a slightly different answer. When you're having sex for the first time, that really shouldn't hurt.

There's like no, there's no reason. There's really no reason, like unless there's like a specific trauma that occurred where there's a medical condition or something going on, there's no reason. So it's supposed to never hurt.

That being said, when should you seek help? My rule is the same, that it's three times, but just know that the first time if there's something painful, not normal. Not normal. Whether it's physical, whether it's physical blended with psychological, I highly recommend getting help as soon as possible.

And what's cool about having these questions together is that I'll find just clinically, and I don't have any statistics to back this up, but this is just what I'm seeing is that the woman who are having pain in the beginning of marriage are the same woman coming back with pain after birth. So if you take care of it in the beginning of your marriage and you have the tools, you learn the breathing strategies, you learn the stretches, you learn the exercises, then you're setting yourself up for success in the future when you God willing have kids one day.

[Galya Falkson]

I love that, yeah.

And also when I always say, when I say girls like when they're getting engaged and they're afraid that, oh no, it's going to hurt, I say like there's no, exactly, there's no reason for it to hurt. The vagina is like an inelastic. It has like a stretchy elasticity to it.

And if you have the right hormones and everything is good and healthy in your body, there shouldn't be pain. And if there is pain, it's an indicator of something else, or it's an indicator that the person maybe was educated incorrectly and they've been told to just push through, which is no, it's a stretchy thing. You don't just stretch something open like this.

You slowly stretch it so that it doesn't break. Now we obviously can't break a woman. I mean, we could tear her, but we don't want to do any of that pushing mentality because we're not pushing anything.

We slowly stretch and we slowly get this space comfortable and ready. So if you're not yet having sex and you're in that engagement period, you could even do specific exercises. And that's where seeing a sex coach or even a pelvic floor therapist before marriage is also useful.

Again, you would have to ask your rabbi because there are some people who are stringent about this, but in the end of the day, I think it's really important to know your body and know what your body is able to do and handle, and to then be able to guide the person that you're now having sex with in the best way and slowest and the most comfortable way for you so that there isn't any of that pain. 

[Dr. Millie Schweky]

I wanted to add that shout out to my kala teacher when I was getting married. And I actually remember laughing at her because I was like, dude, I'm going to be a pelvic floor PT.

But she was basically telling me like, oh, if you have any problems, here's a card, someone to call. And she was telling me like, yeah, there's so many girls that I send. If I see that they're nervous going into it, I'll send them to go for a consult.

And I was like, wow, that's actually very smart. So I myself, who I don't think I had taken so much training yet, I think I just had taken the basics in the pelvic floor world. And it was enough for me.

I was like, oh, let me do some breathing exercises. And I guess I was like my own guinea pig before even being certified. And I was like, wow.

So when I started working and getting referrals from kala teachers, I knew exactly what tools what tools to teach them. That's amazing. And it's really interesting.

I'll just like make one more funny point. I'll randomly get patients of like single from girls who have like another issue, whether it's like back pain or urinary issues, but we're not even doing internal work. But just from doing the work on their body, they learn so much about what does it feel like when I'm contracting my muscles? What does it feel like when I'm relaxing my muscles? What does it feel like to hold a stretch comfortably or to hold a stretch that's like maybe too much? When should I back off? And they learn how to be in touch with their breath and their body.

And then those girls, when they come back to me three years later, pregnant or newly married, they're like, oh, I just need to check out. I'm like, oh, well, nothing's going on. Like, no, no, I kind of like had this pain.

I knew what to do because like I learned it once with you. I was like, great. Like that's that's exactly what we want.

We want you to feel like in touch and empowered with your body. So by the time you get to this like new chapter in life, nothing feels foreign and scary to you. You're just like, this is my body.

I could do it. Exactly. All right!