Not long ago, the words impotence and incontinence would never have been mentioned in polite company.
Now, thanks to drug company marketing campaigns, erectile dysfunction and overactive bladder are the subject of nightly TV commercials and even party talk.
Here's another taboo topic that some physical therapists and doctors — and their female patients — would like to bring into the open.
Pelvic pain during sexual intercourse.
"It is a very prevalent problem," said Carol Casper Figuers, a physical therapy faculty member at Duke University School of Medicine. "It's a very underappreciated but very common complaint among women of all ages."
An Indiana University survey found that 30 percent of women reported difficulty with pain during their most recent sexual encounter. Estimates are that pelvic pain affects 70 percent of women over age 40, interfering with urinary continence as well as sex.
But many women just live with it. They're embarrassed. They don't know there's help.
Physical therapists have known for decades that pelvic pain can stem from spasms in the muscles of the pelvic floor. And as with other muscles, exercise and stretching can restore flexibility and relieve pain in the pelvic area.
"Most people don't even know they have a muscle there," said Barbara Green, a Charlotte, N.C., physical therapist who specializes in women's health. "They don't know that it's too tight, and they don't know how to relax it."
Green and other physical therapists say they help women recover the ability to have pain-free sex — or have it for the first time — by massaging the pelvic muscles to help them relax and by teaching women to relax and contract those muscles themselves.
Only in recent years have medical schools taught gynecologists about using physical therapy to treat pelvic pain.
"I've been out of residency for 10 years, and I never heard a thing about this," said Dr. Chris Morris with Providence OB/GYN in Charlotte.
Patients and doctors may have a hard time believing pelvic pain can be a muscle problem, Morris said. Maybe it doesn't start that way, he said, but at some point women "get a contracted pelvic floor that they are unable to relax. They have sort of accepted that 'This is life, and I'll never be able to enjoy sex again.' "
When Morris began referring patients to Green, he was impressed by the results.
"I can think of probably five patients who say it has changed their life," Morris said. "(One) had not had sex with her husband for more than five years. Now, she says, 'I'm having pleasurable, comfortable sex in a way that I never thought I would.' "
Dr. Alyse Kelly-Jones, co-founder of the Center for Sexual Health and Education in Ballantyne, N.C., said doctors should refer women to a physical therapist as part of the evaluation of any pelvic pain disorder.
"What often happens is women hurt below their belly button, and their gynecologist doesn't really find anything but says, 'Maybe we should do some surgery to look around.' Some women get surgery that's unnecessary."
Today, gynecologists can specialize in pelvic medicine through fellowships in urogynecology. Most academic medical centers now have pelvic pain clinics, where patients can get treatment and professionals learn about physical therapy.
For some women, the problem can occur early in life, making it impossible for them to insert a tampon or have a gynecological exam. Others can have normal sex lives and develop pelvic pain later.
The cause can be related to scarring after surgery, such as episiotomies, C-sections and hysterectomies, or to vaginal dryness with menopause. It can also be a response to stress.
Therapy includes massage, with the therapist helping to release tension by touching pelvic muscles, ligaments or scar tissue with a gloved finger.
"It's like a gynecological exam, but we're working with muscles, just like we work with any other muscles in the body," she said.