By Jandra Mueller
- painful spasmodic contraction of the vagina in response to physical contact or pressure (especially in sexual intercourse).
What is vaginismus?
Above is the definition that comes up when you google vaginismus. You may have seen blogs or posts on social media about vaginismus or painful sex or may have experienced it yourself at one point and asked your doctor about it. I remember telling my doctor at one point that sex had become uncomfortable and she attributed it to my five year relationship and that “things like that happen after you’ve been together for so long.” It is extremely common for doctors to dismiss these symptoms or normalize them, because they are common. I’ve had patients even tell me their doctors just tell them that they need to “relax and have a glass of wine.” Here are some other common symptoms that occur with vaginismus:
- Burning or stinging with tightness during sex
- Difficult or impossible penetration, entry pain, uncomfortable insertion of penis
- Unconsummated marriage
- Ongoing sexual discomfort or pain following childbirth, yeast/urinary infections, STDs, IC, hysterectomy, cancer and surgeries, rape, menopause, or other issues
- Ongoing sexual pain of unknown origin, with no apparent cause
- Difficulty inserting tampons or undergoing a pelvic/gynecological exam
- Spasms in other body muscle groups (legs, lower back, etc.) and/or halted breathing during attempts at intercourse
- Avoidance of sex due to pain and/or failure
Vaginismus is a term that describes tightening of pelvic floor muscles but does not answer the question of why. Vaginismus.com has a great list of both physical and non-physical causes of vaginismus as well as a plethora of information describing what vaginismus is and resources for women who are experiencing this. Often I hear women say “I have a broken vagina,” “I can’t even think about dating,” “how will I be able to consummate a marriage?” Vaginismus does not only affect women who have never had sex, some women have had years of pain free sex but the pain or discomfort has become increasingly worse and no longer worth having – this is the difference between primary versus secondary vaginismus. If you are experiencing any of these symptoms you should seek help from an experienced pelvic floor physical therapist. The good news is, vaginismus is treatable and you can have sex again, without pain! Check out our website to find more information about pelvic floor physical therapy here.
Awhile back, Stephanie Prendergast and Elizabeth Akincilar (the co-founding physical therapists of the Pelvic Health and Rehabilitation Center), did a Q&A blog post about what a good pelvic pain PT evaluation should be like, you can read this post here. In today’s blog I will describe more specifically what an evaluation should include for this diagnosis, especially how a differential diagnosis is important to understand the underlying cause of symptoms because that will ultimately guide what all is involved in the treatment, including the providers you should be seeing in addition to a pelvic floor physical therapist. In these types of conditions it often takes a team of experienced providers to fully address what is going on as there may be both physical and non-physical causes of your symptoms.
The patient history is a crucial portion to figure out why this is happening and it may get a bit personal. For example, some questions that should be asked to help determine the underlying cause would include questions like:
- Have you ever been able to successfully use tampons?
- Have you ever been able to have a successful gynecological exam?
- Have you ever had sexual intercourse or penetration of any kind?
- Describe your pain and difficulty with intercourse, is there pain with initial penetration? Can penetration occur at all? Pain with thrusting?
- Have you had a history of abuse (sexual, emotional, physical) that you are aware of?
- Do you have a history of being on the pill or other forms of systemic birth control or any acne medications such as spironolactone or accutane?
- Have you had recurrent yeast infections or UTIs?
- Do you have a history of painful or difficult periods?
- Are you fearful of sex?
A good thorough history should also include other symptoms that are associated with pelvic floor disorders including bowel and bladder history, medications, and any surgical history or current medical conditions you have been diagnosed with, which may be included in your intake forms.
As stated in Stephanie and Liz’s blog we do both an external and internal examination; externally we are assessing the muscles that connect to the pelvic girdle trying to find any impairments that may be contributing to your symptoms as well as connective tissue restrictions or fascial restrictions. The abdomen is also a key area to assess as well as breathing which can be a useful tool to relax during intercourse as well as treatments.
The internal examination is a crucial part of any pelvic floor evaluation and it also gives us a lot of information about what could be causing or involved in your specific case. Some women are extremely cautious when it comes to this part of the examination because of their history of failed attempts at intercourse or medical procedures or history of abuse if that is present. It is common that women may be more anxious or are already anticipating the pain before anything has happened. In certain cases, it is helpful to delay the internal portion until a good relationship is established between patient and provider. I will talk later about treatment strategies that can be utilized to make treatment more successful in these cases.
With the internal exam these are what should be evaluated to help further identify potential causes for your pain.
- Appearance of vulvar tissues: clitoris size, labia majora/minora size and symmetry, and tissue color.
- Irritability of the vestibule (opening around the vagina and urethra) using a Q-tip aka a Q-tip test
- Palpation to the external vulvar tissues to look for provoked pain
- Internal palpation of the pelvic floor muscles to identify resting tone and muscle trigger points
- Motor control of the pelvic floor i.e. (can you contract, relax, and bulge (lengthen) your muscles)
Based on your history and your specific findings, we can determine the possible causes or cofactors for your symptoms and come up with a treatment plan that typically includes manual therapy for both external and internal muscle tightness and trigger point release, connective tissue manipulation, and breathing techniques to relax and calm the nervous system. Your home program will include exercises that further reduce muscle tightness such as foam rolling, stretching, as well as pelvic floor relaxation exercises that may include the use of dilators. The reason I say “may” use dilators is that if you have irritation to the vestibule also known as vestibulodynia, there are some things that should be addressed to heal the tissue irritation prior to use of dilators. Additionally, women should be taught how to use dilators properly by a pelvic health specialist as they can be frustrating for women with vaginismus if not shown how to properly use them, further feeling defeated. There are also many types of dilators and some work better for certain women than others.
Some helpful tips that I have learned to help the evaluation and treatment be more successful are the use of soothing music, aromatherapy, visualization and deep breathing. If you are feeling really anxious or not relaxed during your appointments, feel free to ask your therapist if they can provide you with some of these tools or ask if you can bring something in that will help you relax. Occasionally patients will also take medications that help them relax prior to treatment but this should be discussed with their current medical doctor, preferably a psychiatrist, if these are needed.
I wanted to discuss more specifically in this blog about the differential diagnosis as it seems vaginismus is being used as a more general term to categorize all women who have painful sex. There are three diagnoses I would like to review and briefly talk about the causes and typical treatments for each.
Vulvodynia is a term that has been under scrutiny and Stephanie recently wrote a very good blog post on the new terminology, the evaluation and the treatment process that you can read here. It is sort of an umbrella term similar to vaginismus that can be broken down into more identifiable causes. Essentially it is described as vulvar pain of at least three months’ duration, without a clear identifiable cause, which may have potential associated factors. The following are descriptors:
a. Localized (eg, vestibulodynia, clitorodynia) or generalized or mixed (localized and generalized)
b. Provoked (eg, insertional, contact) or spontaneous or mixed (provoked and spontaneous)
c. Onset (primary or secondary)
d. Temporal pattern (intermittent, persistent, constant, immediate, delayed)
Vestibulodynia is pain specifically located in the vestibule and is often called provoked vestibulodynia (PVD) and it can be primary or secondary. Typical causes of primary vestibulodynia include neuroproliferative and is present from the first attempt at putting anything into the vagina. Typical causes of secondary can be from long term birth control use (oral contraceptive pills, NuvaRing, depo-provera shot, the patch, and the implant) or history of acne treatments – Accutane or use of Spironolactone. Urologist and sexual medicine specialist Joshua Gonzalez, MD has written a two part blog on how birth control can affect the vulvar tissues called Jagged little Pill: How oral contraceptives wreak havoc on the female body Part 1 and Part 2. PVD can also be due to nerve hypersensitivity from recurrent UTIs or yeast infections.
This is an important diagnosis to make because in addition to the physical therapy, it will be beneficial to see a specialist to begin treatment to help improve the tissue health to desensitize it. I will often hold on the use of dilators until the tissue improves slightly so that it is less painful and therefore less traumatic and it allows for a more successful outcome. Women with vaginismus may also have vestibulodynia from the aforementioned reasons and if it goes untreated, you may find treatments that are therapeutic ineffective. The standard treatment is thought of as internal stretching of the pelvic muscles by a pelvic floor therapist and dilators, which for some women may be an appropriate course, but for others it may not be.
Vaginismus again is defined as involuntary contraction of the pelvic floor muscles in response to physical contact or pressure which would prevent sexual intercourse. However, it is not the only diagnosis that can prevent non-painful sexual intercourse. As I mentioned earlier in the blog, vaginismus can be caused by both physical and non-physical causes. Awhile back Malinda Marshall wrote another excellent blog post on vaginismus and the different types.
There is also a subset of patients that have been subjected to sexual, physical, or emotional abuse which can play a role in their ability to have non-painful penetrative intercourse. In these women, likely still have the physical cause (the tight muscles), but there is also a psychological component that needs to be addressed. A referral to a therapist would be helpful in addition to PT for these women. That being said, a referral can be indicated in women without abuse as well. As I said before, when you’ve had pain in such an intimate area and feel you cannot date, consummate a marriage, and are in pain, there can also be a psychological piece that can develop and it can also be helpful to talk with a therapist while going through physical therapy. We often work with sex therapists that specialize in treating conditions relating to sex, and can be a great resource for dealing with all the feelings that may come up during the physical treatment.
Other procedures and treatments that can be helpful in conjunction with physical therapy are botox, acupuncture, and dry needling. Botox will help temporarily release the muscle tension and may be a great adjunct therapy. Acupuncture and dry needling will help release any muscle trigger points that could be contributing and can also have a calming effect on the central nervous system to reduce anxiety, pain, or tension. When it comes time for your annual gynecologist appointment, ask for a pediatric speculum and ask if it would be okay if you helped insert it yourself.
Vaginismus should not define who you are, there is treatment available and there may be more going on than you may think. Make sure that you have been thoroughly evaluated and know that treatment is not the exact same for everyone and it may take a team of experienced providers to treat you, but that you can have pain-free sex! Check out our website at www.pelvicpainrehab.com for more information on pelvic health or to get more information about conditions we treat.
I asked a couple of my patient’s (anonymously of course, names are fictitious) to share some information for this blog post about their experience living with vaginismus and their process throughout the years seeking treatment. Both stories have different beginnings but in the end, they are both dealing with difficult or painful intercourse and have been determined to find help. I feel that many people reading this blog can somehow relate to these incredible women and I thank them for sharing their stories.
Can you tell me a little bit about your struggle with vaginismus prior to seeking out PT – doctor appointments, gynecological exams, intimacy with partners?
I was a bit of a late bloomer, and wasn’t sexually active until I was 25, which meant that my vaginismus went relatively undetected until that point. There were, however, signs that something was not quite right. My first pap smear was so incredibly painful that my eyes were watering and for each subsequent visit, I would sit in my car prior to feeling crippling anxiety. This was explained away as an issue due to me still being a virgin.
After I had sex for the first time, which was an incredibly painful process where I bled so heavily that I had to sit on the toilet for 30 minutes while we contemplated calling 911. Each time we had sex after, it was incredibly painful, which when I mentioned this to my gynecologist, she just suggested trying new positions. Sex became an incredibly stressful event, and this stress, while not the main factor, contributed to the breaking up of my relationship. After this break up, I finally convinced my gyno that something wasn’t right, and she performed a test for vaginismus, which she concluded that I had. She then prescribed a numbing crème and antidepressants to help manage the pain. I felt very uncomfortable with taking antidepressants, and decided to seek out a second opinion when I moved to Los Angeles.
After moving to LA, I met my current partner, who has been incredibly supportive and encouraging through this process. Telling him on our third date that I couldn’t have sex was extremely stressful on my end, I was sure he was going to end things like my last partner, but he surprised me by not only accepting it, but also encouraging me to put aside my fears and be proactive. I finally made an appointment with my current gynecologist. The night before, I cried myself to sleep because I was so worried about the appointment (I was due for a pap smear), but Dr. Kumetz was amazing and put all my fears to rest. She was also the first doctor who really listened to my concerns. She very quickly confirmed the diagnosis of vaginismus and recommended pelvic floor therapy. She also used a pediatric speculum for the exam, which lessened the pain. For PT she recommended PHRC, which has been life changing.
When you found PHRC, what was your experience on your first visit and throughout treatment – how has it helped you thus far?
Before my first visit, I sat in my car and cried. I was so nervous about the potential pain as well as any potential diagnosis. My first visit was nothing like what I had built up in my imagination. Jandra was incredibly knowledgeable and compassionate. It also was a relief to hear that other women suffered from the same thing I was going through, and that I wasn’t an anomaly. Over the last year, I have done consistent pelvic floor therapy, added in daily dilator work, and when it became apparent that it was needed, hormone therapy. Every step of the way Jandra has guided me through this process. What was once such a stressor is now just a part of my routine. I look forward to going to PT, and have enjoyed seeing the results.
When it became clear that my tissue health was also a problem, PHRC had connections to a very good urologist, Joshua Gonzalez. He specializes in sexual medicine for both males and females and his hormone treatment has produced great results when coupled with my physical therapy. As of a few months ago, my boyfriend and I have started adding in sexual penetration! It’s been a process, but one that has improved immensely. We’re now able to add in sex to our bedroom routine. While it’s not perfect, it’s not something that I’m afraid of anymore. I feel so much more secure, and have realized that I deserve to have good sex. Not sex where I try to just bear the pain for my partner’s benefit. As much as this has positively impacted my relationship, which it definitely helps to have such a supportive partner, this has been my journey to the realization that I deserve to have a healthy body that benefits my sexual needs. PHRC has provided not only bodily treatment, but it has also helped me break through my mental barriers.
What would you want to share with women that are struggling with this condition that may not know what is going on or are afraid of seeking out treatment?
You are not alone! This problem affects so many women, and you deserve to know that not only does it not define you, but it is treatable. If your doctor doesn’t listen to your concerns, then find a new doctor. Seek out experts. They have the answers that you might not even know you’ve been searching for. It may take time, but with the right treatment things do improve. The unknown is terrifying, and that first step is daunting, but you deserve to not live in pain and to actually have pleasure during sex.
Note: Noel is part of upcoming panel and Tightly Wound screening in LA on May19th, sharing her story. For more information and to register please click here.
Can you tell me a little bit about your struggles with vaginismus prior to seeking out PT-doctor appointments, genealogical exams, intimacy with partners?
I grew up in a very religious family where sex/women’s health was never discussed. I was even taken out of sexual education classes in middle school. My first visit to a gynecologist’s office was at 24. After many painful failed sex attempts with my first serious boyfriend, I figured it was time to see a specialist. However, I did not receive the help or answers I expected. Firstly, I had panic attacks and was unable to complete gynecological exams. When mentioning failed sexual attempts to the gynecologist, no deep insight was offered. My doctor just kept telling me “you’re just nervous. You’re overthinking it.” The other two doctors I went to see would make similar remarks like “have a cocktail” or “try to relax.” I had such deep frustration. How could I make them understand, that for me, attempting to have penetration was like hitting a brick wall? Nothing was going through. My boyfriend became extremely frustrated with me and the resentment became more and more visible. Eventually, he cheated on me with another girl. I was devastated and just completely unmotivated to date for quite a while.
When you found PHRC, what was your experience on your first visit and throughout treatment – how did it help you thus far?
It wasn’t the clinical, cold setting I pictured. I walked into my physical therapist’s office and saw colorful paintings and pretty plants. A diffuser was on that gave the room a very zen-like feeling. Jandra was very friendly and I felt like she just instantly understood me. We talked for a good 15 minutes before actually starting the first physical therapy session (which really helped break the ice and set expectations about the first session). During future sessions, she even put on calming music to help ease my anxiety (FYI the Buddha Bar Pandora station is amazing). The more Jandra got to know me throughout our sessions, the more she understood my fears and trigger areas and helped me learn how to navigate around them.
Another unexpected revelation about treatment: Jandra is not just my physical therapist. She has played the surprising role of my counselor and project manager for battling vaginismus. I was explained that vaginismus was very complex and had to be addressed through many different channels. I was connected to a therapist who specializes in working with women with vaginismus which helped me cope with the illness emotionally. Additionally, I was connected to an urologist who discovered some hormonal issues that accounted for some of my physical pain.
Flash forward to four months later, I now have a team of 4 doctors working together to help me fight vaginismus. I have made a lot of progress in physical therapy and am currently on a level 7 dilator (out of a scale 1- 8). I smile writing this because I honestly never thought I would get this far. Additionally, Jandra encouraged me to make some healthy changes to my lifestyle which have dramatically lowered my level of anxiety and helped me learn how to relax my muscles. I was advised to try meditation and any physical activity like dance or yoga. I eventually started listening to hypnosis recordings focused on relaxing my muscles/curing vaginismus. My muscles are now so much less tense during appointments. Included below is the link to the recording: https://www.hypnosisdownloads.com/sexual-problems/vaginismus-treatmen
What would you want to share with women that are struggling with this condition that may not know what is going on or are afraid of seeking treatment?
I would tell any woman not to delay her anxiety. I knew I needed help and couldn’t push myself to seek treatment for over two years. I didn’t think I could tolerate the discomfort involved in any session after so many traumatic and anxiety inducing gynecologist appointments. I ended up falling into a very deep and dark depression during my two years prior to getting treatment. There were some days I couldn’t get out of bed. I felt unmotivated to go on dates and I kept thinking…everything is hopeless. Eventually, I came to the realization that the only thing scarier than facing vaginismus treatment was not facing it. I couldn’t handle living with so much pain and sadness any longer.
When I finally walked into PHRC it was more of a relief than anything else. I had specialists to talk to who were not only empathetic and understood my condition, but had a game-plan for tackling it and all the right resources. My life has changed so drastically since starting treatment 4 months ago. It will sound crazy, but I view my life in two parts: before I started treatment for vaginismus and afterwards. The results are honestly that drastic. My mood is just so much better and I no longer suffer from depression. I am not constantly worrying about whether I will ever have a normal love/family life. I sleep with ease knowing I have a future ahead of me and that everything will be ok.