Vaginismus is a condition where the muscles around the entrance to the vagina tighten involuntarily, making penetration of any kind painfully uncomfortable or impossible, as the muscles form “a wall." This could occur during a gynecological exam, while inserting a tampon, or when attempting to have sex. Trying to insert something into the vagina of a woman with vaginismus will cause her to experience generalized muscle spasm, pain, and she may even stop breathing temporarily. Vaginismus most commonly affects the pubococcygeus muscle group that is responsible for a wide range of important bodily functions including intercourse, orgasm and childbirth, but also urination and bowel movements. The symptoms and their severity vary widely between women. While vaginismus, sometimes referred to by clinicians as “Genito-Pelvic Pain/Penetration Disorder” (GPPPD), can be distressing and incredibly frustrating, it is ultimately highly treatable.

There are several different types of vaginismus that can affect women at all stages of life, even those who have enjoyed many years of pain-free intercourse.

Primary vaginismus
Primary vaginismus, also called lifelong vaginismus, happens when a woman has had pain every time anything entered or tried to enter her vagina.

Secondary vaginismus
Also known as acquired vaginismus, this is when a woman has had sex before without pain, but it has now become difficult or impossible.

Situational Vaginismus
This is when symptoms occur only under certain conditions, for instance during sex but not when she attempts to insert a tampon or speculum.

Symptoms
Painful sex that may or may not end after withdrawal of the penis or toy is often the first sign of vaginismus. Some women may continue to experience burning after removal of the item, and they may acquire a fear of pain or sex that leads them to avoid sexual activity. It is important to understand that these symptoms are involuntary, meaning a woman cannot control them without treatment. It is not anyone’s fault and is not something that should cause embarrassment. Note that “dyspareunia” is the medical term for painful intercourse and while some many confuse it with vaginismus, they are not the same. Painful sex could be due to other issues such as pelvic inflammatory disease, cysts, or vaginal atrophy .

What causes vaginismus?
Vaginismus can be caused by physical or emotional stressors – or both. It can also occur when a woman expects fears pain will happen, creating a negative feedback loop where anticipation can actually bring on the pain. In fact, when intercourse become painful or impossible, additional attempts at sex can reinforce the muscular response, making it more ingrained in mind and body.

Physical triggers
These may include medical conditions such as a yeast or urinary tract infection, or other conditions such as endometriosis or treatment for cancer. It can also be a result of physical trauma such as childbirth or pelvic surgery. Some women may also encounter this as a side effect of medication. Inadequate foreplay or insufficient vaginal lubrication (as may occur in perimenopause or menopause) can also trigger vaginismus.

Emotional triggers
Like physical symptoms, emotional triggers for vaginismus are complex and can be wide ranging. They may include anxiety (around performance or otherwise), relationship problems, fear, traumatic life events such as rape or sexual abuse, or childhood experiences like attitudes towards sex (such as in families or cultures with strong religious beliefs).

Diagnosis
You should have a frank discussion with your health care provider about vaginal pain and your medical and sexual history, including when you first experienced symptoms and what seems to trigger it. You can – and should! – ask them why you are experiencing pain with penetration and what kind of treatments might work for you. They may need to do a pelvic exam – slowly and gently! - to look for other health conditions that could be causing pain. If you can’t tolerate the exam, you may need some treatment before it can occur.

Treatment
Treatment for vaginismus varies depending on the cause, but it may begin with pelvic floor exercises (you may know these as Kegel exercises) to improve muscle control. However, it’s important to be seen before doing these and assuming Kegel’s will fix everything. Sometimes these kinds of exercises can actually make things worse because what you need is more muscle relaxation, not strengthening. A pelvic floor physical therapist can help guide you in this kind of treatment, and your healthcare provider can help connect you with one in your area

You can also practice reducing sensitivity to insertion by touching as close to the vaginal area as possible every day without causing pain, moving closer each day. Once comfortable with this, you can start by inserting one finger into the vagina, about up to the first knuckle joint. After a while, you may work your way up to two or even three fingers You’ll want to make yourself comfortable for this practice, clipping your fingernails and using a lubricant, or trying it in the bath using water as lubrication. You may want to use an app to use deep breathing or other relaxation methods before/during this practice.

Once you can do this without pain and are ready to take the next step, you can try dilation and insertion training using a vaginal dilator or a cone-shaped insert. If putting this in doesn’t cause pain, you can leave it in for 10 to 15 minutes, letting the muscles get used to the pressure. You may want to start this with a smaller size dilator and progress to a larger one as you grow more comfortable. Again, pelvic floor physical therapists are trained in this area and can help you select and coach your initial use with dilators. From here, you can bring in your partner and teach them how to use it before bringing a penis into the mix. You may want to spend some time getting comfortable with a penis or any toys before attempting intercourse again.

Counseling or sex therapy may be useful by providing information about your sexual response cycle and what your body is going through. It can also help bring a partner in to the discussion if appropriate, as they may also be experiencing issues as a result of the vaginismus. Sex therapists may also be able to help you find different sexual positions that are more comfortable. Cognitive behavioral therapy, an effective treatment for anxiety, depression and post-traumatic stress disorder can also help you understand how your thoughts affect your emotions and behaviors.

Hypnotherapy or anti-anxiety medication may sometimes be used to lessen anxiety related to penetration.

Physical therapy and biofeedback can help lessen pelvic floor tension.

If these fail to provide needed relief, your health care provider may suggest other more medical solutions, including intravaginal injection of Botox and progressive dilation under anesthesia, which has been shown to be effective. Topical lidocaine or compounded creams may also be prescribed to help with pain (and may also be available over the counter). In very severe cases of vaginismus, surgery to remove a small area of the most sensitive eperineal mucosa (vestibulectomy) may be indicated, but that is a surgery requiring an extended healing period and can leave scar tissue.

Of course, penetrative sex is only one way to achieve sexual satisfaction, so if you or your partner suffer from vaginismus, there may still many ways you can enjoy each other sexually and achieve orgasm including oral sex, massage, or (mutual) masturbation.

Knowing there are options can be liberating, but it may take time to reach your treatment goals. You will likely want or need to use several of these treatments together to find something that works for you. Open communication with your partner, if you have one, and your health care professionals are critical to success. With time and attention, it is possible for women with vaginismus to overcome the obstacles they face and to have a happy and fulfilling sex life.

Reviewed by Body Board Member, Dr. Jennifer Lincoln, OB Hospitalist and author of Let’s Talk About Down There

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