Vaginismus Overview

Do you dread going to the gynecologist because of traumatic pap smears? Does painful sex prevent you from achieving healthy intimacy with your partner? Do you find it impossible to insert a tampon? Or maybe you’ve been told you have an “overactive” or “tight” pelvic floor.

If any of this resonates, you may be suffering from a condition called vaginismus, and you are not alone.

Vaginismus is a common condition and can affect women of all ages, including trans women if a vagina is constructed during gender-affirming surgery¹. Recent data suggests up to 17% of those with a vagina are affected, but that number is thought to be underestimated, as many women do not seek help for the condition due to shame or embarrassment².

So, what is vaginismus exactly?

Vaginismus (vaj-uh-niz-muhs) is a genito-pelvic pain penetration disorder that may cause painful vaginal penetration. It is thought to be caused by involuntary contraction of the pelvic floor muscles.

If you are suffering from vaginismus, you might hear clinicians or physical therapists describe your pelvic floor as “hypertonic” — that’s just a fancy word for saying tightly contracted. It means your pelvic floor muscles have a difficult time relaxing.

Dyspareunia is an umbrella term used to describe “painful sex.” Vaginismus is often associated with painful intercourse, but it can cause pain or discomfort with any type of vaginal penetration, such as with a finger, speculum, or tampon. Dyspareunia can also occur due to a variety of other reasons, often without vaginismus.

Similarly, vulvodynia (or vestibulodynia) is often lumped together with vaginismus but these words refer to a complex pain syndrome associated exclusively with the vulva, whereas vaginismus is not limited to the vulvar area.

Before we talk about anything else, let’s go back to the basics.

Symptoms:

What does vaginismus feel like? The exact symptoms of vaginismus vary from person to person. Many describe the sensation of hitting a “wall” when trying to insert anything into the vagina. Others describe burning, stinging or tightening of the vagina, and for many, this manifests as sharp and debilitating pain. These symptoms can cause considerable distress, fear, and difficulty with vaginal penetration.

Although vaginismus is often discovered when attempting penetrative intercourse, painful sex is not a necessary symptom. Individuals suffering from vaginismus often have difficulty using vibrators or self-stimulation during masturbation; struggle with inserting a tampon for menstrual flow; or resist going to the gynecologist because of painful speculum exams.

For years, vaginismus was considered a purely psychological condition or not considered at all. Women suffering from painful intercourse were often told it was “in their head” and rarely examined for an underlying cause.  Historically, the diagnostic criteria for vaginismus in the Diagnostic and Statistical Manual of Mental Disorders (DSM) required the presence of muscular spasm to qualify as vaginismus.

However, new data suggests that this spasm-based definition of vaginismus might not capture the diversity of vaginismus symptoms. Therefore, the updated DSM 5 has removed “vaginismus” from its handbook and replaced it with a broader spectrum of conditions termed “genito-pelvic pain/penetration disorders” (GPPPD). This spectrum-based approach emphasizes that there are varying degrees of pain, fear, muscle contraction, and penetration difficulties when it comes to vaginismus-related conditions.

We know this is complicated, but we want to make something clear: whether you call it vaginismus or GPPPD or pelvic floor tightness, these symptoms are not in your head.

If you think you may be affected by vaginismus, or any form of genito-pelvic pain, we recommend discussing your symptoms with your provider to ensure adequate care.

Diagnosis:

Although many women self-diagnose, it may be helpful to confirm the diagnosis with a medical provider, especially to rule out any underlying medical or mental health issues. Unfortunately, there is no definitive test for vaginismus. Rather, providers make the diagnosis from patient history and physical exam and can rule out other underlying gynecological conditions.

Vaginismus does not alter the appearance or anatomy of your vagina. In other words, it is not possible to diagnose vaginismus simply by looking at a patient’s genitalia.

Therefore, after taking your history, your provider will typically perform an external exam to inspect the area just outside the vagina (clitoris, vaginal opening, labia, and urinary outlet). This entails a visual inspection, looking for any unusual redness, irritation, growth, or discoloration. The provider will also palpate (touch) the area to see if you have any pain or discomfort in a certain area. Be sure to communicate with your provider during the exam and let them know if anything they touch causes you discomfort. [KC1]

Next, you provider will most likely recommend a speculum exam so that they can see your cervix and vaginal tissues. They may use a cotton swab to collect a small sample of the fluid in the vagina to see if there are any signs of an infection. They may also recommend taking a sample of cells from the cervix for a pap test, which is a screening tool for cervical cancer. If you are not able to tolerate having a speculum placed into your vagina, the provider may suggest a gentle manual exam where they would insert a finger to see how tight your vaginal muscles are which, will help them with their diagnosis. During these exams, be sure to communicate with your provider letting them know if anything they touch is particularly uncomfortable or painful. You may ask them to talk through what they are doing and see if that helps you feel more comfortable.

While attempting the internal exam your provider may also grade the severity of your condition by using the Lamont Scale. The Lamont Scale classifies vaginismus as first, second, third, fourth, and fifth degree, from least to most severe. To do so, the provider will attempt to insert a speculum into your vagina and categorize the severity of your response according to this scale.

Additional testing, such as with a transvaginal ultrasound, are typically not warranted unless an underlying gynecological condition, such as fibroids or endometriosis, is suspected.

We understand that gynecological exams can be distressing and uncomfortable, especially for those with vaginismus.. It is important to express these concerns with your provider so they can approach your exam in a trauma-informed manner.

Types of Vaginismus:

Vaginismus is classified into two main types: primary and secondary. Primary vaginismus is when vaginal penetration has never been achieved, while secondary vaginismus is when vaginal penetration was once achieved but is now difficult or no longer possible. Secondary vaginismus can be caused by a variety of triggers, including childbirth, gynecological surgery, menopause, yeast infections, hormone changes, or a traumatic event or abuse. See below for a more complete list of conditions that may lead to vaginismus.

Vaginismus can also be further classified into global vs situational. Global vaginismus refers to women who experience symptoms during any and all types of vaginal penetration while situational vaginismus refers to those who only experience symptoms with a certain type of penetration, such as only with tampons, or only in a specific context.

Causes:

So what causes vaginismus? Unfortunately, finding a specific reason the vaginal muscles tighten involuntarily is not always an easy task. However, some known risk factors for developing vaginismus are:

• A history of a traumatic experiences with vaginal penetration
• Mental health conditions such as depression, PTSD, or anxiety
• Rape, sexual abuse or physical trauma
• Injury during childbirth, including vaginal tears
• Menopause or hormonal changes
• Medical conditions such as recurrent yeast infections, UTIs, chronic pain syndromes, lichen sclerosus, cancer, or endometriosis
• Prior pelvic surgery
• Any experience of pain with sex may cause the pelvic muscles to tighten when vaginal penetration is attempted again

Quality of life:

Vaginismus can have a negative impact on your sex life, relationships, and self-esteem, resulting in increased anxiety and depression. It can also prevent women from seeking adequate gynecological care because of fear of pelvic exams. This means that women suffering from vaginismus may be less likely to be screened for cervical cancer and sexually transmitted infections (STIs).

Urinary Tract Infections (UTIs) and yeast infections, which can predispose women to developing vaginismus, can also worsen vaginismus symptoms.

Lastly, if you have vaginismus and are trying to become pregnant, you may have a more challenging time conceiving and confront unique obstacles³ during the prenatal and child birthing process.

Notably, women who have vaginismus are more likely to have a cesarean section when giving birth4. We encourage you to discuss this with your obstetrician to ensure you are adequately prepared for the birthing process.

Management and treatment:

So, you have vaginismus. Now what?

First, take a moment to recognize that you are part of a community of women. Beyond Milli, there are a growing number of resources aimed at connecting individuals who suffer from vaginismus.

Second, management of vaginismus is tailored to YOU. A big part of learning to overcome the symptoms of vaginismus is getting to know your body and what it needs. If you are someone whose symptoms are mostly spastic, pelvic floor relaxation might be what you need. If you are a survivor of sexual trauma and have an overwhelming fear of sex, you might benefit from desensitization therapy through dilator use coupled with regular talk therapy. Below is a list of the most common approaches to treating vaginismus. See which one or ones might be right for you.

Pelvic floor therapy:

Initial treatment for vaginismus usually begins with techniques to relax your pelvic floor. This involves exercises and breathing techniques that train your pelvic muscles to consciously relax, reducing painful spasms. Most of these exercises can be done in the comfort of your home; however, specially trained physical therapists can help ensure that you are performing the exercises correctly and often accelerate the process.

Therapy:

Treatment for vaginismus often includes different forms of therapy such as sex therapy, cognitive behavioral therapy (CBT), and couple’s therapy.

In sex therapy (or psychosexual therapy), you work with therapists (often called “sex therapists”) to help you address sexual problems. You might learn about sensate focus5, a stepwise approach to non-penetration intimacy with a partner or develop strategies to talk to your partner about your symptoms.

CBT is a form of talk therapy that focuses on breaking thought patterns that cause distress. Although each modality is unique, the goal of therapy is the same: to reduce anxiety and fear and improve your confidence, intimacy and sexual health.

Dilators:

Another common approach to treating vaginismus is desensitization through vaginal dilators. Click here for a more extensive discussion on dilators. Just as there is not a one-size fits all solution to treating vaginismus, there is also no one-size fits all dilator. That’s why we’ve developed Milli, a unique vaginal dilator tailored to fit your unique vaginismus needs.

The goal of any dilator is to slowly desensitize your body to increasing degrees of vaginal penetration. Similar to other forms of exposure therapy, dilators help reduce the fear and anxiety associated with vaginal penetration, which can in turn help your pelvic muscles relax and break the cycle of pain.

Botox: 

Botox is an emerging treatment for vaginismus, especially for those unable to tolerate dilator therapy. It involves injecting Botox intravaginally under local or general anesthesia to reduce muscle spasms.

 

The Multimodal approach: 

It is important to remember that vaginismus is a psycho-sexual-physical condition. As a result, the best approaches include multiple modalities and techniques. Clinical studies showing the highest treatment success rates employ multiple therapies rather than one alone. We encourage you to talk to your provider about what strategies might work best for you.

Does vaginismus last forever? 

Can I be cured? Does vaginismus go away? How long will it take to reduce the pain? These are all commonly asked questions by individuals suffering from vaginismus.

Fortunately, vaginismus is a treatable condition. With the right combination of education, counseling, and management, most women are able to break the cycle of pain. That’s why it’s so important to be your own best health advocate and get the help you need.

Clinical studies have shown that the symptoms of vaginismus can be fully resolved, regardless of severity or cause. Our friends at Hope & Her have listed a number of studies⁶ that demonstrate nearly 100% success rate after various treatment strategies. Indeed, individuals who suffer from vaginismus can achieve comfortable vaginal penetration after sufficient treatment.

So how long will it take? That part depends on several factors. One clinical trial published in 2017 found that 71% of participants were able to achieve pain-free intercourse within an average of 5.1 weeks following a multimodal treatment approach including Botox, vaginal dilator therapy, and group therapy⁷. Of course, that is a fairly intensive treatment plan that might not be possible for all women. Rather than focusing on how long it may take, focus on what you can start doing today to take control of your sexual health.

The bottom line is that vaginismus is treatable, and with the right support and strategy, you can overcome this vicious cycle of fear and pain. We know how frustrating it can be. We know how lonely it can feel. But we are here to say that you, too, can achieve physical intimacy without pain. And by shedding the shame of these far too common symptoms, we can form a community of women who no longer have to suffer alone. It’s time to put the US back in vaginismus.