Vaginismus

Vaginismus is a condition where there is involuntary tightness of the vagina during attempted intercourse. The tightness is actually caused by involuntary contractions of the pelvic floor muscles surrounding the vagina. The woman does not directly control or ‘will’ the tightness to occur; it is an involuntary pelvic response. She may not even have any awareness that the muscle response is causing the tightness or penetration problem.

In some cases, vaginismus tightness may begin to cause burning, pain, or stinging during intercourse. In other cases, penetration may be difficult or completely impossible. Vaginismus is the main cause of unconsummated relationships. The tightness can be so restrictive that the opening to the vagina is ‘closed off’ altogether and the man is unable to insert his penis. The pain of vaginismus ends when the sexual attempt stops, and usually intercourse must be halted due to pain or discomfort.

In its mildest form, a woman can get a penis into the vagina for very short periods, but it’s unpleasant and painful. Or it can be so severe that she can’t even touch herself near her vagina, can’t have a gynecological exam and can’t insert a tampon because the pain is so severe and the fear so great.

Women with severe vaginismus will often describe the feeling as the penis “hitting a wall” when they attempt intercourse. Vaginismus can be devastating and debilitating, not because the absence of intercourse means the patient can’t have a satisfying sex life, but because women with vaginismus start to think there is something crazy or abnormal about them.

Because of the pain, there is nearly always fear associated with penetration. Sometimes this can be a more significant factor than even the tight muscles. You can say that vaginismus lives on a double continuum of tight muscles and fear, (think of an x axis and a y axis). So some patient’s muscles aren’t that tight but they have overwhelming fear and some patient have little fear but extremely tight muscles. Some patients have both.  Usually the patient who are on the inside groupings can be helped with an appropriate combination of therapy and dilation work.  But the ones on the outer margins often can’t and those are the patients for whom Botox is tremendously helpful.

Sometimes, women with vaginismus believe that if people knew the “truth” about them they would think they were aberrant. Often they find many excuses as to why they haven’t dealt with the problem in the past or why they cannot begin to explore solutions now. They often begin to avoid every type of sex or sexual encounter.

Vaginismus’ diagnosis is made based on a patient’s history, symptoms and physical exam findings. Commonly reported history and symptoms by patients with vaginismus include:

• Difficult penetration or impossible intercourse / unconsummated couples
• Avoidance of sex due to pain and/or failure
• Inability to insert tampons
• Avoidance of gynecological exams
• Anxiety and fear about vaginal penetration
• Ongoing sexual pain after a pelvic problem, medical issue, child birth or surgery

The physical exam to diagnosis vaginismus begins with a pelvic exam to review the patient’s genital anatomy using a mirror. This can be a challenge for some women with vaginismus, as just looking at their anatomy can be too overwhelming. However, viewing anatomy with the patient gives us a great opportunity for education, as well as an opportunity for patients to ask questions.

Next, a Q-tip test is then performed to see if there is pain in the area of the vestibule to help rule out vestibulodynia. A wet Q-tip is pressed against the vestibule at the 2, 4, 6, 8, and 10 o’clock positions to determine if there is pain. In cases in which the Q-tip test is negative, vestibulodynia is ruled out.

After the Q-tip test, an examination of the internal vaginal muscles is attempted. The practitioner will insert one or two fingers into the vagina to palpate the internal vaginal muscles to feel for tension. It is through this exam the practitioner can classify the severity of vaginismus using the Lamont Scale. There are four degrees of vaginismus:

First degree: perineal and levator spasm-relieved with reassurance, able to tolerate gynecological exam

Second degree: perineal spasm-maintained throughout pelvic exam, unable to relax for a gynecological exam

Third degree: levator spasm and elevation of buttocks to avoid being examined

Fourth degree: levator and perineal spasm, elevation of buttocks; adduction of thighs and retreats to the back of the table, unable to tolerate gynecological exam

For some women, a pelvic exam, or examination of the vaginal muscles is just not possible, and that’s ok. We can often diagnose and begin treatment, even if the examination is not completed.

The causes for vaginismus differ between primary and secondary vaginismus. In the case of primary vaginismus, the cause lives on a spectrum of fear and tight muscles.

Primary vaginismus refers to when a patient has had life-long painful penetration. These women will often have painful first tampon insertion, painful gynecological exams and often they are unable to have intercourse. The involuntary spasms of the vaginal muscles are the physical reason why these women have this condition. The “cause” for the involuntary muscle spasm is still unknown, however, anxiety, strict sexual upbringing, strong family religious overtones, fears of first-time sex, exposure to sexually transmitted diseases and pregnancy have been linked to primary vaginismus.

The “fear factor” is triggered when a patient realizes (consciously or unconsciously) that there is pain when anything (finger, tampon, penis) anything attempts to insert into the vagina. This pain then causes more anxiety and triggers additional tightening of the muscles, which in turn creates more pain. The patient then has entered into a cycle of fear and pain which feeds on itself.

Secondary vaginismus refers to a patient who once had pain free vaginal penetration, but develops painful penetration at some time. It can be triggered by medical conditions, traumatic events, relationship issues, surgery, child birth, or menopause. Generally, secondary vaginismus does not have a fear component to it.

Vaginismus is not triggered deliberately or intentionally by women. It happens involuntarily without their intentional control and often without any awareness on their part. Vaginismus has a variety of causes, often in response to a combination of physical or emotional factors. The mystery of the problem can be very frustrating and distressing for both women and their partners.

Vaginismus can be confused with vulvodynia or vestibulodynia. The fear and anxiety component of vaginismus can cause women to confuse the penetration fear with pain. Careful history and physical exam is important in distinguishing vaginismus from vulvodynia and vestibulodynia.

The goal of treatment for vaginismus is to eliminate painful sex.

Treatment usually involves the use of vaginal dilators to relax and stretch or re-stretch the vaginal muscles. The goal with dilation is to retrain the tight vaginal muscle to respond differently to the anticipation of penetration. Slow, systematic, progressive dilation, will help connect the body and mind, to take conscious control of the vaginal muscles, so involuntary tightness no longer occurs.

Additional treatment may involve increasing lubrication through topical creams, using hormone therapy, muscle relaxant suppositories and pelvic floor physical therapy. There are times when anti-anxiety medication is introduced to aid in the treatment.

For cases of vaginismus where a patient is unsuccessful after treatment with dilators and coaching, and in cases where a patient is extremely fearful of standard treatment, we use the vaginismus treatment under anesthesia, a procedure with a very high success rate, pioneered by Peter Pacik, MD. Contact us for a free phone consultation to learn more. While the  treatment is a more involved procedure, resolution is fast and permanent.

Lastly, it always makes sense to explore any psychological factors that may be contributing to the condition.

Here are some things we’ve learned from our patients over the years:

As you overcome the vaginismus, learning to control the muscle spasms, manage the pain, you start to let go of some of the fear and terror of the pain. As you start to accept that your body is normal, you might start feeling angry because:

• You can’t believe people are making you change. On some level facing this issue was a decision you made, but sometimes you might feel like “Damn it, I was fine the way I was before.” I don’t want to have to be like everyone else! I don’t want to change the way I am in order to have a relationship. I was fine, fine, fine and I don’t want to give up who I am!”
• You might feel scared that now you will be expected to do something you haven’t done before. For example, if you’ve been avoiding dating because of your vaginismus, you might now feel like suddenly your last excuse to yourself is gone and now what? Now you have to start dating. If you are in a relationship you might feel pressured to have intercourse now that you “can,” and you don’t feel ready.
• You might feel furious at yourself for waiting so long to get treatment, especially if it feels as though the treatment was less traumatic than you expected and less work.
• You might feel angry that treatment is taking so long and is so much work. First of all, have some patience with yourself. Changing your vagina is a big deal. You are not crazy. Try to get a handle on what is going on with yourself, and accept that the road might be a bit bumpy.

Now, here are some things to think about. Focus on the ones that resonate with you. Everyone is different and the things that bother (or help) one person might well not bother (or help) you. So think about which of these ideas might make you feel better:

• You don’t have to change one little thing about the rest of your life just because you can. Fixing the vaginismus does not mean you have to start dating, get into a relationship or start having intercourse. It means you CAN change those things if you want to, and if you do decide that those are things you want, you can make a decision, either by yourself or with the help of a therapist to change those things. One is not necessarily a byproduct of the other and you are, in the end, the only one who really has control over those secondary changes.
• See if the anger is really turned inward and try to take the time to see what exactly you’re blaming yourself for. You didn’t ask for things to be this way and you couldn’t really control the outcome. Vaginismus is not something we “make happen to our bodies” or that we are responsible for creating. It’s not our fault.
• If you’re angry at how long it took for you to seek help, yes, maybe you could have gone for help sooner but let’s be honest, finding help for this kind of problem is complicated and scary. It’s not so straightforward. As much as possible, you should give yourself credit for having gotten help now. So if you’re blaming yourself for having waited this long, letting the problem overtake your life or ignoring it, realize that’s a fairly normal response and try to appreciate where you are now rather than what’s behind you.
• Try to share your fears and concerns and anger with your health practitioner. We can handle it. And it’s much, much easier for us to help you if you’re honest with how you’re feeling, even if what you’re feeling is anger at how long the whole damn process is taking!

If you don’t live in the NY, NJ, CT area, please don’t despair. We treat dozens of women who suffer from vaginismus, but live far away. Learn more about our vaginismus treatment options for out-of-town patients.

My experience at Maze was amazing and life changing.  Helen and Alla were excellent from the start. They exuded confidence in the process and in me. They made me believe I wasn’t broken and that treatment was manageable.  They explained everything simply and direct.  It was clear what I had to do and it was a team effort.  If I put in the work, they would be able to get me to the right outcome.

The office was warm and inviting and everyone there, including reception, made me feel comfortable.

I had tried multiple vaginal remedies with my gynecologist over the years and nothing worked!  In less than 8 weeks I was able to have vaginal intercourse again, comfortable with zero pain.

I have already shared my experience and I recommended Maze to many. 

It’s amazing to me how much women’s health is not researched or known even by gynecologists!  Maze is a blessing to all women!

–C, 49

Four years ago, I was married and began my sexual life. That’s when my problem started. Every time we tried having intercourse, it didn’t work out. I couldn’t even insert my finger or a tampon into my vagina.

I went to see a hypnotist, a physical therapist and had a special massage, but nothing helped. Everyone told me that the problem was all in my head! Then I heard about Maze Women’s Sexual Health. I called them right away but didn’t make an appointment. I was so afraid that like the previous services I tried, they would not be able to help me. A few months later, I decided enough was enough and called to schedule an appointment.

My husband came with me to the first appointment because I was so nervous and embarrassed by my problem. I thought that I was the only one with such an issue but then I found out that a lot of women experience this.

At Maze Women’s Sexual Health, they explained to me what my problem was and discussed treatment. I started using a small dilator and was surprised that I could actually insert it into my vagina! I continued the exercises every night, going from size extra small to large plus. After 2 months, I was ready for intercourse. I was crying because I couldn’t believe it was finally going to happening.

Maze changed our lives. My husband and I are much closer now. I want to thank Melissa and Rachel for everything they have done for us. And if you have the same problem, please don’t wait, schedule an appointment. This place is amazing!

– I, Age 21

I am a former Maze (nyc office) patient. Your practice changed my life and I will be eternally grateful. Ten years ago I came to you scared and ashamed with a severe case of vaginismus. The vaginismus treatment under anesthesia and dilation was a lifesaver. You and your staff are quite literally the reason that my two precious little boys exist today. Without the treatment I would most likely still be single, childless and hopelessly unable to do anything about it. Instead, I’m a happy wife, mother, woman! Thank you, thank you, a million times thank you! You do amazing work!!

– H, 41 –