Vaginismus is a mind-body response to the fear of vaginal penetration - the vaginal muscles tighten involuntarily, making penetration impossible or very painful. We find out what it's like to live with the condition and how best to treat vaginismus and hypertonic (overactive) pelvic floor muscles.
Rather than being a precise diagnosis, vaginismus is now more often referred to as a clinical syndrome that includes converging issues - pain, anxiety, hypertonic pelvic floor muscles and problems achieving penetration.
For some women with vaginismus, the debilitating symptoms have been ever-present - from puberty and attempted use of tampons to painful first experiences of sex. Known as primary vaginismus, this is the condition that is often the focus of medical and media articles.
Vaginismus can, however, also occur after vaginal function has been normal for many years (secondary vaginismus). It can be total or partial - the latter refers to some penetration being possible, but often with accompanying pain. Vaginismus can also occur intermittently - in certain contexts and circumstances only.
Sam Evans had secondary vaginismus for many years and still has episodes from time to time. She says the condition was triggered initially by using an intimate lubricant containing additives that contributed to recurrent bouts of bacterial vaginosis, thrush and urinary tract infections.
"Every time we used this lubricant during sex I would get irritation or an infection and that made me start to view sex and my vagina in a negative way," she says. "I still wanted to have sex and I tried to relax, but my vaginal muscles were so tight that penetration was either impossible or really painful. On some level, I was worried about getting another infection and over time those worries had become a body response that I couldn't consciously control."
Evans saw her GP who diagnosed vaginismus and suggested a psychosexual approach to reduce stress. It was only when she removed the initial trigger for the vaginismus that she started to recover, explains Evans.
"It was using a lube that didn't irritate that made the difference because then I stopped getting infections and eventually my body got the message that I didn't have to clamp up and protect myself from sex anymore. Also, realising we could still enjoy ourselves through mutual masturbation took the pressure off having penetrative sex every time."
Vaginismus or an overactive pelvic floor?
Increasingly, women with symptoms of vulval and vaginal pain are presenting with a hypertonic (overactive) pelvic floor, which may trigger pain further up in the vagina, the bladder and related areas (whereas vaginismus refers only to the muscles at the bottom third of the vagina).
Helen Forth is a specialist pelvic and women's health physiotherapist with 20 years' experience treating vulval pain issues and hypertonic pelvic floor muscles. She explains the important overlap between these conditions:
"Vaginismus is the spasm of the muscles at the entrance of the vagina. Often women will describe the sensation of a physical block when they try to insert something. That's different to overactive pelvic floor muscles that may be in a constant, chronic state of increased tension a lot of the time, which does seem to be the case for some women."
In a hypertonic pelvic floor, the muscles are working harder than they need to be, which means they gradually shorten and become stiff and tight. Forth says this reduces blood flow and sensitises the nerves in the area. The muscle then becomes tense and painful, described as tension myalgia.
"Sometimes the pelvic floor will go on to develop painful 'trigger points' which are areas of tension within the muscle, that are painful when pressed," adds Forth. "There is some debate as to what trigger points actually are, but in clinical practice we certainly see the benefit of performing myofascial release within the pelvic floor. For some women that can be quite a useful focus from a treatment point of view."
A woman, and in some cases her partner, can be shown how to find this muscle tension - in the vagina, for example - and learn how to apply gentle pressure to reduce tension and pain in the muscles. This needs to be done at a level that the body does not perceive as a threat, in order to break the cycle.
Cause and effect
"In the same way that some people will hold all their tension in their neck or shoulders, and go on to develop headaches as part of that, there's a very similar phenomenon in the pelvis," continues Forth.
"Overactivity of the pelvic floor muscles can occur gradually, or as the result of a trigger within the body - possibly an infection, or something that may have caused discomfort in the genital area."
Other possible triggers for vaginismus include:
- A traumatic gynaecological examination.
- Sexual abuse or an episode of painful sex.
- A belief that sex is shameful and unpleasant.
A complex interplay may then begin between mind and body.
"A woman then holds tension in her pelvic floor in response to that trigger, trying almost to pull up and away from the discomfort," Forth adds. "The muscles go into a protective guarding mode, in response to the perceived threat. Sometimes a woman might desperately want to have sex, but her muscles will respond in an involuntary way that makes penetration impossible or very painful."
Treatment - a combined approach
Forth often sees patients with secondary vaginismus who have also been diagnosed with vulvodynia and vulval pain syndromes. "There can be more than one thing going on - potentially a wider pelvic dysfunction alongside psychosexual issues and neuropathic pain, so it is important to take a multidisciplinary approach to treatment for the best results."
Research published in the Journal of Sexual Medicine in 2018, indicated that 'women with vaginismus benefit from a range of treatments in almost 80% of cases'. NHS guidelines for treatment focus on the use of graded vaginal dilators and desensitisation, psychosexual counselling, relaxation techniques and sensate focus.
"What you're wanting to do is chalk up positive experiences when something is inserted into the vagina so that the brain stops anticipating that insertion relates to pain," says Forth. "Always use dilators within your comfort zone and increase your tolerance slowly: the same goes with any myofascial release of the pelvic floor muscles. This is only something you should do when you've had some guidance from a specialist pelvic health physiotherapist. Using specific breathing techniques and yoga positions are a vital part of treatment too, as they encourage relaxation and lengthening of the pelvic floor. Combining all this with psychosexual counselling (if indicated) will really help."
Where to seek help
If you think you may have vaginismus or a hypertonic pelvic floor, visit your GP or local sexual health clinic in the first instance to rule out any underlying infection or other cause of your symptoms. You may be referred to a gynaecologist or vulval pain clinic and can ask to be assessed by a specialist pelvic health physiotherapist. Some vulval pain clinics will offer this service on the NHS, or you can seek a private consultation via Pelvic, Obstetric and Gynaecological Physiotherapy or Squeezy directories.