Recently I had a question from a MissE26. She was a 26 year old woman who related that, after three years of marriage to a man she deeply loved, they were still unable to have intercourse. Another 20 year old, Kate987, wrote about having increasingly severe painful penetration since first sex with her husband at age 16. Both described “this giant problem that is ruining everything.” Both women had been given the diagnosis of vaginismus.
What Is Vaginismus?
Most simply described, “Vaginismus is an involuntary spasm of the muscles surrounding the vagina. The spasms close the vagina” (National Institutes of Health, 2010). Such spasms can make it difficult or impossible to insert a finger, tampon, yeast cream applicator, penis — or to do a GYN pelvic exam.
There are six different classification systems used world wide to identify sexual medicine conditions. Vaginismus is described in each. I personally prefer this version (Basson, 2004):
The persistent or recurrent difficulties of the woman to allow vaginal entry of a penis, a finger, and/or any object, despite the woman’s expressed wish to do so. There is often (phobic) avoidance, involuntary pelvic muscle contraction, and anticipation/fear/experience of pain. Structural or other physical abnormalities must be ruled out/addressed.
It seems essential that easily identified physical obstructions to penetration be evaluated (e.g., intact or very firm hymen, septate vagina). Also important to identify would be problems like chronic yeast infections, lichen planus, vaginal atrophy from lack of estrogen, or prolonged pain at an episiotomy site which could make penetration painful. MissE26 mentions, “I have had a hymenectomy over a year ago.” Kate987 said, “I’ve been tested for everything in the book, infections, STDs, diseases, all negative. I’ve also had a pelvic sonogram that came back normal.”
How Is It Diagnosed?
Interestingly, vaginismus is one of two GYN conditions which is as likely to be diagnosed by a psychiatrist as by a GYN MD (the other is PMDD). Vaginismus is included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) as a sexual pain disorder. A psychiatrist or psychologist may make the diagnosis by asking the woman specific questions about persistent or recurrent difficulties for at least six months with inability to have vaginal intercourse and/or pain for the majority of sex attempts.
By contrast, a GYN, or a specially trained pelvic floor physical therapist (PT), may give the diagnosis after an exam and patient history. As secondary outcome, Reissing and colleagues (2004) compared diagnostic abilities between two GYN MDs and two pelvic floor PTs. They were asked to evaluate for vaginal muscle spasms among women with vaginismus, women with vulvodynia (painful vulva), and women without pain. Overall, the vaginismus women had an increased number of painful vaginal muscle spasms, but not an increased frequency of spasms compared to the vulvodynia women. The PTs had a better record for detecting vaginal spasms compared to the GYNs. This suggests that vaginal muscle spasms may not be the only factor in the problems from vaginismus.
Further support for this can be inferred from studies using electromyography measurements (use of needles or a vaginal probe to record levels of muscle tension). Usually women with vaginismus are compared to women with vulvodynia and or women without pain. Of eight studies, four studies found increased levels of muscle tension among vaginismus sufferers and four did not find increased muscle tension.
Thus, simply measuring muscle tension may not give the most accurate diagnosis. Rather it may by a combination of symptoms reported by the woman coupled with exam data. During an actual exam there are a number of classic reactions which can give the examiner the impression of vaginismus (e.g., closing of the thighs, arching back or very tightly closed muscles around the vaginal opening). In reading widely on this topic, I was amazed to find two descriptions of exams of women with vaginismus which matched my own experiences. The first description was written in 1942 by Dr. Joan Malleson, the second by Dr. William Masters in 1970-both gynecologists.
One group from the Netherlands (Klaassen & Ter Kuile, 2009) has published test results for a questionnaire called the Vaginal Penetration Cognition Questionnaire, or VPCQ. This questionnaire attempts to identify non-physical correlates linked to vaginismus. Again, this supports the idea of vaginismus being evaluated best by looking at physical symptoms and their emotional sequelae.
How Many Women Have Vaginismus?
Prevalence rates vary widely from 4%-42% (Hope, 2010). This huge variation reflects both what groups of women are being questioned, and how vaginismus is defined. For example, one might expect higher rates among women being seen in a psychiatry department for sexual problems. Among 54 such Turkish women seeking psychiatric care for sexual pain, almost 76% were diagnosed with vaginismus (Dogan, 2009). When 301 healthy women in Ghana were given the same questionnaire used in the Turkish study, 68% had some difficulties with vaginismsus. Yet only 6% had very severe penetration problems (Amidu, 2010).
Recently, scientists have begun to recognize that vaginismus can be partial as well as complete. In the instance of partial vaginismus, the woman still has a non-voluntary contraction of the vaginal muscles but at least partial penetration can occur. Binik (2009), in an excellent review of published studies, posits that women who have vaginal pain after intercourse may in fact have partial vaginismus. If this is true then one would wonder if the pain of repeated partial intercourse would predispose the woman to complete contraction of the muscles of the vaginal opening. This could be akin to the body “protecting itself” from the likelihood of further discomfort.
When Does Vaginismus Begin?
Sometimes this problem has been present from the very beginning of sexual life. As MissE26 confided, “I did know beforehand that I had a sort of fear of penetration, but I didn’t think it would actually prevent me.”
In other situations the inability to have intercourse arises later. Kate987 explained, “When I was younger I thought it would go away, and I was too embarrassed to ask anyone, including my gyno. Now that we are married, needless to say, it has gotten much worse.”
It is often written that vaginismus arises following past sexual trauma, abuse, psychological disorders (e.g., anxiety, marital discord), or a history of pain with intercourse (National Institutes of Health, 2010). Yet many of the women with vaginismus do not have any of these “predisposing” factors. Miss E26 asserts: “I feel the need to state a couple things that have come up in my past cries for help…1. I’ve never been sexually molested. 2. I do love and am attracted to my husband 3. I am attracted to men (again, specifically my husband).” Kate987 confirms: “I have never been sexually abused and I don’t have any mental trauma about sex or anything.”
Can Vaginismus Be Treated?
Everyone from Dr. Joan Malleson in 1942 through Drs. Jindal & Jindal in November 2010 write that vaginismus can be successfully treated. Treatment strategies can include:
- Education: One thousand married virgins were interviewed in 1964 by Balzer as to the reasons for nonconsumation of the marriage. He asserted that most problems would have been resolved had the woman had “adequate scientific knowledge at their disposal” (Chisholm, 1972).With today’s sex saturated media, and the availability of information via the Internet, it is hard to believe that women would need basic sex education. Yet information specific to situations such as vaginismus may enable a couple to find specialized treatment.
- Pelvic muscle training: Variations of training for relaxation of pelvic muscles is a mainstay in vaginismus treatment. This can be accomplished by use of biofeedback of muscle tension, or ability of the woman to relax until any muscle spasm resolves. Sensate focus has also been used successfully. Jindal & Jindal (2010) reported that 60 of 76 women with primary vaginismus had symptomatic resolution of their penetration pain.
- Vaginal dilators: Plastic dilators in graduated sizes have been a common treatment for decades. These may be sent home with the woman and her partner or they may be used in the presence of a pelvic floor PT. One small study of ten women with lifelong vaginismus (Ter Kuile, 2009) were seen for six hours during a one week training session by a PT. Two follow up sessions were held over the following five weeks. At the end of treatment, nine of the ten women reported successful intercourse. The research team attributed their success to the contributions of the female PT.
- Counseling: According to the National Institutes for Health success rates can be very high if treatment is rendered by a specialist in sex therapy. A sex therapist usually incorporates specialized counseling (including the partner) along with dilators and/or referrals to pelvic floor physical therapists. Dogan and Dogan (2008) published a study on sexual function of the partners of 32 women with vaginismus. According to strict criteria, 65% of the males had one or more sexual dysfunctions with the two most common being premature ejaculation (50%) and erectile dysfunction (28%). Thus partners may need information and counseling as well.
In my clinical experience the best results have been from a combined treatment approach which utilizes both a sex therapist and a pelvic floor PT. There are also specialized clinics for the treatment of vaginismus.
In conclusion, there are some very obvious reasons to get treatment for vaginismus such as the desire to have a child. Pain with attempted intercourse can certainly have an impact on the relationship. As Kate987 explains, “Since I’ve been dealing with this for so long, I’m truly terrified of the thought of intercourse, although we still try. But it always ends with me in tears and my husband frustrated.” Vaginismus has the potential to impair a woman’s quality of life. As MissE26 attests: “I have an issue that has become more and more of a thorn in my side over the years, to the point that is affecting my quality of life, marriage and at some times even my emotional state of mind…”
So if you have problems with vaginal penetration know that you are not alone. Successful treatments exist.