Vaginismus - difficult to say, and often really difficult to talk about. 

Although perhaps most recently brought to people’s attention through Season 2 of Netflix’s Sex Education (you might remember Lily’s confession to Ola of “It’s not you, it’s me. I have something called vaginismus. My vagina’s like a Venus flytrap.”), vaginismus can be the elephant perched in the corner of the bedroom for around 1 to 6% of people (although it is difficult to estimate reliable prevalence rates) (1, 2).

But what is it, really, and can it be treated? Let’s get into it.

What is vaginismus?

Vaginismus is a condition in which the vaginal muscles involuntarily contract or spasm, resulting in discomfort, burning and/or pain and making penetration difficult or near impossible (3). This is considered a pain disorder and it can be incredibly distressing. Vaginismus is often accompanied by feelings of confusion, frustration, isolation, anger, shame, embarrassment, worry and fear (4). This contraction of vaginal muscles occurs unconsciously, particularly during times of stress or when there is a perceived threat. 

Just like you would pull your hand away from a hot iron or blink if something goes close to your eyes, the body automatically responds by clenching and guarding around the urethra (opening where you pee), vaginal opening and anus, creating a barrier to penetration that can make it feel as if there is no hole or opening at all, or as if something is “hitting a wall” (5). 

Vaginismus is broken up into two classifications (6):

• Primary vaginismus: this describes people that have never been able to have or tolerate penetration. For example, they have never been able to insert a tampon or have an internal vaginal exam.
• Secondary vaginismus: this refers to when a person who used to be able to have penetration goes through an experience and then something has happened that changed their ability to tolerate penetration that later in life. That experience something could be a medical event (like having a baby or experiencing cancer), a stressful or traumatic event (abuse, trauma) - and can even be completely unrelated to sex or from an unknown cause altogether.

What is the cause?

The cause of vaginismus can vary greatly according to each individual. Sex, while seemingly simple, is actually quite complex with many factors such as “sexual motives, scripts, pleasure, power, emotionality, sensuality, communication, and connectedness” playing a role (p. 90) (7). As a result, the reasons or causes of vaginismus are often highly unique and multifaceted – meaning it isn’t just one thing but rather a combination. Some of these might include stress, anxiety, depression, body image concerns, past sexual trauma, fear of intimacy or relationship problems are just a few of the possible factors that may result in the pelvic floor muscles contracting, vaginal spasm and the resulting painful sex (1). 

The vicious cycle of pain

Our bodies have a very good memory. Once we start to experience pain with sex, it learns to associate the two. When sex equates to pain in our minds, it isn’t uncommon to begin experiencing fear, anxiety and worry around sex, potentially leading to the avoidance of it altogether. The vicious cycle of pain (also called the fear avoidance model) that occurs with vaginismus starts with this anticipation or fear of pain, resulting in the vaginal muscles automatically tightening and contracting creating a greater barrier and penetration/insertion even more difficult and painful (9). Thus, the vaginismic response is often conditioned through experiences and a cycle that only reinforces the pain.

What is the role of the pelvic floor? 

When it comes to vaginismus, we can’t not mention the role of the pelvic floor. These are the muscles that      control many functions, including orgasm (the pelvic floor muscles contract between three to fifteen times during orgasm). In vaginismus, the pelvic floor muscles can in often be hypertonic, meaning they are excessively tight. It is these pelvic floor muscles that contract and guard, resulting in difficulties with penetration and/or insertion (10). The pelvis contains the bladder at the front, the      vagina and uterus in the middle and the rectum at the very back. Meaning that these organs are very closely connected. When the pelvic floor muscles supporting these organs are tight, it also results in compression to these other organs and even underlying inflammation.      

It is for this reason that people with vaginismus can experience      some constipation, painful bowel movements, difficulty emptying their bladder or pain when the bladder is full alongside the pain during sex that we primarily associate with the condition. Nope, not fun at all. 

Treatment options

While there is no magical or instant “cure” for vaginismus, there are ways to go about managing it and even achieving pain-free penetration/insertion (11). Yes, it is possible! However, it’s important to recognise that treatment for vaginismus can take time, and progress may not always be linear. Vaginismus does not magically get better on its own – it requires patience, commitment and often a healthcare provider team.

What is your why? 

At the beginning of this journey, it is important to question why your vaginismus might be occurring. This can certainly be a challenging question to answer, and you may even require a multidisciplinary team to help you get to the bottom of it. However, understanding the root cause of vaginismus can be a great indicator of what the best way might be to go about tackling it. When did the pain start? Did it coincide with any life events? What beliefs do you hold about sex? How might these be impacting you?  

These are some examples of attitudes and beliefs about sex that were identified in a qualitative study of people who experience vaginismus (12):

“sex is dangerous, pregnancy is frightening, you can be damaged, childbirth is frightening, sex is painful, sex is undignified, contraception is frightening, sex is disgusting, sex is animal-like, nice girls don’t, pleasure is not allowed, sex makes me feel guilty, sex is terrifying, I’m too small, I’ll be ripped apart”. 

How to overcome vaginismus (13)

• Discuss with a doctor to rule out anything underlying. Start by discussing your symptoms and concerns with your healthcare provider. If you feel that they are not listening, are dismissing you or telling you to “relax” or “have a glass of wine” (which can be very real experiences for some patients), know that those are not solutions to managing vaginismus. You need to find someone who is going to listen to you and be a helpful part of your team. So, keep looking until finding someone who is a good fit.
• Find a pelvic floor physiotherapist. They can help determine what your unique needs are in managing your symptoms. They can often help to retraining the pelvic floor muscles and gently stretch and mobilise the tissues around the vagina. This is best done under the guidance of a pelvic floor physiotherapist. 
• Create boundaries. The best way to break the vicious cycle of pain that often occurs with vaginismus is to find sexual activities that don’t hurt and to create clear boundaries with your partner/s so you know that it won’t hurt. An example, maybe you only want certain areas stimulated and not others. Perhaps only outercourse – whatever it is, define it and communicate the boundary assertively. 
• Familiarise and educate yourself about your own anatomy. It is important to become aware of your own individual, unique and beautiful anatomy. Sadly, a lot of people have never properly looked at their genitals. It is important to understand where all the different structures are and what they do so that you can begin gaining coordination and control of them. The underlying undoing of vaginismus is going to come down to gaining coordination of those muscles so that you can relax them when it’s appropriate instead of tensing.

Exercise: Know your anatomy 

Get a hand-held mirror and find a comfortable position. Use your mirror to get a good look at your anatomy. The vulva, urethra, vaginal opening, clitoris and anus. Where are they? How do they look? Knowing where your own anatomy is can be incredibly powerful. 

Exercise: how are your pelvic floor muscles working? 

Using your hand-held mirror still, imagine that you are going to shut off the flow of urine. In order to shut off the flow of urine, when we are in this position (so not on the toilet), the pelvic floor muscles are going to contract. When the pelvic floor muscles are coordinated and working well, what you should see is a little bit of a pucker or the clitoral hood, the anus clenching, and the vaginal opening closing and lifting towards you. So, when we are upright, the pelvic floor muscles contract and lift upwards – that is the activation of the pelvic floor muscles, also known as a kegel. You may even find that the muscles are already so tight that you don’t even feel a good contraction and that’s okay. 

You don’t need to do a bunch of kegels: often when people have vaginismus, certain pelvic floor muscles are tight and Kegels are not going to be a treatment or a remedy for them. In fact, what you actually want to do is the opposite, you want to be able to drop and relax the pelvic floor muscles. But first, it is important to know what “up” or activated is (as indicated in the exercise above).  

Exercise: learning to relax the pelvic floor

The next thing that you are going to do next is to gently pass gas (or blow a bubble with the vagina). So right where you are, and still using your mirror to help provide reference. Imagine that you are going to pass gas gently (or blow a bubble) and what you should see if a dropping or opening around the vaginal opening and maybe a little bulge around the anus. Note: If you are trying to do this and you are not seeing any changes, don’t give up and don’t get frustrated. It will get easier. If after a few days of trying this you just don’t feel it is working – this is where a pelvic health physio comes in. They have different approaches such as manual techniques that can help you learn this. The purpose of this exercise is to be able to, on command, get the pelvic floor muscles to drop and relax. How this works is the pelvic floor muscles because less tense, which results in a drop of the vagina that can help other things pass through. 

Other management options

• Medications such as muscle relaxants or topical anaesthetics may also be helpful in reducing muscle spasms and pain during penetration. 
• Relaxation techniques, such as deep breathing (for example doing 10 deep belly breaths every few hours) or visualization, can be seriously helpful. You may even choose to practice these techniques before and during sexual activity to help reduce muscle tension and discomfort.
• Further your sex education: see a sex therapist. can help a person understand and work through any emotional or psychological issues that may be contributing to their vaginismus. This may include cognitive-behavioural therapy (CBT), which helps a person change negative thought patterns and behaviours, or sex therapy, which focuses on improving sexual function and communication with a partner.
• Taking things slowly: It is important to go at a pace that is comfortable for you. This may mean starting with non-penetrative activities and gradually working up to penetration. 
• Vaginal dilators can be very useful. Dilators often come in sets that range from very small to larger. This is a gentle stepwise progression. What these tools do is they help you learn to drop and relate the pelvic floor, tolerate penetration without pain and then have gentle mobilization (by moving the dilator around) to train the vaginal tissue for pain-free penetration. Many people start off by using the dilators for 10 minutes one or two times a day. The goal is to train the coordination between the brain and the pelvic floor muscles to relax and drop the vagina. 
• Vaginal wands can also be a great tool. When the muscles have been clenching for a long time, knots or tension points can develop. Just like a knot in your back. A pelvic floor physio can really help you identify these points. A wand can help relieve these tension points that a dilator cannot reach. 

Exercise: using vaginal dilators 

Get a towel, sit down and be comfortable. Practice your breathing and dropping the pelvic floor muscles (as indicated in the earlier exercise). Find a lubricant that works best for you and be very generous in applying it (some on the dilator and some at the vaginal opening). If this is your first time using a vaginal dilator, you want to try take things very slowly. If just having the dilator near the vaginal opening is causing you pain or distress, try placing it somewhere else on your body like your arm. Touch your arm with the dilator and use self-talk. Tell yourself, “this dilator is here to help me”, “I am worthy of reaching my goal” or any other positive belief. That positive self-talk can help pull you out of a fight, flight, freeze stress response that often happens with vaginismus and into a more relaxed state. So, we are working on not feeling a sense of threat or harm but that we are in our bodies so that we can be aware and control those muscles around the vaginal opening. Getting one dilator all the way in could take you one day or it could take a month – both of these are totally okay. Once inside, to stretch out the vaginal tissues, imagine that you have a clock and want to press at each hour.

How do I navigate talking to my partner about vaginismus? 

There's no doubt that vaginismus can certainly impact sexual relationships significantly. But don't worry, there's still hope for intimacy and pleasure! While people with vaginismus may feel anxious or self-conscious about their condition, they should remember that it's not their fault that they have this condition. Having open and honest conversations about your feelings, concerns, and working together to find ways to manage your condition and improve your intimacy can be incredibly helpful.

The bottom line

Vaginismus is a condition that can have a significant impact on a person's sexual and intimate relationships. It is important to work with a healthcare provider or therapist to develop an appropriate treatment plan, and to communicate with your partner about your condition. There are also a number of strategies that can be helpful for managing vaginismus and improving intimacy with a partner.