Health check: what is vaginismus?

What is vaginismus?

The NHS website describes vaginismus as “the body's automatic reaction to the fear of some or all types of vaginal penetration.”

The concept of a "fear of penetration" here can be a misleading one: individuals might not consciously "fear" penetration and they might actually want to be penetrated, but find it impossible. For some, vaginismus may be experienced as an unconscious bodily response.

Vaginismus is considered to be a genito-pelvic pain/penetration disorder, as the condition occurs due to tightening of the pelvic floor. The pelvic floor is a collection of muscles and ligaments around the bladder, bowel and vagina. “In vaginismus, muscles may contract so tightly that the vagina is effectively closed and sexual intercourse can be impossible or painful,” explains Mr Narendra Pisal, consultant gynaecologist at London Gynaecology.

It's important to remember that there are different severities and types of vaginismus; it can sometimes be situational, it may develop due to a specific event after a life of pain-free penetration, or it may be a life-long condition. No person experiences vaginismus in the exact same way, which is why accounts of what it feels like can vary.

There are multiple reasons why vaginismus can develop. Some scenarios may be as a result of anxiety around penetrative sex (perhaps due to a fear of pain or pregnancy) or growing up in a culture or religion where penetrative sex is taboo. It can also be triggered by an event or string of events, such as after childbirth or miscarriage and after experiencing sexual trauma.

Some clinicians may describe vaginismus as a "cycle of pain": the body anticipates pain so automatically tightens muscles, this tightness creates pain during penetration or prevents it from happening, this pain enforces the reflex response, and the body then braces more on an ongoing basis.

Vaginismus is often described as a psycho-sexual disorder because of the psychological elements mentioned above. However, that doesn't mean it's "all in the mind" - the symptoms experienced in the body are very real. Vaginismus may also be caused by so-called organic factors, such as local infections, endometriosis, pelvic trauma, medications which cause pelvic pain or overactive pelvic floor muscles, potentially as a result of activities like gymnastics.

The condition is generally classified as a form of sexual dysfunction. However, many individuals with vaginismus will generally still be able to enjoy clitoral stimulation or outercourse; i.e. kissing, non-penetrative touching, erotic massage, tribbing, nipple play. Not all sex involves penetration, and some individuals with vaginismus may be content with having a sex life where it doesn't feature.

What's it like having vaginismus?

“Vaginismus can feel extremely traumatic. It’s like your own body is against you and then it’s a nasty cycle of mind over body. The penetrative angle of the condition is tricky to navigate as sometimes you can actually want to be penetrated but can’t be," explains Naomi* from Birmingham.

“I’ve struggled with the condition for two years. Conversations around it with partners can be really difficult, some people think you’re making it up or you’re just a bit ‘tight’ down there and not everyone understands. I’ve now been using dilators with numbing cream alongside therapy to work through it. A lot of people think the condition stems from trauma and abuse, which it absolutely can; but there can also be a huge stigma around having sex, especially in different cultures and religions. I was always taught that sex was a bad thing and something necessary for procreation rather than fun, it’s now trying to relearn a whole mindset and physical reaction.

I used to wish I could just be ‘normal’, joining in on conversations surrounding sex and even using a tampon. But now I know I just need to respect my body and know that it thinks it’s helping me, I need to thank it for that really. I am making progress on recovery every day. I think it’s incredibly important to remember that sex shouldn’t be painful. A lot of people seem to normalise sex sometimes being a bit uncomfortable, but it’s really important to speak out to your partner and medical professionals."

How to treat vaginismus

According to Pisal, vaginismus can be treated in a number of ways which may focus on the psychological causes or the physical impacts of the condition:

• Topical treatment: “Topical treatments can be tried such as local anaesthetic gels." This is intended to help with the pain of vaginismus.
• Pelvic floor physical therapy: “Physiotherapy and directed exercises are also helpful. A specialist women's health physiotherapist is able to assess and advise regarding what exercises to use." In this instance, you may be taught how to better identify, relax and control the muscles in your pelvic floor.
• Cognitive Behavioural Therapy (CBT) or sex therapy: “Commonly CBT or psychosexual therapy is employed to try and break the cycle of involuntary vagina contractions on attempted intercourse. Oral medication such as antidepressants or gabapentin may sometimes prove necessary." CBT helps you understand thoughts and how you feel, while providing coping mechanisms. Sex therapy is focussed on helping you to improve sexual pleasure and intimacy and work through any sexual difficulties.
• Dilator therapy: "Patients can be prescribed vaginal dilators which they can use themselves: they come in a range of sizes and are inserted vaginally by the patient every day over a period of time." Vaginal dilators are used to familiarise the body with penetration. The size of the dilators is increased little by little over time. To begin, a topical cream may be used in conjunction with a dilator.
• Mindfulness: "Practising mindfulness techniques and other relaxation techniques can help disassociate penetration with stress."

Different methods may work for different people, and the outcome will depend on your personal experience and severity of symptoms.

How is vaginismus diagnosed?

Common signs of vaginismus include discomfort using tampons, burning or stinging pain during penetrative sex and difficulties achieving penetrative sex. If you have these symptoms, it is recommended you visit your GP.

Once at your appointment, your GP will likely ask you a few questions about your symptoms and may ask if they can carry out a quick vaginal exam to ensure that they have not been caused by something else, such as an infection. It is unlikely that an internal vaginal exam will be carried out. Know that you can refuse a vaginal exam of any kind if you do not want it or feel uncomfortable.

Before your appointment, you might want to note down a timeline of when your symptoms started, write down any specific instances where you noticed discomfort, and practise using terms associated with your vagina, so as to avoid feeling lost for words in your consultation.

If you would prefer a doctor of a specific gender, you can ask for this when you book your appointment. You can also request a chaperone to come with you into the room.

After the GP inspects you, if they believe you have vaginismus they will likely refer you to a specialist.

Vaginismus and cervical screenings

Cervical screenings are a medical test which all women (and trans men, as well as some non-binary people) should be invited to if they are between the ages of 25 and 64.

Often, you'll receive a letter or text to know that your cervical screening is due. This test checks your cervix by taking a small sample of cells from the area to detect precancers or cell changes on the cervix. The cervix is a canal between the uterus and vagina, so cervical screenings involve the insertion of a speculum via the vagina.

Cervical screenings are intended to take five minutes, but they can take much longer and be painful or impossible for people with vaginismus. As a result, individuals with vaginismus may feel anxiety, stress or fear at the prospect of cervical screenings, or avoid them altogether.

However, there are things you can do. If you have vaginismus, you can phone ahead and request a longer appointment time and can also ask for a smaller speculum during the appointment. It is also possible to request an appointment with the sole purpose of becoming familiar with the instruments, procedure, and the process before your actual screening. If you have a diagnosis, you may also be able to request diazepam to be administered for the screening to help ease the pain.