The condition can make it difficult even just to insert a tampon.
Nearly three-quarters of women experience pain during sex at some point–but for a small number of women, the reason is a little-known condition that causes the muscles at the opening of the vagina to involuntarily squeeze. Called vaginismus, this can cause pain during sex or gynecological exams, as well as discomfort and difficulty inserting a tampon.
“In women, when something is inserted into the vagina, the muscles around the vaginal opening have to relax a bit in order for the opening to stretch,” explains Nazema Y. Siddiqui, MD, associate professor of obstetrics and gynecology at Duke University Medical Center. “For women with vaginismus, this relaxation doesn’t happen, and instead, the muscles reflexively tighten up, thus narrowing the vaginal opening and making it more difficult to insert anything into the vagina.”
There are several types of vaginismus. Primary vaginismus is when the pain and muscle contractions have always been present.
“With primary vaginismus, you have women who have never tolerated any kind of vaginal penetration,” says Kristin Rooney, MD, a urogynecologist with the University of Nebraska Medical Center.
Secondary vaginismus is when a woman has had pain-free penetration at some point before symptoms start. Experts think that childbirth, a traumatic event (like sexual assault), or an infection may be triggers.
Global, general, or total vaginismus means a woman feels pain whenever anything enters her vagina. Situational vaginismus is when the pain happens only during certain types of penetration, for example, during sex, but not during a pelvic exam.
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No one knows the exact cause of vaginismus, and there are likely many different factors that contribute.
“Sometimes you see it after you give birth and have stitches, or after a really bad, long yeast infection. [That may] do something to the pain sensors,” says Jennifer Wu, MD, an obstetrician and gynecologist at Lenox Hill Hospital in New York City. “It could be due to trauma, infection, nerve damage–so it’s hard to know.”
Vaginismus can also happen to women experiencing generalized anxiety. “This is the person who just tends to hold their body tight in that area,” says Dr. Rooney. Or, it can be due to more specific anxiety, like from a prior negative sexual experience.
It’s also possible that vaginismus is a response to pain on the vulva, the external parts of a woman's genitalia. External irritation and discomfort, like vulvodynia, may make women tense up and have a hard time tolerating penetration, Dr. Rooney adds.
Menopause may also play a role. Sex can become painful as declining estrogen levels make the vagina less pliable. When this happens, muscles may involuntarily contract.
The main symptom of vaginismus is burning pain when something enters the vagina. Vaginismus can also make inserting a tampon or penetrative sex difficult.
After a woman experiences actual pain, she often develops a fear of anticipated pain. This can end up in an escalating spiral. “When we become fearful of pain in the vaginal area, we tend to reflexively tense our pelvic floor, which essentially results in a vicious cycle of some prior pain leading to tightening of the pelvic muscles, which then leads to more pain and more fear for the next time it might happen,” says Dr. Siddiqui.
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Vaginismus needs to be treated as soon as possible to stop the cycle of fear, says Dr. Siddiqui.
There’s no test for the condition. Instead, a doctor will make a diagnosis after talking to you about your symptoms and possibly doing a pelvic exam (very slowly and gently). He or she would also want to rule out infections and other reasons for vaginal pain that could be treated with medication.
The most common treatments for vaginismus actually don’t involve medication or surgery but instead, physical therapy and progressive desensitization training. In fact, there are specially trained pelvic floor physical therapists who can help with exercises (including kegels) to strengthen your pelvic floor and stretch your muscles. These specialists can also use vaginal dilators to help you slowly get used to having something inserted vaginally, says Dr. Rooney. Often partners are involved in the therapy.
Pelvic floor physical therapists may also have you do something as simple as a “pelvic floor check”–focusing on and noticing your vaginal muscles, then trying to relax them. “By doing these techniques over and over, women can change the reflexive response that happens with vaginismus over time,” says Dr. Siddiqui.
Mental relaxation exercises can also help you learn to ease tension in your vaginal muscles.
Pain relievers, muscle relaxants, and even antidepressants are sometimes used to treat vaginismus, but the results are mixed. “Many gynecologists feel that if women are able to work with a good pelvic floor physical therapist, this is the best option,” says Dr. Siddiqui, “with medications being a short-term aid.”