When there's pain on penetrative intercourse, it isn't caused by endometriosis or an active infection, and it doesn't go away on its own, two of the most common diagnoses are vulvar vestibulitis syndrome (VVS) and vaginismus. It could be either one, depending on the nature of the pain.
The difference between vaginismus and VVS is that vaginismus is caused by muscle spasms, while VVS is caused by inflammation of the tissue or the nerves. And, just to complicate things, the pain of VVS can trigger vaginismus as well, so it's quite possible to have both! I’ll talk about VVS and other causes of pain during sex in another post (Understanding VVS / Vulvodynia), but I want to focus on vaginismus in the post.
Vaginismus is caused by muscles that remain permanently tight or that spasm involuntarily, tightening the entrance to your vagina and causing pain on penetration. The expectation of pain then reinforces the subconscious trigger for subsequent spasms, which creates more pain and so on. The cause can be either physical, from a painful experience, or psychological, like the fear many virgins have of penetration, or both, as in the aftermath of rape, or simply the habit - often acquired as toddlers - of keeping the muscles around the vagina tightly clenched.
Typical Vaginal Opening vs Vaginismus: https://flo.health/menstrual-cycle/sex/sexual-health/vaginismus
Vaginismus can begin in early childhood or anytime thereafter. It can begin with surgery, childbirth, physical or psychological trauma, an allergic reaction to something, a painful vaginal or urinary infection, premature toilet training, menopause, unlubricated sex, or anything that creates a fear of sex and/or vaginal penetration. Or it can seem to come out of nowhere for no reason. Severe cases can prevent couples from consummating their marriages for years, and even moderate cases can be shattering to a woman's sense of herself as a healthy sexual person.
Primary vaginismus is tightness that existed before becoming sexually active and is usually discovered when a girl first tries to insert a tampon or first tries to have sexual intercourse and discovers that she can't, or that it's painful. This always requires stretching therapy, but it also helps a great deal to diminish fears about losing virginity. Often girls are subjected to horror stories about pain and bleeding and are understandably tense, yet a majority of women have no pain or bleeding when they lose their virginity, and it is nearly always preventable with a little bit of forethought and care.
I outlined a program for getting ready and having a pain-free first time, which may be helpful if you are in this situation. You can find it here:
If you have mild vaginismus - for example, you can insert a finger or a slim tampon with little or no pain - this may be all you need. If initial stretching doesn't provide relief, however, you will need to get a therapy kit and do the full stretching program, as described below and in the resources at the end.
In addition, this pattern can cause problems when you are trying to have sex for the first time. If your partner is doing a lot of g-spot stimulation with his fingers inside you or is irritating your urethral opening by something he's doing on the outside, it's possible you are feeling an urge to pee that makes you tighten up, and when you clamp one opening, you're unintentionally clamping both.
If you think this is the case, be sure you empty your bladder completely before sex and ask your partner to avoid the centerline when he is stroking the upper wall of your vagina or the middle part of your vulva, where your urethral opening is located. The G-spot is located directly under the urethra, so for G-spot stimulation, he needs to split his fingers slightly apart. They need to be at the 11 o'clock and 1 o'clock positions instead of the the 12 o'clock position. In this way, he will stroke outward on either side of your urethra instead of pressing right on it from below.
Coping with Tightness/Pain on Penetration
Secondary vaginismus generally comes on in adulthood, often after years of being sexually active. It can have a clear cause, like trauma, childbirth, surgery, or menopause, or it can happen for no apparent reason.
If you can have normal sex without too much pain, the standard remedy for tightness of the vaginal muscles is to take longer on foreplay, get more completely aroused before you start vaginal sex, and use lube, even if you don't think you need it. If you have mild vaginismus and a willing and supportive partner, try adding fifteen or twenty minutes of yoni massage and oral sex to the agenda, including one or more preliminary orgasms before starting penetration and see if that helps. That may be all you need.
If you can have normal sex without too much pain, the standard remedy for tightness of the vaginal muscles is to take longer on foreplay, get more completely aroused before you start vaginal sex, and use lube, even if you don't think you need it. If you have mild vaginismus and a willing and supportive partner, try adding fifteen or twenty minutes of yoni massage and oral sex to the agenda, including one or more preliminary orgasms before starting penetration and see if that helps. That may be all you need.
If not, there's a possibility that there's something about the kind of sex you're having that is subtly irritating your vagina, vulva, or urethra, and your body is tightening up in anticipation and self-defense. You might want to try changing the brand of condom or lube, or try using lube if you haven't been. Ask your partner to wash his hands well before sex and to be sure to rinse ALL of the soap off. There's also a possibility that his penis is hitting and irritating your cervix. To prevent that, ask him to shift his whole body an inch or so forward or backward relative to your body, to change his entry angle so he misses the cervix.
Kegel exercises are often prescribed as a way to strengthen the muscles at the vaginal entrance, but you can also use them to learn how to relax those muscles voluntarily. Instead of clenching hard, just contract lightly for a few seconds and then try to get all of those muscles relax completely. (It's best to do this on the john until you know it's safe!)
It will also help a lot if you learn to do PMR (progressive muscle relaxation). There are some excellent audio tapes at Dartmouth University's wellness website that many people have found helpful: Relaxation Downloads.
Physical Therapy
Sometimes, even when vaginismus is relatively mild, finding and treating the cause is difficult or impossible and it's better to just treat the symptoms. And it IS important to get it under control. Besides the discomfort this causes for you and your partner, the worry is that if the muscles in your vaginal opening get much tighter, painful penetration can create a vicious circle by aggravating the vaginismus and making the muscles tighten even more. So it's a good idea to be somewhat proactive about using physical therapy to deal with this.
If you already have a more severe case of vaginismus and penetrative sex is very painful or impossible, then physical therapy will be required.
The standard treatment for vaginismus consists of relaxation exercises and stretching using vaginal dilators, usually accompanied by pelvic floor massage and stretching exercises. The dilators are like slightly tapered dildos. They come in inexpensive sets with graduated sizes, and you insert one as far as you can without pain, and then wait for 10-15 minutes as the muscles get used to it and relax. When you can comfortably insert one size several inches, then move up to the next size, and so on.
You can also do the pelvic floor massage by yourself, but it's much easier to do it if you have a therapist or partner help you. Unfortunately, the links below focus primarily on using dilators and much less on the hip stretches and the massage process, so I strongly recommend seeing a trained pelvic floor massage therapist to help you learn how to do this properly. With or without coaching, many women and couples have done DIY home care for vaginismus and have had reasonable success doing standard hip-flexor, IT-band, and adductor stretches and just trying whatever massage felt right around the perineum, the sides of the vulva, and the butt and thigh muscles and seemed to help everything loosen up.
Some women say that taking a muscle relaxant or some alcohol or marijuana can make the therapy easier. Your GP or gynecologist can prescribe a muscle relaxant in the form of a vaginal suppository or cream that can be stronger and more effective than a pill because it is much more localized in its effect.
Cognitive Therapy
Many doctors and psychologists assume that vaginismus is primarily a psychological problem and turn to psychotherapy first. Clearly, psychological issues can play a big role, particularly in cases where a woman has suffered sexual trauma or grew up in a severely sex-negative, repressive, and/or religiously conservative household.
If you struggle to view sex as a clean, healthy, enjoyable activity, if you feel shame or anxiety when you think about sex or your body, or if you have trouble looking at or touching your own or your partner's sex organs, some kind of counseling or psychotherapy will almost certainly be needed to help you overcome vaginismus and get to the point where you can have pain-free sex.
On the other hand, vaginismus can also strike women who have never felt repressed or negative about sex, or who shed a repressive upbringing long ago and have always enjoyed masturbation and sex. Sometimes vaginismus starts with a purely physical irritation or injury, sometimes it's the result of menopause or other hormonal changes, and sometimes it seems to have begun for no reason at all. In these cases, it's usually best to resist pressure for psychotherapy and see if physical therapy alone will solve the problem.
When counseling or psychotherapy is appropriate, the best results have generally come from CBT (cognitive behavioral therapy) and MBCT (mindfulness-based cognitive therapy). I generally recommend the latter, partly because it serves two purposes: you gain the benefit of the therapy and you also gain a skill – meditation – that can improve your life in many ways, such as helping you cope with stress and helping you have better sex. On the other hand, it may be harder to find a good, experienced MBCT therapist, and you can easily learn to meditate on your own. Both approaches seem to yield good results.
However, do NOT let anyone talk you into a "psychotherapy only" approach to treating vaginismus. Even when the cause of the vaginismus is clearly or primarily "in your mind," the consequence of your fears or feelings about sex have created physical changes in your body that need to be addressed. I don't know of a single case of a woman recovering from vaginismus solely as a result of talk therapy, without substantial physical therapy as well.
Botox
Starting around 2000, we've seen a number of clinics popping up to treat vaginismus with Botox instead of physical therapy. Botox paralyzes the nerves that tell the muscles to contract, allowing the muscles to relax without pain. This is still somewhat experimental, and this use of Botox is "off-label" as far as the FDA is concerned, so there is not a great deal of data on success or safety. However, many women with severe cases of vaginismus, particular those who cannot get even the thinnest dilator in, have reported success with Botox treatment.
My biggest concern in even mentioning this as an option is the high cost and the potential for being scammed. Because this use of Botox is "off-label" and unsupported by a lot of research, there are no quality controls, and it can be very easy for unscrupulous people to exploit desperate women with unverifiable tales of magical cures.
For all of these reasons, I strongly urge you to try physical therapy first, with or without talk therapy as seems appropriate. There is an excellent chance that that will resolve your problem in six months or less. Only if you see no progress in a year of conventional therapy should you consider a Botox clinic. And if you do decide to go to one, please subject it to very careful scrutiny, verifying the doctors' medical credentials, looking up the names of all of the clinic's owners in databases of medical complaints, and checking with the Better Business Bureau as well. Do not be fooled by an upscale address or a fancy facility. References and testimonials can be faked very easily. If at all possible, try to meet former patients face to face in a private setting, away from clinic employees.
Summary
Vaginismus can be anything from annoying – mild pain for the first minute of intercourse – to such severe muscle contractions that not even the thinnest finger or tampon can be inserted. Because of the ignorance of most doctors, some women suffer from it for a decade or more before getting help. But the good news is that nearly all cases can be resolved successfully. Most estimates I have seen are that about 70-80% cases can be cured through physical therapy alone, and that between 95% and 99% of all cases respond successfully to either physical therapy or combination therapy. So there's excellent reason to get started and to expect success!
Good luck!
Here are some resources for you to explore:
Kegel exercise - Wikipedia
Reddit has a "subreddit" devoted to vaginismus where you can get support and helpful suggestions. Read the sidebar on the right before skimming the posts.
There's also a Facebook page devoted to vaginismus support that is somewhat more active than the subreddit, but it has many ads for clinics and products, which may be confusing or distracting when you are just starting to look for information and support.
If you need to locate a specialist, here are some referral sources:
The National Vulvodynia Association
The International Society for the Study of Women’s Sexual Health
The American Association of Sexual Educators, Counselors and Therapists
The International Society for Sexual Medicine.
If you need to locate a specialist, here are some referral sources:
The National Vulvodynia Association
The International Society for the Study of Women’s Sexual Health
The American Association of Sexual Educators, Counselors and Therapists
The International Society for Sexual Medicine.
[Standard disclaimer: I am not a doctor and this is not medical advice! I have researched this subject because people I know have suffered from it, but I am an informed layman, not an academic expert or physician.]
No comments:
Post a Comment