Vaginismus (also called Women’s Genito-Pelvic Pain/Penetration Disorder) is defined as an inability to experience vaginal penetration, or an experience of pain and fear with penetration. Vaginismus may have always been present (Primary Vaginismus), or it may have started as a response to a trauma, medical procedure, or other difficult experience. Some people with vaginismus are unable to experience any form of penetration, and others may be able to tolerate some forms of penetration but not others (ex: tampon vs. intercourse), or may only be able to experience painful penetration.
Often, women with vaginismus experience other symptoms as well, such as difficulty with pelvic self care and hygiene activities, difficulty with intimacy and self pleasure, and difficulty with gynecological care. There is often a disconnect from the pelvis, and discomfort being present in one’s own body. The pelvis often has high tone (hypervigilant protective response), and reduced strength and range of motion of the pelvic muscles. The muscles around the vaginal entrance contract and close in a protective response to maintain the body’s boundary of safety. The protective response gets maintained every time there is an unsuccessful attempt, and the fear and avoidance cycle persists.
You can learn more about Vaginismus here: https://www.womentc.com/
Vaginismus is best treated with a multidisciplinary approach, addressing medical, physical, and psychosocial aspects of the condition. Treatment often includes a combination of psychotherapy, sex education, sex therapy or sex therapy informed interventions, and pelvic therapy. Several treatment modalities used in the treatment of vaginismus are outlined below.
Increasing Access to Safety and Comfort in the Body through Somatic Therapy
It is common for people with vaginismus to experience a lack of safety in their own bodies, especially in the pelvis. Early treatment often involves building access to safety and comfort within one’s own body. This might start with looking at and touching your hand with your other hand. What does your hand look like? What does it feel like? What kind of touch feels comfortable? Squeezing? Lightly brushing? What do you notice elsewhere in your body when you touch your hand? What happens when you move to touching your arm or shoulder? Can you stay present with your body during this activity? This also allows us to build a greater connection with the boundary of the body.
We can also learn how to differentiate between when we feel safe or unsafe in the body. What does safety feel like to you? Can you feel your feet on the floor, feel your breath moving in and out of your body, and maintain awareness of the room? Or is the concept of feeling safe unfamiliar to you? How can you tell when your body moves into activation and self protection? We can work on building your awareness of what fight, flight, freeze, or collapse feels like for you, and help you build capacity to allow these self protection responses to move through you so you can come back to the present.
Pleasure Research: Exploring Pleasure through the Senses:
Pleasure research involves increasing access to things that feel good, which can actually feel scary to some people. Forms of pleasure and enjoyment are explored through the senses:
- What is a smell that you enjoy? Do you enjoy the smell of flowers or the forest, coffee, a favourite essential oil?
- What tastes are calming or enjoyable for you?
- What sensations do you enjoy? A hot bath, touching a fuzzy blanket, the sensation of a cat on your lap?
- Do you have a favourite song or sound that you enjoy?
- When you look around your space, is there something you see that brings you a sense of calm or joy?
By increasing access to things that feel good in the body, we create new neural pathways to use instead of the familiar pain pathways. This also helps being more safety into the system to support other pelvic work.
Graded Motor Imagery:
Sometimes hands on therapy can feel scary in the early treatment of vaginismus, and some people may not feel comfortable with manual treatment for cultural or religious reasons or because of past trauma. Graded motor imagery is an approach to treating chronic pain that can be applied in a unique way to treating pelvic pain conditions such as vaginismus. Often, this approach can help with preparing for manual therapy, or combined with other approaches such as muscle retraining and trauma therapy.
Graded Motor Imagery is a brain based Exposure Therapy approach to treating chronic pain. It consists of three stages:
- Left/Right Discrimination: Observing movements and identifying if they are left or right (we have to get creative here when working with the pelvis)
- Explicit Motor Imagery: Imagining movements and sensations without actually doing them. This stage often includes looking at images while connecting with the pelvis in the mind.
- Mirror Therapy: This stage may or may not be utilized, but there are benefits to getting more comfortable with what our own pelvis looks like, which can include use of mirrors.
How does this approach work for Vaginismus?
We can apply these same approaches to vaginismus, with some slight modifications. The process might look a little like this:
- Looking at images of hips and low backs and identifying directions of movement.
- Looking at images of hips and clothed pelvises and imagining yourself doing those movements.
- Working towards looking at more challenging images such as images of exam rooms, speculums, dilators, tampons, pelvic anatomy, and unclothed pelvises.
- Imagining being on an exam table, inserting a tampon, or being intimate with a partner.
- Increasing comfort with seeing own pelvic anatomy through use of mirrors.
We can also progress to other treatment approaches such as a personalized Sensate Focus protocol, which involves gradually increasing types of touch on the body, either alone or with a partner.
You can learn more about Graded Motor Imagery Here: https://www.noigroup.com/graded-motor-imagery/
Manual Therapy and Muscle Retraining:
Treatment of vaginismus also includes increasing the connections and control between the brain and pelvis through actual movement, and often manual therapy. With vaginismus, there is often both weakness and increased tone in the pelvic floor, which is further exacerbated by a strong protective response. By learning what it feels like when the pelvic floor is relaxed vs. contracted, and learning how to move between these movements, we gain greater control of the pelvic floor muscles. We can also learn about how our breath, posture, and movements impact the pelvic floor. However, it is important to first be able to access safety in the nervous system and be able to shift out of an activation or stress response in addition to working with the muscles themselves.
If you have had past traumatic experiences, these may also be addressed in treatment to allow your body and nervous system to start to move out of the state of threat that follows trauma. There may be difficult medical exams that continue to bother you, pelvic surgeries, sexual trauma, or other boundary violations that impact your body’s ability to feel safe, resulting in the automatic protective response of vaginismus. Working through these traumas in a safe space can be an important part of the healing journey to allow your body to no longer need to work so hard to protect you.
You can contact me at firstname.lastname@example.org or visit our website to set up a free discovery call to see if this approach is a good fit for you.