By Allison Danish, MPH
Vaginismus is a condition that can cause a lotta strife in the bedroom. But what is it? And why does it happen? We talked to Dr. Jill Krapf, MD, MEd, board-certified Obstetrician Gynecologist specializing in vulvar pain conditions, and Dr. Alicia Jeffrey-Thomas, PT, DPT, PRPC, pelvic floor physical therapist and TikTok educator, to get the answers.
What is vaginismus?
Vaginismus is when the pelvic floor muscles around the vagina involuntarily contract, usually in response to attempts at penetration. This can make inserting tampons, getting a pelvic exam, and having penetrative sex difficult—or even impossible in some cases.
“There are often elements of fear of penetration and anxiety associated with this response,” says Dr. Krapf.
Dr. Jeffrey-Thomas says “The condition can range in its severity—some people may have difficulty even inserting something as small as a q-tip and some people may be able to comfortably use tampons but have pain or difficulty with pelvic exams or intercourse.”
It comes in two main types:
- Primary vaginismus: when pain or difficulty with penetration has always been a thing
- Secondary vaginismus: when penetration hasn’t been painful in the past
Vaginismus, to our knowledge, was first described by an Italian doctor named Trotula of Salerno and was later called “vaginismus” by the so-called father of modern gynecology, J. Marion Sims (more on why that guy sucks here). It was described as the “spasmodic closure of the vagina.” This definition stuck around for close to 200 years—until the DSM-5 was published in 2013.
Dr. Krapf says, “More recently, medical societies that establish names and definitions have come away from using the term “vaginismus.” The American Psychological Association (APA)’s most recent edition of the Diagnostic and Statistical Manual (DSM-V) combined “dyspareunia” (pain with intercourse) and “vaginismus” into a single diagnosis of Genito-Pelvic Pain/Penetration Disorder (GPPPD).”
I’ve said it before, and I’ll say it again—that’s a lot of p’s.
Specialists have primarily moved away from “vaginismus” because research has shown that difficulty accommodating penetration doesn’t always mean the pelvic floor is involuntarily contracting. In fact, this contraction may only occur in about ¼ of cases. That, and, clinically, it’s been difficult or nearly impossible for doctors to identify whether a patient has dyspareunia (pain with sex) or vaginismus.
This new term can describe pain on the outside of the body (vulvar pain), pain with entry, and pain deeper inside the body. Oftentimes, people with GPPPD will have another medical condition (like endometriosis) that can explain the sexual pain. If treatment of the medical condition resolves the sexual pain—awesome! It wasn’t GPPPD. If pain persists after successful treatment, then maybe it is GPPPD.
Tldr; a lot of docs might call vaginismus GPPPD. For the purposes of this blog, we’re still talking about involuntary clenching of the pelvic floor muscles, and for ease we’ll be calling it vaginismus.
How common is vaginismus?
Thaaaaaat’s a hard question to answer. Estimates vary from 1-6% people with vaginas because “vaginismus is difficult to measure due to the issues with the definition of vaginismus itself.” Dr. Krapf says.
In addition, Dr. Jeffrey-Thomas says prevalence is “likely much higher and unreported due to the nature of the condition and that many people will not report their symptoms out of feelings of fear or shame.”
Even getting an idea of how many people experience pain during penetrative sex in general is difficult to pinpoint. One study estimates 15% of cis-women experience chronic painful sex, another study says 32% of cis-women had pain the last time they had sex, and the American College of Obstetricians and Gynecologists says nearly 75% of cis-women will experience painful sex in their lifetime. Not to mention the exclusion of people with similar healthcare needs who aren’t cis-women. A very recently-published study reported that 61.5% of trans-masculine people may experience unintentional pain during intercourse. A meta-analysis describing outcomes after gender-affirming bottom surgery for trans-feminine people reported painful sex estimates of anywhere from 0-63.6%.
What causes vaginismus?
Experts say vaginismus is related to fear and anxiety surrounding penetration. How we feel has very real impacts on what’s going on in our bodies. Just think about the last time you felt anxious—you might have felt your chest tighten or your stomach churn, your heart rate and blood pressure go up.
Dr. Krapf says, “There are two main ways to think about muscle tightening/spasm related to vaginal penetration.”
- There’s a fear of touch and penetration, and so the pelvic floor muscles clench involuntarily, preventing vaginal insertion.
- The pelvic floor muscles surrounding the vaginal opening are always contracted, so touch or penetration hurts. “This can lead to pain-related anxiety, which reinforces a pain cycle.”
“In reality, these are likely ends of a spectrum and people with sexual pain related to muscles fall somewhere on this spectrum,” Dr. Krapf adds.
But where does this fear and anxiety come from? Dr. Jeffrey-Thomas says, “Anecdotally, a lot of pelvic floor physical therapists report seeing vagnismus in people who were taught shame-based sex education, including some highly religious communities. There are also many people who have experienced [sexual] assault, or other trauma who will have… vaginismus (and if these traumas occurred in childhood, one may not know they have vaginsmus until their first time trying to use a tampon, or seeing a gynecologist, or attempting intercourse). Secondary vaginismus may also develop after childbirth or after surgery.”
How do you know if you have vaginismus?
If you experience pain or difficulty with penetration, here are some of the main indicators that it could be vaginismus according to Dr. Jeffrey-Thomas:
- You have difficulty or pain with initial penetration (use of tampons, insertion of a finger/sex toy/penis, or speculum exam)
- This pain is around the entrance of the vagina. It may feel like you're hitting a wall and can't insert anything further.
- Your gynecologist may be able to give you the diagnosis officially once they have ruled out anything else anatomical that could explain the problem.
Buuuut if you’re already considering vaginismus may be the culprit, you may be right (though we always recommend seeing a trusted doc first). As Dr. Krapf says, “Someone with vaginal spasm that is mostly fear-initiated is often very aware. Even the thought of vaginal penetration brings about a level of fear and anxiety.”
How do you treat vaginismus?
"Treatment is a combination of pelvic floor physical therapy including myofascial release, vaginal trainer therapy, downregulating the nervous system, and management of fear and pain-related anxiety," says Dr. Krapf.
This can mean working with a variety of healthcare professionals, from physicians, to pelvic floor physical therapists, to sex therapists.
As Dr. Krapf says, "A sex therapist can be very helpful in managing the psychosocial components of the condition. This includes addressing any past trauma, cultural considerations, phobic responses, and relationship effects."
In terms of dealing with the muscular dysfunction that can come with vaginismus, Dr. Jeffrey-Thomas states, “The gold standard treatment for vaginismus is pelvic floor physical therapy. Pelvic floor PTs work to teach voluntary control of the pelvic floor muscles, especially relaxation in this case.”
This relaxation is super important because “people with overactive pelvic floor muscles that result in vulvovaginal pain are not always aware that they are clenching their pelvic floor muscles and that this is often causing the bowel, bladder, and pain with insertion symptoms they are experiencing. In addition, there is an association between clenching the jaw and tight pelvic floor muscles,” Dr. Krapf explains.
Dr. Jeffrey-Thomas says pelvic floor physical therapy “can involve hands-on manual therapy, stretching, breathing exercises, dilator therapy, and graded exposure therapy. Dilator therapy involves the use of cylindrical devices that progressively size up in width to practice pain-free penetration and work on soft tissue restrictions. Sometimes people may also need botox injections in their pelvic floor muscles to help control the spasm/tension.”
“The approach and the best use of these resources depends upon where the patient falls on the spectrum of pelvic floor muscle-related pain,” says Dr. Krapf.
Experiencing pain during sex—or not being able to have penetrative sex even if you wanted to—can be incredibly frustrating. The good news is there are treatment options. This is not something you have to live with forever.
Awesome, inclusive post! Would also love to see mention of lichen sclerosis and hormonally mediated changes to the vulva mentioned as another possible reason for involuntary clenching + pelvic floor dysfunction.