Vaginismus
Encyclopedia
Vaginismus, sometimes anglicized vaginism, is the German name for a condition which affects a woman's ability to engage in any form of vagina
l penetration, including sexual intercourse
, insertion of tampon
s and/or menstrual cups, and the penetration involved in gynecological examinations. This is the result of a reflex of the pubococcygeus muscle
, which is sometimes referred to as the "PC muscle". The reflex causes the muscles in the vagina to tense suddenly, which makes any kind of vaginal penetration—including sexual intercourse
—painful or impossible.
A woman suffering from vaginismus does not consciously control the spasm. The vaginismic reflex can be compared to the response of the eye shutting when an object comes towards it. The severity of vaginismus, as well as the pain during penetration (including sexual penetration), varies from woman to woman.
and women in their early twenties, as this is when many young women in the Western world first attempt to use tampon
s, have penetrative sex, or undergo a Pap smear. Women with vaginismus may be unaware of the condition until they attempt vaginal penetration. It may be confusing for a woman to discover she has vaginismus. She may believe that vaginal penetration should naturally be easy, or may be unaware of the reasons for her condition.
A few of the main factors which may contribute to primary vaginismus include:
Occasionally, primary vaginismus is idiopathic
.
Vaginismus has been classified by Lamont according to the severity of the condition. He describes four degrees of vaginismus: In first degree vaginismus, the patient has spasm of the pelvic floor which can be relieved with reassurance. In second degree, the spasm is present but maintained throughout the pelvis even with reassurance. In third degree, the patient elevates the buttocks to avoid being examined. In fourth degree vaginismus (also known as grade 4 vaginismus), the most severe form of vaginismus, the patient elevates the buttocks, retreats and tightly closes the thighs to avoid examination. Pacik expanded the Lamont classification to include a fifth degree in which the patient experiences a visceral reaction such as sweating, hyperventilation, palpitations, trembling, shaking, nausea, vomiting, losing consciousness, wanting to jump off the table, or attacking the doctor. The Lamont classification continues to be used to the present and allows for a common language among researchers and therapists.
However, it does not provide for a language with which a woman might best be able to verbalise her concerns, pain or problems. A woman with a lot of trust in the doctor might be classified as 1 but experience severe pain. A woman with less trust, or a woman who is or has been subjected to harsh examination, might be classified as 4 or 5 even if the physical discomfort she experiences with attempts at penetration in non-clinical settings is comparatively mild.
Though spasm of the pubococcygeus muscle is commonly thought to be the primary muscle involved in vaginismus, Pacik identified two additionally-involved spastic muscles in treated patients under sedation. These include the entry muscle (bulbocavernosum) and the mid-vaginal muscle (puborectalis). This accounts for the common complaint that patients often report when trying to have intercourse: "It's like hitting a brick wall".
, while in some cases it may be due to psychological causes, or to a combination of causes. The treatment for secondary vaginismus is the same as for primary vaginismus, although, in these cases, previous experience with successful penetration can assist in a more rapid resolution of the condition.
has been reported as low as 2% in elderly British women, yet as high as 18–20% in British and Australian studies.
Another study documented vaginismus rates of between 12% and 17% being reported in women presenting to sex therapy clinics (Spector and Carey 1990). The National Health and Sexual Life Survey, which used random sampling and structured interviewing, found that between 10% and 15% of women reported having experienced pain during intercourse during the previous 6 months (Laumann et al. 1994).
The most recent study-based estimates of vaginismus incidence range from 5% to 47% of people presenting for sex therapy or complaining of sexual problems, with significant differences across cultures (see Reissing et al. 1999; Nusbaum 2000; Oktay 2003). It seems likely that a society's expectations of women's sexuality may particularly impact on these sufferers.
or physiological, and the treatment required can depend on the reason that the woman has developed the condition. As each case is different, an individualized approach to treatment is useful. The condition will not necessarily become more severe if left untreated, unless the woman is continuing to attempt penetration, despite feeling pain. Some women may choose to refrain from seeking treatment for their condition, or be unaware that treatment might be available or even that their difficulties constitute a medical condition.
According to the Cochrane Collaboration
review of the scientific literature, "In spite of encouraging results reported from uncontrolled case series there is very limited evidence from controlled trials concerning the effectiveness of treatments for vaginismus. Further trials are needed to compare therapies with waiting list control and with other therapies." Although few controlled trials have been carried out, many serious scientific studies have tested and supported the efficacy of the treatment of vaginismus. In all cases where the systematic desensitization method was used, success rates were approximately 90% or better. For an example of one of these studies, see Nasab, M., & Farnoosh, Z.; or for a basic review, see Reissing's literature review (links below). A Dutch study showed that many women were subsequently able to be penetrated, but far fewer women actually enjoyed being penetrated.
One treatment that is employed is the use of vaginal probes. Vaginal probes are graduated or tapered blunt-ended probes. They come in different sizes, usually no larger than the size in length and diameter of a tampon. Here, the woman can work with a trusted nurse practitioner, doctor, or other person trained in sexual dysfunction and disorder, to help her organize a therapeutic program to (slowly and gradually) assist her in overcoming her fear of penetration. Vaginal probes are introduced into the woman's vagina, usually with her own hand so that she can maintain control both physically and psychologically over the rate of insertion. This procedure requires a great amount of trust and compassion to take place between the patient and the practitioner for the outcome to be successful.
Vaginismus patients are twice as likely to have a history of childhood sexual interference and held less positive attitudes about their sexuality, whereas no correlation was noted for lack of sexual knowledge or (non-sexual) physical abuse.
For some women, especially those with primary vaginismus, it is important to address the psychological aspects of the problem as well as the actual muscle spasm. A woman may choose to address the issue on her own terms, or she may seek the help of a therapist. Some women, especially those with secondary vaginismus, may rely on a physical rather than psychological treatment and also be successful. There are emotional difficulties associated with vaginismus, even for women whose vaginismus has a purely physical cause, which can include low self-esteem, relationship issues, continuing fear of penetration, and depression
.
with vaginal dilators. Dilation therapy involves inserting objects into the vagina. When treating the spasms through dilation, the dilators, or probes, used are replaced with gradually larger sizes as the woman progresses.
as vital to achieving comfortable penetration.
One of the problems which may accompany vaginismus is that a woman may be extremely hesitant to engage in penetrative sexual activity with others, due to a fear of pain associated with any kind of vaginal penetration. Solo masturbation, with penetration, can alleviate this fear.
Orgasm
need not be the only goal of masturbation. It may also serve to increase comfort with the genital area, to explore various sensations through genital and clitoral touch, and to become aware of those sensations which are relaxing and pleasurable. Sexual arousal causes changes in the shape and color of the vulva
, as well as in the vaginal lubrication
produced. As a woman becomes more aware of her individual sexual response, she can learn which sensations are best for bringing her to a state of arousal. She will then be better equipped to teach her partner which sensations feel best for her.
These associations can lead to negative emotions arising during any kind of sexual expression, including masturbation, and these emotions can take time to process. Feelings of shame, inadequacy or a fear of being "defective" can be deeply troubling. If multiple attempts at penetration are made before treating vaginismus, it may lead to fear of sexual intercourse, and worsen the amount of pain experienced with each subsequent attempt. Relaxation, patience and self-acceptance are vital to a pleasurable experience.
Vagina
The vagina is a fibromuscular tubular tract leading from the uterus to the exterior of the body in female placental mammals and marsupials, or to the cloaca in female birds, monotremes, and some reptiles. Female insects and other invertebrates also have a vagina, which is the terminal part of the...
l penetration, including sexual intercourse
Sexual intercourse
Sexual intercourse, also known as copulation or coitus, commonly refers to the act in which a male's penis enters a female's vagina for the purposes of sexual pleasure or reproduction. The entities may be of opposite sexes, or they may be hermaphroditic, as is the case with snails...
, insertion of tampon
Tampon
A tampon is a mass of cotton or rayon or a mixture of the two inserted into a body cavity or wound to absorb bodilyfluid. The most common type in daily use is designed to be inserted into the vagina during menstruation to absorb the flow of menstrual fluid...
s and/or menstrual cups, and the penetration involved in gynecological examinations. This is the result of a reflex of the pubococcygeus muscle
Pubococcygeus muscle
The pubococcygeus muscle or PC muscle is a hammock-like muscle, found in both sexes, that stretches from the pubic bone to the coccyx forming the floor of the pelvic cavity and supporting the pelvic organs. It is part of the levator ani group of muscles.-Function:The Pubococcygeus muscle controls...
, which is sometimes referred to as the "PC muscle". The reflex causes the muscles in the vagina to tense suddenly, which makes any kind of vaginal penetration—including sexual intercourse
Sexual intercourse
Sexual intercourse, also known as copulation or coitus, commonly refers to the act in which a male's penis enters a female's vagina for the purposes of sexual pleasure or reproduction. The entities may be of opposite sexes, or they may be hermaphroditic, as is the case with snails...
—painful or impossible.
A woman suffering from vaginismus does not consciously control the spasm. The vaginismic reflex can be compared to the response of the eye shutting when an object comes towards it. The severity of vaginismus, as well as the pain during penetration (including sexual penetration), varies from woman to woman.
Primary vaginismus
A woman is said to have primary vaginismus when she has never been able to have penetrative sex or experience vaginal penetration without pain. It is commonly discovered in teenagersAdolescence
Adolescence is a transitional stage of physical and mental human development generally occurring between puberty and legal adulthood , but largely characterized as beginning and ending with the teenage stage...
and women in their early twenties, as this is when many young women in the Western world first attempt to use tampon
Tampon
A tampon is a mass of cotton or rayon or a mixture of the two inserted into a body cavity or wound to absorb bodilyfluid. The most common type in daily use is designed to be inserted into the vagina during menstruation to absorb the flow of menstrual fluid...
s, have penetrative sex, or undergo a Pap smear. Women with vaginismus may be unaware of the condition until they attempt vaginal penetration. It may be confusing for a woman to discover she has vaginismus. She may believe that vaginal penetration should naturally be easy, or may be unaware of the reasons for her condition.
A few of the main factors which may contribute to primary vaginismus include:
- a condition called vulvar vestibulitisVulvar vestibulitisVulvar Vestibulitis Syndrome , vestibulodynia, or simply vulvar vestibulitis is vulvodynia localized to the vulvar region. It tends to be associated with a highly localized “burning” or “cutting” type of pain....
syndrome, more or less synonymous with focal vaginitisVaginitisVaginitis is an inflammation of the vagina. It can result in discharge, itching and pain, and is often associated with an irritation or infection of the vulva. It is usually due to infection. The three main kinds of vaginitis are bacterial vaginosis , vaginal candidiasis, and trichomoniasis. A...
, a so-called sub-clinicalSub-clinicalSub-clinical is a medical term referring to a disease process that has initiated but has not yet manifested symptoms.One example is sub-clinical hypothyroidism, where a patient will manifest none of the typical symptoms of hypothyroidism, and blood tests will show a normal T3 and T4, but an...
inflammation, in which no pain is perceived until some form of penetration is attempted; - urinary tract infectionUrinary tract infectionA urinary tract infection is a bacterial infection that affects any part of the urinary tract. Symptoms include frequent feeling and/or need to urinate, pain during urination, and cloudy urine. The main causal agent is Escherichia coli...
s; - vaginal yeast infectionsCandidiasisThrush redirects here. For the hoof infection see Thrush .Candidiasis or thrush is a fungal infection of any of the Candida species , of which Candida albicans is the most common...
; - sexual abuseSexual abuseSexual abuse, also referred to as molestation, is the forcing of undesired sexual behavior by one person upon another. When that force is immediate, of short duration, or infrequent, it is called sexual assault. The offender is referred to as a sexual abuser or molester...
, rapeRapeRape is a type of sexual assault usually involving sexual intercourse, which is initiated by one or more persons against another person without that person's consent. The act may be carried out by physical force, coercion, abuse of authority or with a person who is incapable of valid consent. The...
, other sexual assaultSexual assaultSexual assault is an assault of a sexual nature on another person, or any sexual act committed without consent. Although sexual assaults most frequently are by a man on a woman, it may involve any combination of two or more men, women and children....
, or attempted sexual abuse or assault; - knowledge of (or witnessing) sexual or physical abuse of others, without being personally abused;
- domestic violenceDomestic violenceDomestic violence, also known as domestic abuse, spousal abuse, battering, family violence, and intimate partner violence , is broadly defined as a pattern of abusive behaviors by one or both partners in an intimate relationship such as marriage, dating, family, or cohabitation...
or similar conflict in the early home environment; - fear of pain associated with penetration, particularly the popular misconception of "breaking" the hymenHymenThe hymen is a membrane that surrounds or partially covers the external vaginal opening. It forms part of the vulva, or external genitalia. The size of the hymenal opening increases with age. Although an often practiced method, it is not possible to confirm with certainty that a girl or woman is a...
upon the first attempt at penetration, or the idea that vaginal penetration will inevitably hurt the first time it occurs; - personality traits such as pain-catastrophizing cognitions and harm-avoidanceHarm avoidanceIn psychology, harm avoidance is a personality trait characterized by excessive worrying; pessimism; shyness; and being fearful, doubtful, and easily fatigued...
behaviour can aid in keeping these women in the vicious cycle of vaginismus; - being sexualized or told about sex in violent or inappropriately graphic terms, before an age at which one is comfortable with such information;
- any physically invasive trauma (not necessarily involving or even near the genitals);
- generalized anxiety;
- stress;
- negative emotional reaction towards sexual stimulation, e.g. disgust both at a deliberate level and also at a more implicit level;
- strict conservative moral standards with low liberal moral standards — a general difficulty at doing 'wrong' or behaving in ways perceived as transgressive, which also can elicit negative emotions.
Occasionally, primary vaginismus is idiopathic
Idiopathic
Idiopathic is an adjective used primarily in medicine meaning arising spontaneously or from an obscure or unknown cause. From Greek ἴδιος, idios + πάθος, pathos , it means approximately "a disease of its own kind". It is technically a term from nosology, the classification of disease...
.
Vaginismus has been classified by Lamont according to the severity of the condition. He describes four degrees of vaginismus: In first degree vaginismus, the patient has spasm of the pelvic floor which can be relieved with reassurance. In second degree, the spasm is present but maintained throughout the pelvis even with reassurance. In third degree, the patient elevates the buttocks to avoid being examined. In fourth degree vaginismus (also known as grade 4 vaginismus), the most severe form of vaginismus, the patient elevates the buttocks, retreats and tightly closes the thighs to avoid examination. Pacik expanded the Lamont classification to include a fifth degree in which the patient experiences a visceral reaction such as sweating, hyperventilation, palpitations, trembling, shaking, nausea, vomiting, losing consciousness, wanting to jump off the table, or attacking the doctor. The Lamont classification continues to be used to the present and allows for a common language among researchers and therapists.
However, it does not provide for a language with which a woman might best be able to verbalise her concerns, pain or problems. A woman with a lot of trust in the doctor might be classified as 1 but experience severe pain. A woman with less trust, or a woman who is or has been subjected to harsh examination, might be classified as 4 or 5 even if the physical discomfort she experiences with attempts at penetration in non-clinical settings is comparatively mild.
Though spasm of the pubococcygeus muscle is commonly thought to be the primary muscle involved in vaginismus, Pacik identified two additionally-involved spastic muscles in treated patients under sedation. These include the entry muscle (bulbocavernosum) and the mid-vaginal muscle (puborectalis). This accounts for the common complaint that patients often report when trying to have intercourse: "It's like hitting a brick wall".
Secondary vaginismus
Secondary vaginismus occurs when a woman who has previously been able to achieve penetration develops vaginismus. This may be due to physical causes such as a yeast infection or trauma during childbirthChildbirth
Childbirth is the culmination of a human pregnancy or gestation period with the birth of one or more newborn infants from a woman's uterus...
, while in some cases it may be due to psychological causes, or to a combination of causes. The treatment for secondary vaginismus is the same as for primary vaginismus, although, in these cases, previous experience with successful penetration can assist in a more rapid resolution of the condition.
Prevalence
The prevalence of vaginismus has been reported to be 6% in two widely divergent cultures, Morocco and Sweden. The prevalence of manifest dyspareuniaDyspareunia
Dyspareunia is painful sexual intercourse, due to medical or psychological causes. The symptom is reported almost exclusively by women, although the problem can also occur in men. The causes are often reversible, even when long-standing, but self-perpetuating pain is a factor after the original...
has been reported as low as 2% in elderly British women, yet as high as 18–20% in British and Australian studies.
Another study documented vaginismus rates of between 12% and 17% being reported in women presenting to sex therapy clinics (Spector and Carey 1990). The National Health and Sexual Life Survey, which used random sampling and structured interviewing, found that between 10% and 15% of women reported having experienced pain during intercourse during the previous 6 months (Laumann et al. 1994).
The most recent study-based estimates of vaginismus incidence range from 5% to 47% of people presenting for sex therapy or complaining of sexual problems, with significant differences across cultures (see Reissing et al. 1999; Nusbaum 2000; Oktay 2003). It seems likely that a society's expectations of women's sexuality may particularly impact on these sufferers.
Treatment
There are a variety of factors that can contribute to vaginismus. These may be physicalPhysical
Physical may refer to:*Body, the physical structure of an organism**Human body, the physical structure of a human*Physical abuse, abuse involving contact intended to cause feelings of intimidation, injury, or other physical suffering or bodily harm...
or physiological, and the treatment required can depend on the reason that the woman has developed the condition. As each case is different, an individualized approach to treatment is useful. The condition will not necessarily become more severe if left untreated, unless the woman is continuing to attempt penetration, despite feeling pain. Some women may choose to refrain from seeking treatment for their condition, or be unaware that treatment might be available or even that their difficulties constitute a medical condition.
According to the Cochrane Collaboration
Cochrane Collaboration
The Cochrane Collaboration is a group of over 28,000 volunteers in more than 100 countries who review the effects of health care interventions tested in biomedical randomized controlled trials. A few more recent reviews have also studied the results of non-randomized, observational studies...
review of the scientific literature, "In spite of encouraging results reported from uncontrolled case series there is very limited evidence from controlled trials concerning the effectiveness of treatments for vaginismus. Further trials are needed to compare therapies with waiting list control and with other therapies." Although few controlled trials have been carried out, many serious scientific studies have tested and supported the efficacy of the treatment of vaginismus. In all cases where the systematic desensitization method was used, success rates were approximately 90% or better. For an example of one of these studies, see Nasab, M., & Farnoosh, Z.; or for a basic review, see Reissing's literature review (links below). A Dutch study showed that many women were subsequently able to be penetrated, but far fewer women actually enjoyed being penetrated.
One treatment that is employed is the use of vaginal probes. Vaginal probes are graduated or tapered blunt-ended probes. They come in different sizes, usually no larger than the size in length and diameter of a tampon. Here, the woman can work with a trusted nurse practitioner, doctor, or other person trained in sexual dysfunction and disorder, to help her organize a therapeutic program to (slowly and gradually) assist her in overcoming her fear of penetration. Vaginal probes are introduced into the woman's vagina, usually with her own hand so that she can maintain control both physically and psychologically over the rate of insertion. This procedure requires a great amount of trust and compassion to take place between the patient and the practitioner for the outcome to be successful.
Psychological
According to Ward and Ogden's qualitative study on the experience of vaginismus for women (1994), the three most common contributing factors to vaginismus are fear of painful sex; the belief that sex is wrong or shameful (often the case with patients who had a strict religious upbringing); and traumatic early childhood experiences (not necessarily sexual in nature).Vaginismus patients are twice as likely to have a history of childhood sexual interference and held less positive attitudes about their sexuality, whereas no correlation was noted for lack of sexual knowledge or (non-sexual) physical abuse.
For some women, especially those with primary vaginismus, it is important to address the psychological aspects of the problem as well as the actual muscle spasm. A woman may choose to address the issue on her own terms, or she may seek the help of a therapist. Some women, especially those with secondary vaginismus, may rely on a physical rather than psychological treatment and also be successful. There are emotional difficulties associated with vaginismus, even for women whose vaginismus has a purely physical cause, which can include low self-esteem, relationship issues, continuing fear of penetration, and depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
.
Physical
Physical treatment of the internal spasms may include sensate focus exercises, exploring the vagina through touch, and desensitizationDesensitization
Desensitization can refer to:* Desensitization * Desensitization * Desensitization * Desensitization of explosives, see Phlegmatized...
with vaginal dilators. Dilation therapy involves inserting objects into the vagina. When treating the spasms through dilation, the dilators, or probes, used are replaced with gradually larger sizes as the woman progresses.
Paralytics
In cases of vaginismus where more traditional treatments have not been successful, a paralytic agent such as Botox may be used. Botox offers an option that allows women who deeply fear penetration to the point where dilators are "too scary" to move ahead despite this fear. The use of Botox relaxes the muscle spasm for about four months. Optionally, if the procedure is carried out under sedation or general anesthesia, the patient may awaken having already achieved what is usually the hardest first step: the insertion of a dilator. The anesthesia works in concert with the Botox injection(s) to ensure that her first experience with the dilator is not painful.Sexuality
If a woman suspects she has vaginismus, sexual penetration is likely to remain painful or truly impossible until her vaginismus is addressed. This is a highly frustrating condition, as other people, including doctors, may speculate negatively on the origin or existence of her difficulties. Vaginismus does not mean that a woman is frigid, does not want intercourse or does not love her partner. Women with vaginismus may be able to engage in a variety of other sexual activities, as long as penetration is avoided. Sexual partners of vaginismic women may come to believe that vaginismic women do not want to engage in penetrative sex at all, though this may not be true for most such women. There is currently no indication that vaginismus reduces the sexual drive or arousal of affected women, and as such it is likely that many vaginismic women wish to engage in penetrative sex to the same degree as unaffected women, but are deterred by the pain and emotional distress that accompanies each attempt. Psychological pressure to "perform" sexually or become aroused quickly with a partner can deter the sufferer from future attempts and/or cause her vaginismus to become more severe.Masturbation
Many people do not realize that even women without vaginismus commonly experience pain or discomfort upon attempting sexual penetration without being sufficiently aroused. Most women acknowledge sexual arousalSexual arousal
Sexual arousal, or sexual excitement, is the arousal of sexual desire, during or in anticipation of sexual activity. Things that precipitate human sexual arousal are called erotic stimuli, or colloquially known as turn-ons. There are many potential stimuli, both physical or mental, which can cause...
as vital to achieving comfortable penetration.
One of the problems which may accompany vaginismus is that a woman may be extremely hesitant to engage in penetrative sexual activity with others, due to a fear of pain associated with any kind of vaginal penetration. Solo masturbation, with penetration, can alleviate this fear.
Orgasm
Orgasm
Orgasm is the peak of the plateau phase of the sexual response cycle, characterized by an intense sensation of pleasure...
need not be the only goal of masturbation. It may also serve to increase comfort with the genital area, to explore various sensations through genital and clitoral touch, and to become aware of those sensations which are relaxing and pleasurable. Sexual arousal causes changes in the shape and color of the vulva
Vulva
The vulva consists of the external genital organs of the female mammal. This article deals with the vulva of the human being, although the structures are similar for other mammals....
, as well as in the vaginal lubrication
Vaginal lubrication
Vaginal lubrication is a lubricating fluid that is naturally produced in a woman's vagina. Vaginal lubrication or moistness is present at all times, but production increases significantly during a woman's sexual arousal in anticipation of sexual intercourse...
produced. As a woman becomes more aware of her individual sexual response, she can learn which sensations are best for bringing her to a state of arousal. She will then be better equipped to teach her partner which sensations feel best for her.
Emotional experiences
A woman who is interested in having (or, at minimum, willing to have) intercourse, and finds that her vagina responds with a reflex that makes intercourse impossible, is likely to experience a wide range of emotions, from amazement to grief to embarrassment. Some women may already have negative associations with their genitals, including fears that their genitals are ugly, dirty, or sinful. Now "useless" may be added to such a list.These associations can lead to negative emotions arising during any kind of sexual expression, including masturbation, and these emotions can take time to process. Feelings of shame, inadequacy or a fear of being "defective" can be deeply troubling. If multiple attempts at penetration are made before treating vaginismus, it may lead to fear of sexual intercourse, and worsen the amount of pain experienced with each subsequent attempt. Relaxation, patience and self-acceptance are vital to a pleasurable experience.
External links
- Vaginismus – Causes, Diagnosis, Treatment & Self Help entry in NHS Direct Health Encyclopaedia (UK)
- Vaginismus Research at University of Groningen, Netherlands (Females needed for recruitment)