"It feels like I'm having sex with a butcher knife..."
"...It feels like there's a brick wall, nothing can get past it"
"I get this shooting pain throughout my back and abdomen with penetration..."
"...Every time my partner mentions having sex I feel anxiety"
I had a client recently tell me, "It has always hurt to have sex. I lived in essentially a sexless marriage for so long because of it. I mentioned it to my OBGYN but they kind of just...blew me off. So I figured that was normal, and it would be something I'd have to live with forever."
This isn't the first time I've heard a complaint like this, and sadly I don't think it'll be the last.
It's 2023, and the medical field still perpetuates the belief that painful sex isn't a concern. After all, many insurances won't even cover treatment for painful intercourse as it's not seen as a necessary part of living.
There are numerous reasons why penetration may be painful. At this point we aren't only talking about sexual intercourse, we are talking about pain with inserting a tampon, a finger, or a speculum at the gynecologist's office. This complaint is commonly called Vaginismus, but not all pain falls under the umbrella of that term. The purpose of this blog post is to touch on many reasons penetration may be painful, as well as recommendations on next steps.
What is Vaginismus?
Pelvic floor muscle tightening / tensioning with penetration
Anxiety or fear surrounding penetration.
That's a lot to wrap your head around. Essentially, the two most common issues women complain of with painful penetration are:
Restricted or impossible vaginal penetration. "It feels like there is a brick wall in the way."
Pain, or anticipation of pain, anxiety, fear, avoidance, phobia, and defensive or protective behaviors.
This can be life-long, or happen due to a certain event like abuse or childbirth. Lifelong individuals know that from the very first time they tried to put a tampon in it hurt like crazy and something wasn't right. It may hurt all of the time (global vaginismus), or may be only some of the time (situational).
What is the difference between Vaginismus and Dyspareunia?
The lines are a bit more blurred here. If you decide to simply google "what is..." for the two respective terms you get:
Dyspareunia is difficult or painful sexual intercourse.
Vaginismus is the body's autonomic fear of all or some types of penetration. This autonomic response can cause pain.
They sound very similar. They are technically, in the medical realm, described as different entities despite their clinical presentations and symptoms overlapping quite a bit. In 2013, the DSM-V merged the two together into a new classification: genito-pelvic pain / penetration disorder.
Whatever the name, it's unpleasant if not down-right life altering and debilitating.
What causes Vaginismus?
To be completely transparent, there isn't a lot of high-quality research out there that can explain why or how Vaginismus occurs. Some think it's muscle spasms causing pain, others think perhaps there was pain that increased muscle tightening or spasms. Or perhaps decreased estrogen is the culprit. What we do know is ultimately the true cause is unknown, but it is the main reason for unconsummated marriages (Pacik, 2011).
What is understood about pain, especially 'chronic' or persistent pain, is that it's a cyclical response. The longer something causes pain, the more your nervous system lowers the threshold in which a stimulus causes pain, making you more and more sensitive over time to the slightest trigger. In this way, chronic pain is very much a disease.
What might cause painful penetration other than Vaginismus?
Vaginismus is a catch-all term that is used when we have no other explanation for painful penetration. Other causes that are NOT vaginismus, but can cause pain nonetheless:
Vulvodynia / Vestibulodynia
Decreased estrogen (due to breast feeding or menopause)
Certain types of cancer and treatments
Inflammation or infection
Nerve entrapment or injury
Trauma to the surrounding tissues, such as surgery or tearing
Why does pain become so persistent?
Think of it like a small kitchen fire and a fire alarm. One day you're cooking and your stir-fry happens to light on fire. While you're putting the fire out, the alarm is screaming and eventually triggers other alarms. By the time you get the fire put out, all the alarms in your building are going off and the fire department has arrived. Unfortunately, your fire alarm resets itself to being more sensitive to burning food so that you can address the burning before it turns into a fire again.
The next time you're cooking, you slightly burn the food on the high-heat. It smells just a bit, but there is no fire. Despite this, your fire alarm is already going off and so are the other alarms. Once you get that fire alarm turned off and the food dealt with, that alarm resets again to being more sensitive.
Eventually all you have to do is look at your stove and that fire alarm starts screaming, so you decide cooking is an activity you can never do again because you're tired of the fire alarm and fire department showing up each time.
This is essentially what your body goes through as it gets more and more conditioned to pain. Pain is a trigger, and it tells your body you're in danger. You cannot easily tell your nervous system you're not in danger, similar to how you cannot look up at your ceiling and have a rational conversation with your fire alarm. While you can rip your fire alarm out of the ceiling, you cannot do that with your nervous system.
This cyclical response is called central sensitization. And it is exhausting.
What do treatment options for Vaginismus look like?
Since there are a large majority of factors that go into painful penetration, the best course of action is often seeking a multidisciplinary approach. This may mean seeing an OBGYN or physiatrist (a physical medicine and rehabilitation specialist) for medications, but definitely should include seeing a counselor or other psychological / sex therapist who can help with the emotional and anxiety driven response that comes with vaginismus and persistent pain.
Another player in the course of treatment is seeing a Pelvic Floor Physical Therapist. Physical Therapy is a first line treatment due to the fact that it's non-invasive (no medications, no surgeries).
Physical Therapy helps treat persistent and chronic pain by desensitizing the nervous system to non-threatening triggers. With that comes:
Re-training your awareness of your pelvic floor.
Allowing for graded exposure to non-threatening touch so you may receive penetration again without pain.
Manual techniques that might benefit the surrounding tissues to help them calm down and move more freely. These techniques would include myofascial or soft tissue mobilization, and trigger point release.
What can I do at home?
Until you are able to get into a provider to seek help, or are looking for some at home tips to accompany your program, you can follow this general advice below.
Tip #1: Diaphragmatic Breathing
Those who tend to experience a lot of pain also happen to be shallow-chest breathers. We tense to protect ourselves, but the issue with changing our breathing pattern in that way is it can create a heightened sympathetic drive and contribute to recurrent pain.
If you do nothing else, take 5 minutes out of your day both morning and night to deep breathe.
Tip #2: Gentle Stretching
When our pelvic floors are tight or have a lot of resting tension, it can contribute to tightness and tension in other places. Common other culprits are the hips and glutes, even the low back and abdomen.
Stretching should be gentle, held for 30 seconds and repeated 2-3x. To improve your stretching experience, including deep breathing into the routine. Picture as you breathe you melt or soften your pelvic floor like butter.
The following stretches are beneficial but by no means the only ones you can do. Avoid any that cause pain or don't feel good.
Tip #3: Become more aware of your pelvic floor
For the majority of the time our pelvic floor is under subconscious control, similar to breathing, and that's good because we don't have time on our plate to always think about it. But when you do want to think about it, you want to be able to control it and connect with it.
First, we truly have to start by visualizing our pelvic floor. Take a mirror or your phone camera and observe what your pelvic floor looks like. If you're wondering where you fall in terms of other women, looking at helpful sites like The Labia Library will show you we are all truly unique, and that our vulvas can all look as different as individual faces and still be healthy.
Second, if you are comfortable with it, comes feeling the pelvic floor like you would any other area of your body. A great way to feel your pelvic floor relax is to place a few fingers between the anus and vaginal opening. There is a soft tissue area right there called the perineum. When we relax properly, the perineum should gently descend into our fingers. If you're actively trying to let go, and are not feeling anything descend, or even feeling the tissue tighten, that may mean your tissues are either very tense at rest or you are having a slight difficulty with coordination. Whichever the case, a pelvic floor PT can help you learn to connect with your pelvic floor and control it as you would your breathing.
There are numerous reasons why sex and / or penetration may be pain. One common cause is termed Vaginismus. Vaginismus is painful penetration accompanied by fear / pain / anxiety that does not have a root source.
Vaginismus falls under the umbrella of chronic or persistent pain. Pain becomes persistent in a cyclical pattern where one day a threatening trigger resets our nervous system to be more sensitive. Over time, nonthreatening triggers, like light touch, have become just as painful and threatening to your body. This is called Central Sensitization.
Physical Therapy can treat not only persistent pain, but also Vaginismus. It is part of a multimodal approach (OBGYN, Physiatrist, Sex Therapist / Counselor etc) to help you achieve your goals.
Tips and tricks to try before you get in for treatment are to 1) deep breathe regularly as part of your plan to calm the nervous system down, 2) stretch the pelvic floor gently and regularly, 3) become more familiar with and aware of your pelvic floor.
About the Author:
Caroline Gamwell, DPT is a Doctor of Physical Therapy specializing in Pelvic Floor and Women's Health. She is the founder of Worth It PT based in Denver, Colorado, a clinic whose focus is to help others achieve their health and wellness goals through a higher quality of healthcare.