Vaginismus is caused by an involuntary contraction of pelvic floor muscles and often coupled with poor lubrication.
Attempts to get around the problem by using a lubricant usually do not help. Water based lubricants, the most commonly used type, are too slippery if penetration is achieved to get pleasurable sensation and rub off quickly leaving no lubrication causing more pain. Silicone based lubricants or organic oils may be better but only if there is no involuntary contraction of pelvic floor muscles. Astroglide may work.
The problem is usually referred to as psychosexual implying that it is “all in the patient’s head”. This is mostly unfair as the muscle contraction is subconscious and may be best considered as a spinal reflex. Most women are not aware that they have muscle contraction causing the pain. They may even say that intercourse with their partner used to feel good but now his penis feels too big. However, some cases do have a psychosexual origin initially such as sexual abuse when younger.
Vaginismus is diagnosed by digital vaginal examination which finds contacted muscles just inside the introitus. Pressure on the muscles will cause the pain felt with vaginismus.
If the patient can be distracted by conversation while applying gentle pressure on the contracting muscle, the muscle may start to relax and the pain gets less. Any movement of the finger(s) will usually then cause a sudden increase in the pain.
Sometimes, a painful scar may be found as well as muscle contraction. This may need to be surgically relaxed but experience is need to decide if it is best fixed before or after the patient is taught to relax during examinations.
If a painful scar is present and dilators are used at first, it is usually obvious to the woman when the scar needs to be relaxed surgically. Only occasionally will the scar be stretched sufficiently by dilators.
If sexual abuse has been involved, this may need to be resolved with the aid of councillors, psychologists or psychiatrists either before, during or after the use of dilators. This is the most difficult cause to stop vaginismus.
After menopause, vaginal atrophy will need to be treated first. Many patients respond well to vaginal oestriol cream. If they cannot use the cream such as if they are allergic to it, have had oestrogen receptor positive breast cancer or will not use it for some other reason, the MonaLisa laser usually works very well.
If especially after menopause there has been no penetrative sex for some time, the vagina may physically shrink and oestrogen cream plus dilators cannot overcome this. The MonaLisa laser treatment is then usually successful in allowing dilation using glass dilators.
The importance of adequate foreplay should be emphasised to both partners as a key to continuing comfortable and hopefully pleasurable penetrating sex.
Many years ago, I went to an Australian course in treating vaginismus
We were all told that the course organisers sent all of their patients to a psychoanalyst. We were told of a 50% success rate after two years of treatment.
I suspect that after two years of psychoanalysis, virtually no patients were cured but 50% said they were in order to opt out of their frequent psychoanalytic sessions.
I believe that for almost all of the patients that I see and treat, the problem is not “in their mind”. It is a physical reaction at a subconscious level to trauma that was usually vaginal. Some may have confounding problems but the cornerstone of successful treatment of slowly teaching the pelvic floor muscles to relax by physical means. This approach leads to a very high success rate.