Is your vagina uncooperative when it comes to sex?  Are you unable to have penetration or it feels like there is a brick wall in there?  You might have vaginismus.  Dr. Becky Lynn, Director of Evora Center for Menopause and Sexual Health, speaks with Megan Normille, PT and Program Director at SSM Health Physical Therapy, on the topic of Vaginismus. Vaginismus is an involuntary tight contraction of muscles around the opening of the vagina that makes putting anything in the vagina painful.

 Dr. Lynn: Hello, I’m Dr. Becky Lynn. I am a board-certified gynecologist, menopause and sexual health expert at The Evora Women’s Health.  We treat women with problems like painful sex, low libido and orgasm difficulties. We also offer a full scope plan for treating your menopausal symptoms, all of them, not just hot flashes.  Today, we are going to talk about a condition known as vaginismus, which can lead to painful sex or prevent women from having sex at all. I want to introduce you to Megan.

 Megan: Hello, I am a physical therapist with SSM health Physical Therapy and my specialty is pelvic floor dysfunction in women. I am excited to talk about vaginismus because we see so many women with this terrible problem.

 Dr. Lynn: Let’s start with what is vaginismus and what is happening anatomically. The vagina is a long hollow tube that is surrounded by muscles. Vaginismus occurs when there is involuntary contraction of the muscles that surround the vagina. Many women with vaginismus can't have penetration at all because the muscles are so contracted. I often hear my patients say "he is hitting a wall" or “he can't get in”. Many times they have seen several providers in the past and they’ve been told, “oh just relax, drink a glass of wine.” I cringe when I hear this because wine is not going to fix the problem.  Physical therapy is the first step in treating vaginismus, although not the only step.  Megan, how do you go about treating vaginismus with physical therapy?

 Megan: We start with education about the condition. We need to make sure our patients understand that it's not in their head and it's not, like you said, a conscious decision. It usually is something that has been going on for a long time. Recognizing and appreciating the frustration that women feel, and understanding that this is not something women should just power through either, goes a long way in helping our patients.

 When I work with patients, I respect what the body is going through and how the patient is feeling. We start all of the physical therapy externally.  We need to get the muscles to let go first, then we can work on stretching the muscle. We work on different ways to get the muscles to release. Sometimes that’s through diaphragmatic or belly breathing.  Sometimes it is through visualization, where we use a mirror to look at those muscles. I do a lot of education about getting comfortable with the vagina, vulva and the surrounding muscles. We talk about where those muscles are and what their functions are.

 Dr. Lynn: Will you tell us a little more about the function of the muscles?

 Megan- Basically the muscles have three primary functions. One is the “sphincter” function. The sphincters open and close and they help with bowel and bladder functions. The muscles also play a role in normal sexual functioning.  The third function is to support, to hold everything in from the bottom and that includes the internal organs and pelvic organs like the uterus and bladder. We tend to think that the muscles are either relaxed or contracted, that there is an on or off switch.  But that is not the case.  We teach our patients to try to turn down the contraction a bit so they can allow and enjoy sex.

 Dr. Lynn: One way I describe the pelvic floor muscles to my patients is to think of a human skeleton and picture the pelvis. I describe the pelvic floor musculature as a hammock that supports everything, so your organs don’t fall out the bottom when you’re standing up.You mention “diaphragmatic breathing”. What does that mean?

 Megan: Diaphragmatic breathing, also known as belly breathing, is one of my favorite techniques to teach my patients. Diaphragmatic breathing is when you breathe very deeply, high up in the ribcage. When you inhale, the diaphragm, the layer of muscle that sits right underneath the lungs, comes down to give your lungs room to expand. Then the pelvic floor comes down and relaxes just because you are breathing deeply. They work in concert.  When we take short shallow breathes, the diaphragm and pelvic floor muscles stay fixed and they can’t relax. If we can get somebody doing diaphragmatic breathing, then the pelvic floor is automatically going to be moving and relaxed. When the person inhales, the belly fills with air and then when the person exhales their belly is going to go back down.  Many times we will place hands on the belly while the patient is laying down on their back. They are in a comfortable position working on belly breathing that way.

 Dr. Lynn:  Sometimes when my patient can't get to pelvic floor physical therapy, I will recommend yoga because they teach belly breathing which relaxes the pelvic floor musculature. Yoga also strengthens your core and improves flexibility throughout the pelvis.  You also mentioned visualization as a way to treat vaginismus.  Can you tell me about that?

 Megan: Sometimes we do visualization, which is having the patient look at the tissue. This is done using the mirror. The vulva (outside of the vagina) is an area of the body we can’t see very easily and if it's been something that's painful, it's sort of scary to look at. When we google what it is or looks like, we really don’t know what "normal" is. In my practice, when I tell someone to “just relax” the muscles, it is difficult for patients to do. It is like telling someone to walk and then it makes walking more difficult.  When we say make the muscles “mushy” or “soft” or “let go” while looking at the tissue, they can understand relaxation better.

 Dr. Lynn: Do you ever use biofeedback?

 Megan: Yes, we do. In biofeedback we use stickers that go on the outside (nothing is inserted), that measure if a muscle is contracting or not.  Then we can show patients what it feels like when the muscles are contracted and what it feels like when they are relaxed.  

 Dr. Lynn How about dilator use?

 Megan: I have a love-hate relationship with dilators. I think they can be very helpful but patients need to learn how to use them or they won’t help and might make things worse. 

 Dr. Lynn: I agree. I never hand somebody a dilator and say go home and use this.

 Megan: When the muscles are still contracted, it's can be painful to insert the dilator. We want the dilator use to be pain-free. Before using a dilator, we need to get the 3 layers of muscles relaxed. We need to get the outer layers “mushy” or “let go” first, before we work on the inner layer. If those outer layers are still contracted and painful, dilator use won’t be successful in the way we want it to be.  Dilators can be very helpful, but it's usually later on in the treatment.

 Dr. Lynn:  I recommend thinking of dilators as “desentiziers”. Once my patients can relax the pelvic floor musculature, then I recommend that they try to insert the smallest dilator and gradually move up. I explain it by saying that using the dilator tells the brain that you can have something in the vagina and it not be painful. The other thing I've noticed with my patients is that it gives them confidence to try and have sex because they know they are able to have something in the vagina without pain.  If a large dilator can sit in the vagina and the patient is pain free, then they are more likely to go give penetration a try.

 Megan: With intercourse, there is a lot of movement too. We use dilators to work up to rotations and some slight in and out movements. This can bridge the gap between physical therapy and actual intercourse. I will even have the partner of the patient insert the dilator if they feel comfortable. This helps patients get them used to somebody else touching them.

 Dr. Lynn:  Right, I definitely think it's different when somebody else is touching you because you lose control, and I think that can make people very anxious. Once you lose control it becomes that much harder to do your deep breaths. I often recommend that when the woman does decide to have intercourse, that she be the one in control. She should be the one to guide the penis into the vagina, because it takes away the anxiety of being out of control and that makes a big difference.

 Megan: I talk a lot about boundaries. The patient may say to her partner "we are going to work on touching and desensitizing the external tissue", nothing further. That's the boundary that she has set. Then there's a mutual expectation of it not progressing further. Having those boundaries from the beginning can be very helpful.

 Dr. Lynn: I always learn so much when I talk to you because we approach the problem from such different angles.

 Megan: I’m curious what you tell patients about the time frame? I get asked a lot “how long is this going to take?”

 Dr. Lynn: This is a very long process and I think it's really important to set that expectation.  Having treated vaginismus over the long term for many years, I explain to patients that we take baby steps and it's not going to go away overnight. We make a little progress, then most people back up a little bit, and then a little progress forward again. Maybe they hit a stumbling block. It is baby steps forward and then a couple of steps back. But eventually, many women get past the vaginismus and are able to have pleasurable sex without pain. Many go on to get pregnant and have babies!

 Megan: We always do a little cheer when that happens so we can celebrate success with our patients. But you are right, it definitely can get better and can be successful and a good positive experience. As for the time frame, I try to be clear upfront that it is different for everybody. There are so many factors that play into it.

 Dr. Lynn: One thing that I want to say about vaginismus is that it is really important that you see a sexual medicine specialist or a pelvic pain specialist when you get the diagnosis because vaginismus can be due to several other medical conditions. It can be due to endometriosis, interstitial cystitis, irritable bowel syndrome, a history of sexual abuse or trauma, back and hip pain, and/or a lack of hormones. If you have vaginismus and let's say you found that diagnosis on the internet, and you go to pelvic floor physical therapy and nobody is treating the endometriosis or the irritable bowel, then pelvic floor physical therapy alone won’t cure the vaginismus. Only treating all of the contributing factors will. It is very important that you see someone who has knowledge in vaginismus and pelvic pain.

 Megan: I agree.  Many practitioners don’t have the expertise and that's when we hear "have a glass of wine" and other comments I like to think are well intentioned, but are not very helpful.

 Dr. Lynn: Patients get told it’s all in their head. Patients are relieved to know there's a reason they have this.

 Megan: Just the words, “you are not alone” can ease patients fears. Because of HIPAA we don't introduce patients to each other but there are so many patients out there with the same diagnosis. It's not as unusual as you would think.

 Dr. Lynn: Is there anything else you would like to add?

 Megan: I think that is about it.

 Becky- Alright, thank you for tuning in and we will see you soon! 

See this conversation on YouTube: https://www.youtube.com/watch?v=JZG9YD8-6is

 Dr. Becky Lynn is a national and international speaker, gynecologist and menopause and sexual medicine specialist.  She has been featured in Best Doctors in St. Louis, Martha Stewart Living and Self Magazine.  If you would like to make an appointment to see Dr. Lynn, call 314 934 0551 or go to her website.  Evorawomen.com.  You can even schedule a 15 minute visit just to get to know Dr. Lynn and see if she is the right fit for you.  If you have any questions, please email us at info@evorawomen.com. She is licensed to practice medicine in Missouri, Tennessee and Illinois.  She she sees patients in her St. Louis office and offers telehealth consults to Illinois and Tennessee.  Call today to schedule your appointment.  (314) 934-0551 or click here to schedule.