Category: Time to talk treatment

‘Spending all night on Facebook reading threads from strangers, alone in the dark, under my snuggie, is SO much fun on a Saturday night!’ Said no one, ever.

 

Luckily for you this genius GINA has taken all the research, guesswork, Facebook groups, Youtube videos, and Reddit AMAs off your hands and below you will find a simple, straightforward breakdown of the most common treatments for vaginismus. 

It’s important to remember that vaginismus is a neuropathic pain, meaning the nerves in the body are signaling pain up to the brain from your vagina. Therefore, the best approach to treatment is a holistic and multidisciplinary approach; we want to treat the mind and body in a number of ways together. 

Think of treatment like a buffet; you can pick and choose what you like. Feel like having dessert first? Go for it! Need to spend more time in the appetizer section? You sure can!

So go ahead and work your way through each type of treatment and then we can regroup and go through what a possible treatment plan could look like for you. 

Yes, breathing exercises! This is where we begin, and I know what you’re thinking, ain’t nobody got time for that! But this is one of the core exercises you must master as a little grasshopper. 

Breathing seems pretty straight forward but breathing to relax the pelvic floor is what we really need to focus on.

Together, we are going to learn the basics of diaphragmatic breathing, aka filling your diaphragm with air, which in turn lowers and relaxes your pelvic floor. 

1. Sit comfortably. If you are sitting on something, try to sit with your knees bent and your shoulders, head, and neck relaxed. If you are sitting on the floor the same applies; get comfortable and relax your upper body. 
2. Place one hand on your upper chest and the other just below your rib cage so you can feel your diaphragm move as you breathe
3. Breathe in slowly through your nose so that your stomach moves out against your hand, the hand on your chest should remain as still as possible (your tummy should kind of feel like a balloon filling with air) 
4. You will notice your pelvic floor move down and relax (yay!), try and keep this relaxed state as you slowly breathe out through your mouth or nose 
5. Repeat! 

Overactive pelvic floor muscles are not something that’s easily noticed by people day-to-day, in fact, many people notice a lack of tension in their pelvic floor and often exercise to increase strength in the pelvic floor (think kegel exercises).

However, people with vaginismus often have an overactive and tight pelvic floor, or even trigger points or specific areas of tension within the muscle that can feel painful when pressed.

The goal with pelvic floor exercises is to combine simple stretches with mindful breathing techniques to loosen the muscles in and around the pelvis and relax the pelvic floor.

So, you probably skipped the breathing exercises topic thinking you knew everything there was to know about breathing? Go back, because you’ll need to combine these techniques with the pelvic stretches below. 

Ok, now you’re all caught up on how to breathe (lol ok thanks). Below you will find a number of simple stretches that are designed to loosen the pelvic region. Follow the stretching plan and hold each stretch for 30 seconds as you breathe mindfully into your belly.

Remember to stretch both the left and right sides. These exercises will help most when done every day and most GINAs find it useful to do these in the evenings as it relaxes them before bed and loosens their bodies from a busy day. 

 

 

 

 

 

 

 

 

Remember – the most important exercise is an internal one, contracting and relaxing your pelvic floor. Kinda hard to do. 

 

TO NOTE! (aka important)

These exercises should not cause pain, if you do feel pain visit your doctor or physiotherapist, they can investigate further or give you some alternative stretches to suit your body.

If you find these hard to do based on just the images, go ahead and find a video on YouTube by searching ‘pelvic floor guided relaxation’ or search for one of the poses named above.

This will ensure you are holding and performing the stretches properly and will help you get into a routine if you have never tried this before. 

 

Further along, we will discuss physiotherapy in more detail, but any good pelvic floor physio will teach you these stretching and breathing techniques. These are the basics baby, you gotta be able to tango before you can foxtrot! 

You may not have heard of Pelvic Floor Physiotherapists (PFPs) but we thank Beyonce every damn day they exist because your vagina will love them!

A typical physiotherapist treats pain and mobility issues by teaching patients gentle stretches and exercises. A pelvic floor physio is specially trained to help rehabilitate pelvic floor muscles. (Wahooo thank you PFPs!) 

PFPs can help people rehabilitate their pelvic floor muscles that may have been weakened by childbirth, surgery, heavy lifting, constipation, or menopause AND they can also help treat pelvic floor muscles that work overtime, even when no one has asked and no, they are not getting paid! 

 

Your First Appointment 

So what exactly do you do at the PFP and how should you prepare?

Your first PFP appointment will most likely include a diagnosis of vaginismus, as your regular doctor may not be across all the symptoms, (or heck they may not even understand what vaginismus is), so usually, the PFP will be able to give you an accurate and informed diagnosis. Hallelujah! 

Your first PFP appointment will usually begin with a questionnaire on any relevant medical history and the type of pain you are experiencing in your pelvic region. It could be important for you to include any medications you are on or any accidents or injuries you have had. 

Your PFP will then ask you to describe the pain you are feeling, where it is, and what situations trigger it. 

 

They should then explain the pelvic floor muscles and how they work in detail and may ask you whether you have heard the term ‘vaginismus’ before (lol yeah only about 1000 times since I became woke to the world of sexual pain). 

Your PFP may also ask you whether you are comfortable with having a physical examination and if you feel safe and comfortable to do so you may agree. 

They will wear gloves and use a lubricant to perform the physical examination, which usually consists of touching on the outside of the vulva, examining inside the vagina (if possible), and the pelvic floor muscles within.

It could also include pressing the muscles around your pelvic region (tummy, thighs, buttocks). Usually, if your pelvic floor is holding lots of tension these surrounding muscles will also be tight. 

 

Your PFP may ask you to describe or rate the intensity of any discomfort or pain you may be feeling, however, they should not hurt you or push you if you are experiencing pain or discomfort.

The purpose of the examination is to understand and locate the pain, not cause excessive pain or discomfort. This part can often feel weird and scary but remember you can stop at any time and your PFP is there to guide you and support you. 

 

What won’t happen during your session: 

1. Multiple choice test on the history of the burrito
2. Sharing of Netflix passwords and account details 
3. Nail art of any kind 

 

After your first appointment, your PFP could refer you to a sex psychologist, recommend you start using dilators, ask that you undergo further tests or examinations, give you a list of breathing and stretching exercises to do, or provide some further literature to help you understand your condition (hold your horses! we will cover all of these). 

Once you are at a stage where you can tolerate insertion, your PFP may also recommend regular visits to work on internal muscle massage and relaxation.

Yes, we are basically discussing an internal massage for the pelvic floor.

Yes, that means your PFP will massage you from the inside and work on relaxing and unlocking the tension you carry in your pelvic floor. BONKERS! But effective. 

 

Reminders 

Some important things to remember before your appointment: 

1. Some people may feel more comfortable being examined by a female PFP (that’s totally ok, and not a weird thing to ask when booking your appointment so feel free to ask the receptionist on the phone if you are unsure! Names can be tricky and the most important thing is that YOU feel comfortable) 
2. Any good PFP will ask or instruct you on what they are doing before or as they are doing it (‘is it ok if I touch you here?’, ‘I am just going to put some pressure on this spot’) if your PFP is not doing this, you can always ask that they explain or prepare you before they make any movements during your examination, to make you feel more comfortable 
3. It is totally 100% ok to cry! Seriously, we mean it.  PFPs have seen it all and most of the GINAs they meet are scared, in pain, confused, and emotional beautiful butterflies who are on a tremendously personal journey and probably could use a shoulder to cry on (who doesn’t?!). Cry, breathe and get back on track, this appointment is about YOU, no need to feel embarrassed, you are not the first and you will not be the last 
4. If you don’t feel comfortable with a physical examination today, that’s ok! 
5. Depending on where you live (hello sweet dutch daisies we see you!) It may be more cost-effective to get a referral from your medical practitioner or family doctor to see a PFP, as they can be a little expeno (slang for expensive (thanks Australia!)). 
6. Feeling confused about what to say and what to do? Visit the ‘Helpful Conversations’ section of the app which contains a handy conversation script for your appointment with your PFP (super handy and you are super welcome). 

You know how if you strain your neck and can’t move it around easily it helps to get a soft massage and loosen up the muscles? Well, that’s basically the same concept here, loosen the muscles and reduce the pain. 

Vaginal dilation aims to allow the brain and the body to experience non-threatening, non-painful sensations of stretching and touch, without activating those aggressive and painful pelvic floor spasms.

We want to maintain a relaxed pelvic floor and break the pain fear loop (see fear, anxiety, and sexual trauma for more on the pain fear loop). 

So without further adieu, welcome to the weird and wonderful world of vaginal dilators (eeep). Here’s a breakdown of the basics 

1. Vaginal dilators are smooth objects that come in a variety of graduated sizes and weights
2. They usually come in a set that increases in size, starting real small like a pinkie finger 
3. They can be plastic, rubber, or glass cylinder-shaped 
4. They are used to expand the vagina in width and depth, to provide elasticity to the tissues, and to allow for comfortable sexual activity (yes please) 
5. Vaginal dilators are commonly used to treat dyspareunia (aka pain during intercourse) 
6. Can sometimes be referred to as vaginal trainers, desensitization therapy, or pelvic floor down training 
7. Dilators are therapy devices, not sex toys! (well anything can be a sex toy but you know what we mean) 

 

The purpose of using dilators is to reduce sensitivity to insertion. We are trying to train the pelvic floor muscles to relax when something is inserted into the vagina and not to spasm or tighten. So how do you use them? 

 

How to use a dilator 

We thought you’d never ask! Here we goooo 

Step one: Find a safe, comfortable, and private spot, preferably where you are warm, relaxed, and not terrified of someone bursting in to borrow something or ask what you are up to. It is most common to lay flat on your back (pillows are great here), however, you may like to lay on your side if that is more comfortable for you. 

Step two: You may like to start with some simple stretches to loosen up or some breathing exercises to relax and center yourself. Contract and relax your pelvic floor focusing on long relaxing breaths. 

Step three: Choose the smallest dilator (or whatever size you most feel comfortable with) and lubricate it generously (a super important part on lube coming up next, don’t miss it). Seriously the more lube the better! 

 

Top tip! Before you lubricate you may want to run your dilator under some warm water to heat it a little. Cold can sometimes be uncomfortable! You can even lay down with a wheat pack or heat pack if you like, whatever makes you feel more comfortable and relaxed. 

 

Step four: Bend both knees and spread your legs apart. Remember to relax your body by taking deep breaths into that beautiful belly. Gently insert the smaller round end of the dilator into your vagina with a small amount of pressure. It’s important you only insert the dilator as deeply as you are comfortable with into the pelvic wall, remember GO SLOW PLS. 

Step five: Once the dilator is comfortably inserted you may like to remove your hand and any pressure and let the dilator stay in place. At first, your muscles may involuntarily contract and try to push out the dilator, but over time, as you learn to relax, you can keep the dilator in longer. 

Step six: Once you can comfortably insert the dilator you may like to work by stretching it from side to side to massage or stretch the pelvic floor and vaginal opening. This is a great time to explore and learn more about your pelvic floor and vagina, understanding how and why your muscles contract, tighten, and how they can be loosened. You may like to contract and relax your pelvic floor muscles and try different breathing techniques to test your pelvic relaxation with your dilator inserted. 

Once you’re done, clean your dilator in warm soapy water and leave it out to air dry. You may experience a lingering burning sensation after use, this is normal and is related to neuropathic pain (see glossary) where your nerves are sending pain messages up to your brain. It will fade on its own!

So how long do I do this for? How long and how often you dilate is up to you. While some healthcare professionals will recommend 1-2 times per day, or for 30 minutes at a time the great thing is you can go at a pace that YOU are comfortable with. 

 

Does the thought of laying in your bed and sticking something up your vagina while your sister does an online Zumba class outside your room make you wanna cry? Don’t dilate!

Wait until you are relaxed and feeling in control of your body and environment. It could also be important to be in a room with a lock, where you feel confident no one will accidentally come in. 

A great time to dilate is after a shower or a warm bath when you are feeling relaxed and comfortable. Similarly, if you are in the bathroom maybe lay down on a towel or pillow instead of cold tiles, we want to make this experience as pleasant as possible right?

Do you have 20 minutes after your shower before you have to leave for work? That’s a great time to fit in a 5-minute vaginal stretch using a comfortable dilator and get on with your day! 

 

Remember 

Some handy things to remember: 

• Using dilators on your own and in a safe place means you can go at a pace you are comfortable with and will help you feel safe and in control 
• Getting used to dilator therapy can take some time
• GINAs will progress at different rates, depending on their condition
• Only move up to the next size dilator once you feel ready and can insert without pain or tightening 
• Remember that your vagina slants somewhat downwards, so if you are lying on your back do not push the dilator in at a right angle
• If you are going to keep the dilator in for a few minutes, try reading or using your phone to distract yourself
• It’s ok to go backward! Some days are hard, listen to your body, and do what is most comfortable for you
• Sometimes the smallest dilators are best. They allow you to stretch, move, and explore parts of the vagina and pelvic floor slowly, and individually, they are great so don’t forget to keep using them even as you progress to larger sizes. 

 

 

One super idea often not discussed about dilation is masturbation!

YES, MASTURBATION! 

We are all entitled to pleasure so let’s throw out the taboo associated with getting off and let’s get off!

Later on, we will discuss arousal, but basically, masturbation before dilation is super helpful as your brain and body are sending messages to each other and the messages are all saying ‘I WANNA HAVE SEX’.

The vagina will lubricate, lengthen, and will be far more welcoming to any kind of penetration. This is where you can use your dilators, see if you notice a difference! 

You may prefer dilator exercises to be purely clinical and focused on breathing and connecting body and mind, but some may want it to be more fun and enjoyable and similar to the experience with a partner – both are valid. Do whatever makes you feel comfortable. 

Remember that episode where Monica told Rachel and Phoebe that she was experiencing pain during sex and didn’t know what to do?

Yeah me neither! It’s easy to feel let down, confused and isolated and that’s why it’s important to be able to talk with and seek guidance from a professional. 

Sex therapy is a specialized category of clinical therapy, specializing in handling issues with sexual function, sexual relationships, sexual concerns, and sexual expression.

Many people seek the services of a sex therapist for different reasons.

Couples invest in it because they might not be enjoying the sexual intimacy they once had. A patient might want to find a cure for painful sex, intimacy after childbirth, changes in libido, or orgasm. Sexual therapists can help with experiences of trauma, rape, and assault. 

The thought of seeing a sex therapist can be scary, embarrassing, and difficult, however having an open, safe and supportive dialogue around sexual pain is the right of every person and the best part is, sex therapists, know all about vaginismus! 

Your sexual therapist can provide information about sexual anatomy, sexual response cycles you may be experiencing, and help you understand your pain and the processes your body is going through.

Your therapist can also identify, help you express, and resolve any emotional factors that may be contributing to your vaginismus.

Ok sounds good, so how do I get one and what do I do? 

Your regular doctor, PFP, or gynecologist should be able to refer you to a sex therapist. Your first session will usually explore your sexual and personal background, sexual education and beliefs, and your specific concerns.

It’s ok to feel uncomfortable, scared, unsure, silly, vulnerable, and more than a little embarrassed.

After your first session, you should feel more confident in being able to express your sexual pain and talk more openly about what you are going through. Isolation and depression can be some of the biggest and most challenging aspects of vaginismus (we will cover these too) and being able to talk openly without fear of judgment can be freeing! 

The best part is you are talking to a specialist, you are in safe hands and sexual counseling is one of the biggest and bravest steps you can take in your journey to pain-free sex. 

 

Pro tip – If you are struggling with how to discuss sexual pain with your support network, visit the ‘Helpful Conversations’ section of the app for some suggestions on how to start safe and respectful conversations.

No, we don’t mean start some influencer’s 6-week challenge.

Exercise reduces levels of the body’s stress hormones, such as adrenaline and cortisol, and is a great way to relieve tension. Even a short walk outdoors can clear the mind and relax your body and walking is great for your pelvic floor as we tend to spend so much time seated at work and school.

Try incorporating some of these exercises into your weekly routine and see if they help with stress and tension (remember jaw and floor!)

1. Go for a 20-minute walk 
2. Practice some yin yoga 
3. Use a foam roller and massage out some tension in your muscles 
4. Practice your pelvic stretches and breathe into your belly 
5. Contract and relax your pelvic floor

 

Mindfulness is probably one of the biggest words of the 20th century, with everyone from Oprah to Bill Gates getting on board.

Mindfulness is the quality of being present and fully engaged with whatever you are doing at the present moment, free from distraction or judgment, and aware of your thoughts and feelings without getting caught up in them. It combines meditation and breathing to focus on the mind and body in the present.

There are so many really fantastic resources out there so we won’t spend too much time here on them and instead, leave you in the hands of some experts like: 

 

1. headspace.com 
2. mindful.org
3. smilingmind.com.au

 

Once you are feeling more comfortable with mindfulness a great tool to use throughout your day is a full-body meditation scan. This is great for identifying and responding to parts of the body that regularly carry tension and stress (hello pelvic floor we see you!). It’s super easy and can be done anywhere (almost), anytime.

 

Mindful Full Body Scan

Ok here it is: 

Step one: Get comfortable, lying down is preferable, particularly if you’re doing a body scan meditation before you fall asleep. If you’re at work or school sitting down in a comfortable chair works too. 

Step two: Close your eyes, take a few deep breaths, slowing your breathing right down, and expanding all the way into your belly. Rapid, shallow, erratic breathing is a common response to stress so it’s important to focus on a slow, deep, and regular breath. 

Step three: Bring awareness to your feet, feel any tension you may be holding in your toes, arches, or ankles. Gently scrunch your toes and then work with your flow of breath to release slowly. 

Step four: Move your attention up into your calves and acknowledge any tension or tightness you may find here. Slowly release it focusing on deep and slow breathing. 

Step five: move your attention up into your pelvis, noticing any tension in your pelvic floor. Contract your pelvic floor and release slowly focusing on expanding your belly with your breath.  

Step six: Continue to move your attention upwards, towards your stomach, arms, hands, and shoulders repeating the release exercises and focusing on relaxing each area and muscle. Finish with your head, scrunching and relaxing your eyes until you feel loose and relaxed. 

 

“Yeah, thanks but I don’t have time for this!”

Ok ok, we hear you, it’s not like you can lay down under your desk at work during your lunch break for a full-body scan.

Instead, focus on checking in on your pelvic floor at least 5 times a day. Instead of scanning your whole body for tension just focus on what your pelvic floor is doing.

You may be surprised to find that your pelvic floor is probably contracted most of the time. Work on taking some deep belly breaths and relaxing it down.

Do it while you’re on the train on your way to work, do it at every red light in the car on the way home, do it while you are waiting for your nails to dry, or do it while you wait for the microwave to ding! 

 

Ok so there are some treatment options that we haven’t covered and mostly that’s because there is not that much research behind them as possible solutions for vaginismus.

You may have seen some GINAs posting on FB threads from 2009 or in the deep dark corners of ask.com but in the interests of being open and transparent, we thought we would mention a few just so if you come across them on the interwebs you can make a more informed decision about your treatment.

As always, you should discuss your treatment options with your doctor, PFP, or gynecologist as they will be able to advise on the best treatment for you, sweet soybean! 

 

Acupuncture 

Acupuncture is a form of treatment that involves inserting very thin needles through a person’s skin at specific points on the body, to various depths. Some research suggests that it can help to relieve pain. There has been very little research on acupuncture as a method to treat vaginismus but speak with your doctor if you would like to learn more. 

Botox 

Botulinum neurotoxin Type A (commonly called botox) can act as a selective muscle weakening and/or paralyzing agent, to help reduce nerve pain. While the effect is reversible, botox is widely used in medicine for a variety of conditions such as painful muscle contraction, migraine, or excessive sweating. 

Some treatments involve injections of botox into the pelvic floor muscle to provide a temporary window of opportunity to rehabilitate and stretch the over-contracting pelvic floor muscles.

This is presented as an option for GINAs who have not responded to traditional treatments using dilators, pelvic floor physiotherapy, and sex therapy. Again, there is little research into this as an effective treatment method for vaginismus so speak with your doctor to explore this topic more. 

 

Medication 

Before we begin please note that you should speak to your doctor and PFP about pharmaceutical options to treat vaginismus and pelvic pain. GINA is no doctor (duh) so the following is just an exploration of some pharmaceutical options that have shown to be effective for some users in conjunction with vaginal dilation, PFP, and sex therapy. Again, there is little research into these options so we are a good way off a magical pill you can swallow to keep vaginismus away (ugh drainer right). 

Also important to note, stop believing everything you read on the internet! Jeez! What works for one may not work for all. 

Lidocaine Gel: Some GINAs have responded positively to Lidocaine Gel, a topical numbing gel. This is typically used to reduce pain or discomfort caused by skin irritations, scratches, or burns. It can also be used to treat rectal discomfort caused by hemorrhoids. Talk to your doctor to find out more. 

Tricyclic Medications: There are different kinds, and they are usually used to treat nerve pain. There have been some positive studies on patients with pelvic nerve pain and again, nothing substantial on vaginismus. Talk to your doctor if you want to find out more. 

 

Sex toys 

Hello! Got your attention there! This has been lumped in here as it’s not a treatment per se however can be a workaround for pain-free sex. There are some sex toys on the market designed to minimize the amount of penetration on the vagina and hence the pain associated with penetrative sex. Google them if you are interested in learning more. 

 

Pregnancy

Pregnancy is one of the wild wonders of the world, a human being grown inside of another human being. WILD. 

Now we don’t need to go into the birds and the bees here but we do need to talk about postpartum pain (pain following childbirth).

1. Some studies show that as many as 85% of people will experience pain during their first sexual experience postpartum. 
2. At 3 months postpartum, 45% of people reported they were still experiencing pain. 

Physical changes and hormonal changes are happening all at once, levels of estrogen and progesterone, hormones that affect sexual desire and lubrication, dramatically decrease after birth.

This can make becoming aroused or lubricated more difficult. Not to mention injuries to the pelvic floor, where the vagina or perineum (area between the genitals and anus) can tear. 

 

New mothers will benefit from working with a Pelvic Floor Physiotherapist (PFP) to address musculoskeletal dysfunction and postnatal pelvic strengthening.

And remember, sex therapists and mental health professionals can help too! They can address low libido, body image, postpartum depression, or other emotional factors leading to sexual pain. 

 

Menopause 

Following menopause and due to hormonal changes, many people will experience painful sex. Changes in estrogen levels cause tissues in the vagina and surrounding areas to become thinner and dryer.

In addition to dryness, during post-menopause sex, many people experience sexual pain, tightness, and an uncomfortable burning sensation.

Many studies show that the regular use of vaginal dilators and lubricants can be helpful to people experiencing sexual pain post-menopause, as well as seeking help from a Pelvic Floor Physiotherapist (PFP). 

Similarly, people undergoing chemotherapy for cancer will often experience symptoms of early menopause. Some chemotherapy medications irritate all mucous membranes in the body, including the lining of the vagina, which may become dry and inflamed.

 

Genital Reassignment Surgery (GRS)

Genital Reassignment Surgery (GRS) is a surgical procedure that changes a person’s genitalia to match that of their gender identity. During this procedure, surgeons will transform a person’s pelvic area to create a neo-vagina. This procedure is also known as vaginoplasty.

Post-operative vaginal dilation therapy is an essential part of keeping the neo-vagina functional. Vaginal dilation therapy is almost always required for life, as sexual intercourse in place of dilation may not be sufficient.

 

Tampons 

So we talk a lot about wanting to achieve a happy and functional pelvic floor about sex a lot here. However, the pelvic floor controls so much more than just sexual penetration.

Tampons or menstrual cups may be a difficult hurdle when suffering from vaginismus and many young people may struggle with this step during puberty and well into adulthood, and that’s ok! 

There are lots of options for dealing with menstrual bleeding apart from tampons and during your therapy, it might be better to stick to something non- penetrative like pads or period underwear until you can get a bit more comfortable with your pelvic floor and vaginal insertion.

Tampons could be something you work up to once you become comfortable with different-sized dilators.

Or you could just ditch them altogether not everyone likes using them and they may not be right for everybody. No big deal!