“I wake up thinking about my condition and go to sleep thinking about it. I think about it a thousand times a day.”
24 year old pediatric ICU nurse, 6 year duration.
It’s not always easy to answer the questions, “What is Vaginismus?” In its simplest definition, vaginismus (vah’ je niz mus) is an involuntary and uncontrolled fear of penile penetration resulting in an inability to have pain-free intercourse. The fear is so great that it is usually accompanied by severe anxiety, often to any form of penetration, be it tampon, “Q-tip”, digit, dilator, gynecological exam or intercourse. For many women, intercourse is impossible. Vaginismus accounts for 1-7% of unconsummated marriages worldwide and effects women in many different cultures.
Mild to Severe Vaginismus
It is important to understand that this sexual pain disorder can have different levels of severity. While some women have mild vaginismus resulting in painful intercourse (dyspareunia,) others are so severely afflicted that intercourse is brutally painful or impossible. The pain from attempted intercourse is often described as burning, with some describing the pain as being cut with a knife, and others talk about being rubbed with sandpaper. The after effects of pain can last for hours and sometimes days.
Is there Spasm of the Muscles in Vaginismus?
Researchers in the field argue whether or not “spasm” of the muscles is present. My own observations are that a spasm may not be seen in the less severe cases of vaginismus, which are more likely to demonstrate tightness of the vaginal muscles, whereas spasm is invariably present in the more severe cases of vaginismus, especially of the entry muscle, often giving the appearance of a tightly closed fist, not allowing any penetration. When women give a history that intercourse is like “hitting a wall” or “hitting a brick wall” this in of itself speaks of spasm of the entry muscle. If you make a tight fist and try to insert your finger, this is what the spasm looks like and feels like during examination. By demonstrating a tightly closed fist, one can easily understand why attempted penetration is impossible and why it’s like hitting a brick wall.
Fear and Anxiety; Hallmarks of Severe Vaginismus
As women experience pain with attempted intercourse, they begin to develop a fear and anticipation of pain with repeated attempts at intercourse. Soon major anxiety develops with even the thought of penetration. This severe anxiety carries over into gynecological exams where penetration with a digit or speculum may be impossible. When asked to describe how she feels prior to a gynecological exam, this 24-year-old with severe vaginismus writes:
“Like my world is coming down. I feel like I’m going to get raped. I get into defensive mode”.
A 26 year old with severe vaginismus notes “Heart races, stomach hurts, sweating, irrational fear but still afraid; can’t understand how other women do this normally” and a 29-year-old with a severe vaginismus for 16 years writes, “I would rather die than attempt a pelvic exam!” This tells us that vaginismus is so much more than a sexual pain disorder – it seeps into so many other facets of these women’s lives.
Confusion with Vulvodynia, Vestibulodynia and “Vestibulitis”
Since vaginismus falls into the category of non-medical sexual pain, as do vulvodynia, vestibulodynia and the older term “vestibulitis”, these conditions are often confused with one another. Though vulvodynia (pain in the vulva) and vestibulodynia (pain just outside the vagina, inside the labia minora) may co-exist with vaginismus, I find that vaginismus, when present, is the major problem. Associated vulvodynia is more often a manifestation of anxiety (“too close for comfort”) rather than actual pain. This was found to be true in over 300 of my patients tested under controlled conditions.
Vaginismus: Psychologic vs. Physiologic
It is my opinion that vaginismus is both psychologic and physiologic. The body tends to establish natural defenses against pain and injury. The quick withdrawal of a hand about to be burned, the protective blink of an eye and turning of the head to avoid injury, are just some of the quick involuntary uncontrolled reflexes that exist for our protection. It seems to me that fear of penetration due to perceived or actual pain sets up a reflex that tightens the vaginal musculature. The severe cases of vaginismus invariably show severe spasm of the entry or other vaginal muscles. In this way, the body is saying “no entry” to protect itself against pain.
Vaginismus is a complex sexual pain disorder that interferes with the ability to have comfortable enjoyable intercourse. Often the cause is not clear, but the manifestations tend to be similar with heightened vaginal muscle tightness, or spasm especially of the entry muscle, making intercourse impossible. It is accompanied by varying levels of fear and anxiety to penetration.