pelvic health, physical therapy, Sex, women's health

Dispelling Dyspareunia Part 1: Vaginismus

Dyspareunia, in human words, means painful sex. And is technically its own diagnosis, but in my experience, the symptoms usually lead to a more specific secondary diagnosis.

Sex can be a touchy (pun) topic. Most of us keep that part of our life very private, even if you have the best sex-life known to man (or woman). But what if it you have the crappiest sex-life, non-existent, and/or painful sex. Who’s going to talk about that debbie downer with their friends?

A study conducted in primary care practices found that 46% of women who were sexually active had dyspareunia, and another study discovered that out of 62 women, 45% experienced postpartum dyspareunia. In addition, it was found that about 60% of women experience dyspareunia when more generally defined as pain with intercourse. The bigger issue may be that symptom reporting tends to be very low, especially in those who have more persistent symptoms.(1)


Our bodies are designed to have and enjoy sex, so what’s the deal, man?!

There are SO many reasons women experience painful intercourse. Over the next few posts I will highlight and expand on a few of the more common reasons as they encompass a fairly wide array of symptoms and treatment techniques.


VAGINISMUS: Basically vagina lockdown.

This is a spasm of the pelvic floor muscles that occurs when anything comes near the vagina. And I say “near” deliberately. Some cases of vaginismus can be so severe that pelvic floor tenses even with a hand on the inner thigh or even with talk of sex. Imagine a happy vagina as rose in full-bloom, reverting back into a tiny rosebud. Or, like how you shut your eye quickly when a sharp object comes near it. THAT is your vagina on vaginismus.

Most people only recognize they have symptoms of vaginismus after attempting vaginal penetration, or experiencing painful sex. However, I believe one of the earliest, recognizable signs of an issue can be with unsuccessful and/or painful insertion of a tampon.

Vaginismus can stem from a number of things:

  • History of painful sex
    • Like an elephant, our vagina never forgets. Sometimes after experiencing an episode of painful sex, there may be tension and apprehension leading up to the next round of intercourse which puts our vagina on defense. The pelvic floor resists insertion and lubrication is diminished due to apprehension. And that equals pain.
  • Sexual/physical abuse
    • Our body responds similarly here. There may be fear and/or disgust at the thought of sex. So much so, that showing any sort of affection may be terrifying as it could lead to sex. When, or if, intercourse is attempted, the pelvic floor may stand guard and prevent pain-free intercourse.
  • Anxiety/stress
    • A person with a significant amount of anxiety and stress may find it difficult to let go and become vulnerable enough to enjoy sex. They will also experience diminished vaginal lubrication also contributing to pain and pelvic floor muscle spasm.
  • Decreased pelvic floor muscle awareness
    • Even more generally – decreased knowledge of what the vulva is, where things are located, etc. I find this is particularly common in those with a very conservative background (🙋🏻), where no one spoke of sex, vaginas, penises, periods. When we are unfamiliar with something it is difficult to navigate and control what it does.
  • Poor self-image
    • This can contribute greatly to how our pelvic floor operates in a sexy situation. It prevents vulnerability, promotes guarding, which then is transmitted to our pelvic floor muscles causing tension and resistance to sex.
  • Other underlying diagnoses:
    • Painful bladder syndromes, frequent UTI’s, back/hip/abdominal/pelvic pain, post-partum, pregnancy, endometriosis, etc…

Did you notice that 4 out of 5 of those reasons have to do with our psychological processes and emotional history? Our brain is the control center. It decides what is painful, what feels good, how things operate and respond. When I see patients for vaginismus, I typically include a significant amount of behavioral education and modification, as well as, partner education. What I can do here is usually enough, but at times this may be where we insert a sex therapist or relationship psychologist to address deeper issues.

Beyond the emotional component, there are obviously physical issues that need ironing out (poor choice of words?). When I see someone for the first time, I take a very thorough history and decide if it is appropriate to perform a vaginal examination. Sometimes it may take a visit or two or 12 to be able to do an exam, but when I am able I assess many things, especially the mobility of the pelvic floor. From the exam, I determine the need to initiate home vaginal dilator use, soft tissue mobilization (I gently massage and stretch the muscles internally and/or externally), pelvic floor muscle down training/biofeedback, and other interventions that vary based on the patient’s case.

Treatment of vaginismus is highly successful with commitment from the PT and the patient, as well as, support from the partner. People always wonder how long it will take to get better with physical therapy, which is really difficult to define. It varies greatly with each case. BUT I will say, you should begin to see positive changes within 4-6 weeks, even if they are minor.

If you have symptoms of vaginismus, please talk to your doctor and ask for a referral to a specialist – a pelvic health physical therapist, sex therapist, etc. You do not have to live a life filled with painful intercourse. You are capable of and deserve a healthy sex-life!!

Please contact me with any questions or comments!




  1. Heim LJ. Evaluation and differential diagnosis of dyspareunia. Am Fam Physician. 2001;63:1535–1544.
  2. Eyeball analogy credit: @pelvicguru1

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