Although Tara Langdale-Schmidt, 34, began having sex at the age of 16, she didn’t start experiencing burning, stabbing pain with intercourse until she was 26, after multiple surgeries for endometriosis.
“The symptoms started out very slowly, so I thought they were surgically related,” she said.
In time, the pain caused Langdale-Schmidt’s body to seize up during sex. “I could not relax at all for intercourse, and it was absolutely excruciating,” she explained. “I would tense up, knowing the pain was coming; I kept telling my doctor about it, and he said to drink wine and take Advil for over four years.”
If you are having any pain with sex, you should be seen by a doctor, according to Tami Rowen, an OB-GYN at UCSF Health in San Francisco. If they’re not being helpful in diagnosing and treating your pain with intercourse, then you should definitely get a second opinion.
“Don’t let anyone tell you there’s nothing wrong, or that maybe you’re just not into your partner,” she said. “I’ve heard the craziest things.”
In Langdale-Schmidt’s case, she was eventually diagnosed with vaginismus along with vulvar vestibulitis (pain or irritation that occurs in the area of the vulva near the opening of the vagina). Vaginismus isn’t incredibly common, but it’s debilitating for women who experience it.
What exactly is vaginismus?
Although vaginismus and its root cause is not fully understood, the condition is when a woman experiences “painful, involuntary contractions of the vaginal muscles at penetration,” Rowen said. “She will often have a lot of tension around sexual activity.” The condition can also make gynecological exams and even tampon insertion difficult and painful.
The definition of vaginismus has changed a lot over the years, from the psychological realm to the physical. It now lies somewhere in between, according to Carrie Pagliano, a pelvic floor physical therapist and American Physical Therapy Association spokesperson.
“There’s a very specific cocktail of factors leading to vaginismus, but it is a muscular protective response,” she said. “Putting something near the vaginal opening can cause an increase in muscular activity. We just have to figure out why.”
“There’s a very specific cocktail of factors leading to vaginismus, but it is a muscular protective response.”
Pagliano added that sometimes the source of the muscle contractions is psychological; perhaps a woman was taught that her genitalia was dirty or sex was sinful.
“I often ask women about their backgrounds,” she said. “What was her first experience with tampons? What was her first experience with sex? I find out if there were ever any religious expectations around sex or relationships.”
Past traumas or physical conditions can also contribute to vaginismus, causing women to feel uneasy at the thought of penetrative sex or sexual contact at all. Sometimes, no cause can be found at all.
But beyond vaginismus, Rowen said, pelvic pain diagnoses are becoming more specific, as doctors highlight their unique complexities. Like Langdale-Schmidt, many patients have vaginismus coupled with another condition. Some may have other, similar issues — but with entirely different treatments. It’s important to diagnose carefully, both experts said.
Getting to the bottom of the other causes of pain
Doctors need to examine the type of pain closely to determine what it might be. “A lot of patients get sent straight to [physical therapy],” Rowen said. “But a burning pain near the vaginal entrance is different than a pulling or sharp pain that’s higher or deeper.”
If there is burning pain around the entrance of the vagina, or there’s tearing, it could be vulvar vestibulitis ― what Langdale-Schmidt experienced ― and require a topical steroid. A drop in estrogen, like during menopause or after childbirth, can lead to irritation provoked by a lack of lubrication; this might require a topical hormone for treatment. If it’s more of a pulling, sharp pain with thrusting, there might be a muscle-related issue or prolapse. Deep-set pain could be a sign of endometriosis, especially if there are symptoms like heavy periods.
These issues may or may not require pelvic floor physical therapy, but rather a range of other treatments and some tactical guidance for sex. This can include exercises, topical medicine and coaching. “For some women, it might be as simple as getting more aroused, more relaxed and more lubricated,” Rowen said. “That means more foreplay.”
If, however, your doctor determines vaginismus is an issue, Rowen calls pelvic floor physical therapy “the mainstay” of treatment.
Treating vaginismus through physical therapy
Langdale-Schmidt tried a bunch of treatments for vaginismus, from lidocaine (numbing) injections to expensive creams. Nothing worked wonders for her until she tried pelvic floor physical therapy.
Pagliano said the unique thing about therapy is how much more time the patients get with her than they do with a doctor during an appointment — 45 to 60 minutes per session, on an ongoing basis. “It is a collaborative approach to treatment,” she said. “We work with gynecologists and often psychologists or therapists. But as physical therapists, we really learn your story and go at your pace.”
“We work with gynecologists and often psychologists or therapists. But as physical therapists, we really learn your story and go at your pace.”
Patients start slow. You may or may not even have an examination on the first visit; it’s usually up to the patient, according to Pagliano. She stresses the mind-body connection early and often.
“I also just want women to pay attention to their breath and the tension-holding patterns in their body,” she explained. “From there, you can see where you’re holding tension in your pelvis.”
Another piece of the puzzle, she said, is getting familiar with your own body. A physical therapist can teach about female sexual anatomy and help you learn different muscle groups. “I start by just getting a woman aware of muscles, like when she’s inserting a tampon,” Pagliano said.
Exercises can help a patient learn to relax and contract muscles, allowing “more control” of the pelvic region, Pagliano added. Manual therapy can help to massage and stretch the muscles of the pelvic floor. Therapy will also introduce dilators, which can help women learn proper muscle relaxation for easier intercourse.
The path to full recovery
Pagliano said some patients can expect to see reduced pain with intercourse in about four to six weeks with therapy. For others, it may take two or more years. Everyone’s condition and path to healing is different, so it’s important not to set too many expectations.
“Pelvic floor physical therapy is a great opportunity to listen and share,” Pagliano said. “Ultimately, we get to help you put together this complete picture for you. It’s a comprehensive understanding of how your system works.”
Dilators wound up being key to Langdale-Schmidt’s recovery, after completing tons of research on what might work best to treat her vaginismus and vulvar vestibulitis. “They looked like a safe, promising treatment, and I went for it,” she said.
You can check out the Women’s Health section of the APTA website and the Herman & Wallace website to find a pelvic floor physical therapist near you, Langdale-Schmidt said. It’s also vital to do tons of research as well as chat with your doctor to make sure whatever treatment path you take is the right one ― and to get your partner involved, so they understand your condition, too.
“Remember how important you are and your worth,” Langdale-Schmidt said. “You are not broken. You matter.”