Vaginismus: Causes, Symptoms and Treatment Options

In this guide to vaginismus, often also referred to as vaginal cramps, I explain its causes, diagnosis, background and treatment options. From my work with affected women – both as a midwife and a sex therapist – I know that most initially want above all to relieve their physical symptoms. However, for lasting treatment success, it is also important to understand the underlying causes.

If you have already explored vaginismus in depth and are specifically looking for a physical treatment option, you can find our FMS dilators here. Their shape and application are based on my many years of experience in midwifery and sex therapy and were specifically developed for gentle, gradual dilation.

If you are still at the beginning and first want to understand what lies behind your symptoms, this guide provides the key information on the definition, causes and treatment of vaginismus and vaginal cramps.

Contents:

What Is Vaginismus?

Vaginismus and vaginal cramps describe the same phenomenon: an involuntary contraction of the pelvic floor muscles. For affected women, it may feel as though the entire vagina is painfully cramping. This condition can significantly reduce quality of life. Because pain-free insertion of objects into the intimate area is difficult or even impossible, everyday situations – such as inserting a tampon or menstrual cup, undergoing gynaecological examinations and, of course, sexual intercourse – become major challenges.

The term vaginismus is still widely used and is the term under which many affected women know their symptoms. In the current ICD-11, however, vaginismus is no longer listed as a separate diagnosis but is classified under “Sexual Pain-Penetration Disorder”. As the term vaginismus remains firmly established in everyday language, I use it throughout this guide.

Vaginismus is not the same as dyspareunia. Even healthcare professionals often have difficulty distinguishing between these two conditions. You can learn more in my separate guide to dyspareunia.

What Symptoms Occur With Vaginismus/Vaginal Cramps?

Fear of pain during penetration may initially lead to a painful, reflex contraction of the pelvic floor muscles. Pain and muscle tension reinforce one another, creating a cycle that can become increasingly independent over time.

This means that the pelvic floor muscles do not only cramp during sexual intercourse or in anticipation of penetration. A cramp may occur suddenly and without any recognisable external trigger – in the middle of everyday life and completely unexpectedly for the affected woman. This unpredictability in particular can be extremely distressing psychologically.

There is an urgent need to remove the taboo surrounding vaginismus and to take this so-called dysfunction seriously in terms of both its physical and psychological burden.

How Long Does a Vaginal Cramp Last?

The duration of a cramp varies from person to person and may range from a few seconds to several minutes. It is influenced by the situation, the individual's condition and psychological tension. There is little that can be done to influence its duration in advance.

During a cramp, relaxation techniques may help. Rather than tensing up even more out of fear of the pain, it is advisable to focus on breathing, conscious muscle relaxation and mental calmness to achieve relief. Regular Yoni Steaming may also help you become more aware of and relax the pelvic area.

Causes of Vaginismus/Vaginal Cramps

Unlike dyspareunia, vaginismus rarely has purely physical causes. Psychological and sexual factors often play an important role. Fear of penetration – for example by a penis, finger or other object – may develop into a genuine phobia.

The origins may go back a long way. In my therapeutic work, I repeatedly find that a woman's perception of her own body, her relationship with femininity and the way physicality and sexuality were experienced or communicated in her family of origin can play an important role.

However, there is no single cause of vaginismus. Traumatic sexual experiences, painful experiences, negative birth experiences, surgery, infections or repeated pain during sexual intercourse may also be triggers.

What Forms of Vaginismus Are There?

The medical classification of vaginismus has changed. In the current ICD-11, the former diagnosis of vaginismus is no longer listed separately. In sex therapy, however, it can still be helpful to distinguish between different forms and underlying factors.

Here, I follow the distinction described by Dr Karoline Bischof between Type I vaginismus, or phobic vaginismus, and Type II vaginismus associated with identity-related difficulties. This distinction can help us better understand the very different backgrounds of affected women.

Type I Vaginismus – Phobic Vaginismus

This form is particularly characterised by fear of penetration. A penis, finger or other object is perceived as threatening. The pelvic floor muscles react involuntarily with a strong contraction that makes penetration difficult or impossible.

Some affected women experience sexual arousal, while others do not. Sexual intercourse or vaginal examinations are generally very difficult or impossible.

Primary Vaginismus

Primary vaginismus is diagnosed when pain-free penetration has never been possible. This may involve inserting a tampon, undergoing a gynaecological examination or having sexual intercourse.

Of course, many women do not enjoy their first penetrative sexual experience or find it painful without ever developing vaginismus.

The desire to have a child may still be present, but often remains unfulfilled as long as the vaginismus persists. This is frequently the decisive impulse to begin treatment.

Secondary Vaginismus

With secondary vaginismus, penetration was previously possible. The symptoms develop later, often following significant or painful experiences.

Possible triggers include traumatic sexual experiences, negative birth experiences or perineal injuries, repeated pain during sexual intercourse or an upbringing that portrays sexuality negatively or associates it with fear.

Breastfeeding, postmenopause, surgery, cancer treatment or sexually transmitted infections may also leave experiences that increasingly associate the genital area with pain, fear or rejection.

Type II Vaginismus – Identity-Related Difficulties

According to the distinction described by Dr Karoline Bischof, identity-related difficulties are central to this form. The affected women are unable fully to accept their own sex. After sexual maturity, a diffuse fear of motherhood often develops.

These women often use several methods of contraception simultaneously during sexual intercourse. It is not so much penetration itself that causes fear, but rather the idea of something leaving the body through the vagina – “bringing something out”. This fear becomes particularly apparent in the idea of childbirth, when the baby leaves the body through the birth canal. Sexual intercourse may therefore be impossible, while gynaecological examinations may still be possible.

How Is Vaginismus Diagnosed?

The diagnosis of vaginismus, dyspareunia or vulvodynia is initially based on the woman's description of her symptoms as well as her medical and sexual history – including childhood and adolescence.

It must then be ruled out that physical causes are responsible for the pain or difficulty with penetration. These may include very rigid mucosal rings – formerly referred to as the hymen or maidenhead –, anatomical abnormalities such as a vaginal septum, infections, hormonal changes or dysfunction of the pelvic floor muscles.

However, vaginal examination is often difficult because it may be extremely painful or unbearable for affected women. It is therefore important to consult an experienced gynaecologist.

To reduce the fear of “penetration”, the patient can take as much control as possible – for example by sitting upright in front of a mirror, observing what is happening, spreading her own labia and carefully inserting a finger – her own or that of the healthcare professional – with a latex glove and lubricant.

Gentle pushing, similar to having a bowel movement, can make the process easier. It is important that the healthcare professional explains every step beforehand and proceeds with particular care. Asking about the woman's current sensations is essential. The reaction of the vagina may ultimately confirm the suspected diagnosis.

If you do not feel comfortable or well cared for by a doctor, speak openly about it or change doctor before undergoing an examination. A first appointment should always be for consultation only, so that you can calmly decide whether you are in the right place.

What Can Be Done About Vaginismus/Vaginal Cramps?

For affected women, it is often difficult to talk about their symptoms and seek help. Shame plays a major role. Some even avoid relationships and intimate relationships out of fear of sexuality or of having to explain their symptoms. If they are in a relationship, vaginismus can place a considerable burden on sexuality and life together. Comprehensive counselling is therefore especially important – including with regard to relationships and sexuality.

Rule Out Physical Causes

Possible physical causes must first be investigated. As described in the section on diagnosis, anatomical abnormalities, infections, hormonal changes or dysfunction of the pelvic floor muscles may cause or aggravate symptoms.

Pelvic Floor Physiotherapy

I also strongly recommend specialised pelvic floor physiotherapy. There are physiotherapists who specialise specifically in women's health and problems affecting the pelvic and intimate areas. They are also familiar with issues related to sexuality and pain during sexual intercourse. With vaginismus, it is not simply a matter of training the pelvic floor, but above all of becoming consciously aware of the muscles, recognising tension and learning to release it in a targeted way.

Psychotherapy and Sex Therapy

If no organic cause is found or psychological factors play an important role, the psychological and sex therapy component comes into focus. For psychotherapy, you should carefully choose the right method and, above all, an experienced professional.

This is not about dismissing physical symptoms as “just psychological”. Fear, muscular contraction and pain influence one another. It is precisely this cycle that needs to be understood and interrupted.

Relaxation and Body Awareness

Relaxation and body-awareness exercises can be helpful, for example consciously feeling the vulva, vagina and lower abdomen. Gentle exploration and positive experiences of erotic stimulation may also help – all at your own pace and without pressure. Another option is Yoni Steaming: the warmth and conscious awareness of the pelvic area may support relaxation and body awareness.

Physical Treatment With Dilators

Dilators can be an important part of physical treatment. The aim is to become gradually and independently accustomed to insertion and penetration. The woman always remains in control.

Choosing a suitable starting size, progressing in small size increments and proceeding gently are essential. Always use a high-quality lubricant to make insertion easier. Heat may also help relax the pelvic floor muscles.

From my experience as a midwife and sex therapist, however, a dilator is not simply an object for stretching. Its shape, the increments between sizes and the way it is used have a considerable influence on how the treatment is experienced. This is precisely how the concept of our FMS dilators came about.

FMS Dilators for Vaginismus

Flexibilisation Instead of Conical Dilation

“FMS” stands for Flexibility and Massage System.

The effect is based less on stretching and more on gentle mobilisation of the muscles through movement of the dilators. This is a fundamentally different approach from conventional conical dilators.

Conical dilators spread the tissue increasingly as they are inserted further. FMS dilators follow a different design principle: the streamlined head glides gently, while the straight shaft does not exert increasing spreading pressure once inserted.

Innovative Shape and Borosilicate Glass

FMS dilators are not conical like conventional products. Their streamlined head glides gently, while the straight shaft protects the tissue.

The borosilicate glass used is exceptionally smooth, durable and hygienic. It is easy to clean and absorbs neither odours nor liquids. The smooth surface is a significant advantage, particularly for sensitive tissue.

27 Sizes for Small Treatment Steps

FMS dilators are available in 27 sizes starting at 14 mm in diameter and in a wide range of sets. The fine size increments allow treatment to progress in very small steps. This is particularly important with vaginismus: moving to the next size should not become a new hurdle.

Heat to Relax the Muscles

FMS dilators can be warmed. Heat can be particularly pleasant with vaginismus because it supports muscle relaxation. The combination of warmth, gentle movement and a suitable size may help create a new and positive experience of penetration.

Stabilising Treatment Results

Once a certain size has been reached, Theros® Vagina Stents can help stabilise the achieved result over a longer period. They are not intended as a substitute for active treatment with dilators, but as a complementary aid.

Certified Medical Device

FMS dilators are certified medical devices and have been specifically developed for use in the vaginal and anal areas.

Vaginismus, Relationships and Sexuality

Vaginismus, vaginal cramps, dyspareunia and vulvodynia can also be distressing for partners. Men frequently experience situational erectile dysfunction because sexual intercourse is painful or impossible.

Honest communication is essential. Experienced couples therapists can help you and your partner before the relationship suffers. It is important not to equate sexuality exclusively with penetration. Intimacy, desire and shared erotic experiences can continue to have their place during treatment.

Involving Your Partner in Treatment

FMS dilators can also be used together as part of sexual play. Their special shape allows a gentle approach that simulates penetration. The affected woman can decide at any time how far and in what way the dilator is used.

You can find more information under Use of FMS Dilators for Couples.

How Common Is Vaginismus?

The number of unreported cases is high and reliable data on the prevalence of vaginismus are lacking. Many affected women do not talk about their symptoms for a long time because of shame or do not seek medical or therapeutic help.

Different definitions and diagnostic criteria also make it difficult to give precise figures on prevalence. One thing is certain, however: you are not alone with this problem.

Self-Help and Support

Sharing experiences with other affected women can be very helpful, for example in a support group. Realising that other women experience similar fears, pain and difficulties can provide relief and encouragement.

However, be cautious with websites or supposed personal accounts that recommend one specific product exclusively as the solution. Check who is behind a website or group and whether genuine interaction is possible. If possible, look for a real group or a professionally moderated support community.

Further Questions? Therapeutic Support

Do you have questions? Write to me at hsw@theros.de – I will be happy to reply.

Hera Schulte Westenberg, Midwife and Therapist

Further Guides:

• Pelvic Floor Exercises With Kegel Balls for Women and Men
• What Is Dyspareunia? Definitions, Causes and Treatment Options for Pain During Sex
• Yoni Steaming: Benefits, Application and Suitable Herbs