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Breaking the Vaginismus Pain Cycle

If you have vaginismus, the pain you experience during vaginal penetration — whether it’s with a penis, finger, tampon, or speculum — can lead to a self-perpetuating cycle of negative responses that contribute to persistent pain.

In what's referred to as the 'vaginismus pain cycle,' experiencing or anticipating pain leads to fear, anxiety, and muscle tension that can be so intense and automatic that even the thought of vaginal penetration can cause you to feel reflexive pain and experience pelvic floor muscle tension. Over time, this cycle can take a toll on your body, emotional wellbeing, mental health, and romantic relationships.

We want everyone with vaginismus to know that healing is possible. And learning about the details of the vaginismus pain cycle is the first step. Keep reading to gain a deeper understanding of the mechanisms behind pain and the effective treatment approaches that can help you break the cycle.

First, a little brain science

There are two notable areas of the brain that are important in emotional regulation, protection, and survival: the amygdala and the prefrontal cortex. Together the amygdala and prefrontal cortex help to alert you to, and then respond appropriately to, a potential threat.

The Amygdala

The amygdala is the small but mighty portion of the deep brain’s limbic system. It is where we process, interpret, and store emotions and memories. The amygdala is also very important in our sexual instincts as well as our abilities to learn by fear. Your amygdala plays a role in initiating the classic “fight or flight” response which primes your body to either run from, or attack, potential threats. This is a really helpful response if you have to jump into action to put out a kitchen fire or grab someone before they step into the path of an oncoming car. It's not so helpful of your amygdala is triggering your fight-or-flight response every time you open an email from your boss.

In today’s world, the strong, panic-like responses you feel when you run into a friend you forgot to text back can be better thought of as an “amygdala hijack”. Even though the perceived 'threat' is not a matter of survival, your heightened emotional response can be so strong that your amygdala can literally hijack the “thinking” part of your brain, and let fear, anxiety, or even extreme excitement control your actions.

The Prefrontal Cortex

The “thinking” part of your brain refers to your prefrontal cortex, which is the more reasonable, super-evolved part of your brain that helps you to regulate your emotions and is responsible for cognition and problem solving. It's located at the very front of your brain, and is probably why you find yourself mashing on your forehead when you're trying to figure out how to tackle the trickier things on your to-do list.

Together, the amygdala and prefrontal cortex (along with many other important brain structures) form what is known as the corticolimbic system. Normally, these portions of your brain work together to process, interpret, and respond appropriately to emotions. However, changes in these areas of the brain have the potential to contribute to persistent and chronic pain.

In fact, research shows that changes in the amygdala strengthen the fear associations that can contribute to vaginismus symptoms.

The vaginismus pain cycle

So what exactly goes on in the brain and body when you have vaginismus and experience pain during vaginal penetration? Let's get into it.

The vaginismus pain cycle

Phase 1: Amygdala alarm

When you experience pain with vaginal penetration, an internal alarm goes off, triggering your body’s natural fight-or-flight response. Even though you may not be in a life-threatening situation, it can feel like you are. At that point, your amygdala can take over and make it difficult for your prefrontal cortex to think rationally about the situation and remind your body to stay calm.

Phase 2: Muscle guarding

Stuck in fight-or-flight mode, your pelvic floor muscles — particularly the ones near the vaginal entrance — tense up in order to 'guard' against the 'threat' of vaginal penetration. Sometimes with vaginismus, this fight-or-flight response can remain activated and muscle tension can become chronic.

Phase 3: Vulvovaginal pain

Attempts to penetrate the vagina through tight, overactive muscles can lead to even more pain.

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Phase 4: Negative reinforcement

If you experience the pain that your body was guarding against, that experience will fuel future fear and anxiety (the amygdala’s reaction).

Phase 5: Imprinting

As the pain cycle continues, your body is unable to forget or ignore the negative experience, and the potential for pain is marked or 'imprinted' on this part of your nervous system. Like a foot stuck on a gas pedal, you can end up stuck in “survival mode.”

Phase 6: Avoidance

Pain doesn't feel good, and neither is worrying about it, so instead of staying in the mood, you end up avoiding sexual activity and/or dreading sex altogether, further strengthening the fear and anxiety associated with vaginal penetration. This will push you back into the pain cycle, giving your amygdala the confidence it needs to continue hijacking your body’s response.

Break the pain cycle

The good news is that you can recover fully from vaginismus, wear a tampon (if you want to), and have pain-free and pleasurable sex (if you want to). Here are some key steps that can help you heal.

Talk to your doctor

If you haven't already, it's important to see your physician in order to rule out or properly treat any medical causes of your symptoms — an infection or injury, for example. Your gynecologist is a great place to start. Establishing care for this issue with a primary care provider is not only important to ensure your overall health and well being, but they will be able to help with any medical management — like pain medication and referral to specialists — that are often part of a multidisciplinary care approach.

Tip: If you are concerned you may have vaginismus or another type of pelvic pain condition, specifically tell your physician about these concerns. If you need a cervical cancer screening and know that you can barely tolerate a tampon, it is totally appropriate to ask your GYN to either try using a pediatric-sized speculum, or hold off on the cervical exam altogether, in order to prevent triggering your pain. There are other ways to get the information they need.

Keep learning about vaginismus

Learning about your body and your symptoms is not only important in helping you take agency over your health and wellness, but it helps you to feel less isolated in your experience. Plus, education about vaginismus, the pain cycle, and the path toward healing is not only often free, safe, and completely without side effects, but is a proven method for reducing pain and facilitating recovery.

Get psychological support

Depending on your individual background and specific symptoms, there are a variety of specialists who can be an important part of your care. Consider a psychologist or counselor who specializes in sexual pain disorders, trauma, and/or anxiety. Sex therapists can also be an extremely valuable asset, and can work with you and your partner to help you feel confident and comfortable during sex.

Start pelvic floor physical therapy

Pelvic floor physical therapists play a vital role helping to treat those with sexual pain disorders including vaginismus by focusing on holistic recovery of the pelvic floor. Pelvic floor PTs will use various manual therapy techniques and exercises to improve your pelvic floor muscle flexibility, increase conscious control over your pelvic floor muscles during vaginal penetration, and desensitize chronic pain signals. They may use exercise, biofeedback, manual therapy, vaginal dilator therapy, and even lifestyle and behavioral adjustments to help support your sexual health goals.

If you don’t know where to start, that’s ok. Schedule a visit one of our pelvic floor physical therapists, and they will work with you to help map a path toward healing. Our team is highly experienced in treating sexual dysfunction and will help you to break the vaginismus pain cycle and enjoy penetrative sex again (or for the first time).

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Dr. Ashley Rawlins, PT, DPT

Dr. Rawlins is a physical therapist at Origin who specializes in the treatment of pelvic floor muscle dysfunctions including pelvic pain, sexual dysfunction, pregnancy related pain, postpartum recovery, and bowel and bladder dysfunction. In addition to being a practicing clinician, she is a passionate educator and author.

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