Women often suspect they have vaginismus from their symptoms. Medical diagnosis is typically determined by patient history and a gynecological exam to rule out the possibility of other conditions.
Ruling Out Other Conditions
Quick Diagnosis Chart
Strong indicators or manifestations of vaginismus include any of the following:
1) Difficult penetration or impossible intercourse / unconsummated couples
Female penetration problems and unconsummated marriages are typically due to vaginismus. Entry tightness and pain are common symptoms of vaginismus.
2) Ongoing sexual pain after a pelvic problem, medical issue, or surgery
The experience of having ongoing sexual pain or tightness after resolving or managing a pelvic medical or pain issue is typically due to vaginismus (see also dyspareunia).
3) Ongoing sexual pain after childbirth
The experience of ongoing sexual pain or tightness following childbirth (after everything has healed) is typically due to secondary vaginismus.
4) Ongoing sexual pain and tightness with no discernible physical cause
Vaginismus often only occurs during sex attempts. Physicians may initially be unable to find any problem or cause for the sexual difficulties.
5) Avoidance of sex due to pain or failure
When a woman states that she avoids being intimate with her husband because sex does not feel good or has become very painful, vaginismus should be strongly considered.
The Medical Diagnosis of Vaginismus - Challenges
It is beneficial to seek a diagnosis for any type of sexual pain, including pain due to penetration problems. Some women may have an underlying physical cause to their vaginismus that needs to be determined so that it too may be treated. Diagnosis can be complex, especially when a medical condition is involved. We recommend choosing a doctor who specializes in women’s health issues like a gynecologist. In an informal poll, on our private forum, about 60% of women who responded indicated they had received a diagnosis of vaginismus from their doctors.
Some women might feel uncomfortable discussing their sexual difficulties with doctors. It’s common to feel embarrassment, shame, or anxiety in such a situation. If that applies to you, try to ease your apprehension as you seek answers. Remind yourself that by sharing these personal details, you are taking care of your health. If you broke your leg today, would you find treatment? We suspect you would. Just because it is not as easy to see your internal anatomy as a broken leg, does not mean it is less important.
“It isn’t unusual to feel anxious and rushed once the physician enters the room”
Types of Specialists
There are many specialists from diverse fields who can assist with the diagnosis and treatment of pelvic floor problems. Sources for vaginismus diagnostic help may also include:
• Gynecologists - A gynecologist is a medical doctor who has specialized training in diagnosing and treating female pelvic health issues. Not all gynecologists have experience with vaginismus diagnosis and treatment, but gynecologists are tremendously knowledgeable and will be able to help rule out other conditions, clarify health issues and may be a great ally in the road to restoration.
• Physical Therapists - There are growing numbers of physical therapists specializing in pelvic floor and sexual pain disorders like vaginismus. Many physical therapists will work with patients to set up home programs allowing women to work at their own pace, in privacy, and at a lower cost. The American Physical Therapy Association - Journal of Women’s Health Physical Therapy published a recommendation for the use of our materials for all women with vaginismus, and many therapists use the materials to help guide their patients through successful home treatment.
• Sex therapists, psychologists, and counselors - There are many other specialists who have varying degrees of experience with vaginismus.
The Pelvic Exam as Part of Diagnosing Vaginismus
A typical pelvic exam involves two parts: an external review of your genital area, and an internal exam (with a speculum and/or finger). The exam takes place while you are lying on your back on an exam table with your knees spread apart. Your abdomen and thighs are covered with a paper sheet or blanket.
External Exam - The doctor will visually inspect the outer genitalia, which includes the clitoris, vaginal opening, urinary outlet, and the labia. Any signs of unusual redness, discharge, irritations, or growths are recorded. She may then take a cotton swab and touch it to several spots around the vaginal area to check to see if there are any sensitive spots of pain.
Internal Exam - When vaginismus is suspected, doctors will often begin the internal exam by inserting one or two lubricated fingers into the vaginal opening to see if there is any resistance and to check for any tenderness or abnormalities along the vaginal walls.
Depending on how that goes, she may then move on to inserting a speculum. This tool is used to separate the walls of the vagina so that the vagina and cervix can be visualized and examined. To increase comfort, most doctors lubricate and warm the speculum to body temperature before its inserted. You may feel a slight pressure as it is opened. A small spatula or tiny brush may then be used to collect cells from the cervix for a Pap test. This test screens for any abnormal cervical cells. You may feel a cramping sensation at this point. The collected sample is then sent to a laboratory. Cultures of cervical discharge may also be taken using a swab. The speculum is then removed.
Depending on how extensive the pelvic exam is, some doctors may then place two fingers into the vagina while pressing down on the uterus. This assesses the shape and or size of the uterus, checking for any fibroid growths or cysts and/or signs of infection.
If you are unable to complete the internal exam, the doctor will consider this reality in forming the diagnosis. The results from your pelvic exam and your description of the pain and/or difficulties with penetration will help to eliminate other conditions that could possibly be causing the pain. It is important to note that just because you may be able to complete a pelvic exam successfully does not mean that vaginismus should be ruled out. For some women with vaginismus, penetration only becomes painful or impossible during attempted penis entry.
Unique Challenges with Diagnosing Vaginismus
Burning, tightness, and difficult penetration symptoms may not be at all noticeable during the pelvic exam. For some women, these symptoms occur only during intercourse attempts. For this reason, diagnosis must involve serious consideration of the woman’s concerns which may be stated vaguely as “I’m having difficulty with sex.” Sometimes, health care professionals will fail to recognize the signs or causes of vaginismus and give standard (but unhelpful) advice to just “use more lubricant”, “try to relax more”, or “drink some wine”. This may be due to a lack of familiarity with vaginismus or reliance on outdated literature on the condition.
Due vaginal muscle tightness, some women with vaginismus find gynecological exams to be extremely painful and are unable to tolerate them. If a woman suspects she may have difficulty completing an exam, she should communicate this to her physician. There are adjustments (e.g. body positioning, size of speculum used, and nurse support) that can be made to contribute to a more positive experience. A physician who is familiar with the vaginismus condition will be more suited to providing a comfortable and sensitive environment.
When there is constant vaginal tightness for the duration of the pelvic exam, it may appear to the physician as though there is an unusually small vagina or a hymen abnormality problem. Instead of recognizing the vaginismus condition, a physician may falsely believe a woman’s vagina is too small, when/if she is unable to complete a pelvic exam (see diagram below). This combined with the patient’s urgent complaint that she cannot have penetrative sex with her spouse or that sex really hurts, may further lead to the false assumption that the vagina requires corrective surgery to enlarge the opening and allow entry. Though there may be rare exceptions, women with vaginismus typically have completely normal genitalia. The constriction of the vagina is due solely to the tight involuntary spasm of the pelvic floor muscles. Unfortunately, some physicians continue to press forward with the pelvic exam causing great discomfort and pain for the woman. This traumatic experience in itself can contribute to the vaginismus condition.
Figure Showing Constriction During Pelvic Exam
With vaginismus, the simple approach of a physician's hand may have the effect of tightening the pelvic floor muscles and making the vaginal entrance seem very small and tight. Note that not all women with vaginismus will experience tightness during a medical exam (tightness may only occur during sex attempts).
Misdiagnosis and the promotion of invasive or unhelpful surgeries are sometimes the unfortunate result of all this confusion. There is no surgery to cure vaginismus. It is very important to seek a second opinion if surgery to ‘widen’ the vaginal opening has been recommended, as this does not normally resolve the penetration problem but instead may further complicate the problem. Unnecessary, invasive, and potentially harmful surgeries and medications have been suggested for women with vaginismus who have not been properly diagnosed. Remember, vaginismus is a highly treatable condition that does not require any invasive procedures.
Many women seeking diagnosis are often simply left undiagnosed and turned away by physicians who fail to find anything physically wrong and feel there is nothing more they can do. They may not consider a diagnosis of vaginismus due to simple lack of awareness.
Talking to your Doctor
Tips to Ease the Situation
For many women who experience vaginal tightness, gynecological exams can be quite frustrating or difficult. The mere approach of the doctor’s hand or speculum can cause the vaginal muscles to tighten. Here are some tips:
Bring a friend or partner for support.
Request the smallest size of speculum.
Relaxing is key to reducing the level of discomfort. As much as possible relax your stomach, thigh, and bum muscles. As the exam begins, breathe slowly and deeply.
Distract yourself by focusing on a picture on the wall, on your plans for that evening, or by talking to your support person.
Ask your doctor to describe what is being done as it is happening.
Communicate any discomfort you may feel as the exam is taking place.
Be Bold - Advocate for Yourself
Obtaining an accurate diagnosis can be challenging. Some women have been misdiagnosed, resulting in unnecessary, invasive, and potentially harmful surgeries and medications. Often, women have been ignored and left undiagnosed. In some cases, doctors who see nothing physically wrong and have not received training in diagnosing vaginismus, fail to give due attention to the woman’s concerns and do not consider researching a proper diagnosis. Seek a second opinion if you are not satisfied with the results of your examination. Vaginismus symptoms generally do not resolve on their own. We encourage you to be bold and advocate for your health to receive diagnosis and treatment care.
“Seek a second opinion if you are not satisfied with the results of your examination”
Could My Hymen be the Problem?
It is not uncommon for a woman who has never had pain-free penetration to wonder if her hymen is the cause of her problem. This is almost never true. In nearly all cases of difficult female penetration it is due to involuntary vaginal muscle tightening, not hymen problems. Unfortunately, there have been cases where doctors have mistakenly recommended surgery for removing the hymen when they are unable to penetrate the vaginal opening with a speculum during an exam. Again, the speculum insertion difficulties are nearly always due to the tight constriction of the vaginal muscles—not due to a rigid or thick hymen. Regrettably, some women are unintentionally led by well-meaning but uninformed medical professionals to believe that surgery will cure what is in fact actually vaginismus. Instead, surgery may lead to additional pain, scar tissue, and no resolution of the problem.
In very rare situations, surgery for an overly thick or rigid hymen may be warranted. However, it is critical to get a second opinion whenever surgery is recommended, to help prevent acting on misdiagnosis, and to ensure a full review of other options for less invasive alternatives. While surgery may resolve a hymen issue (if there truly was one), misdiagnosis is unfortunately only too common.
To assist women in obtaining reliable diagnosis for their sexual pain, the following sample script includes helpful tips to prepare for a physician visit. The script provides examples related to the vaginismus condition, however, it can be easily modified to help communicate the details of any sexual or pelvic pain problem.
Sample Script: Self-Guided History of Sexual Pain
1. Introduce the Problem:
"I have been having problems with pain during sex and hope you will be able to help me."
2. Provide a Description of the Pain (be specific):
It happens when:
"my husband tries insert his penis in my vagina" or "once he is inside and starts to move I feel burning and tighten up", etc.
The pain is located:
"at the entrance to my vagina. My vagina is like a wall; he just cannot get it in." or "after he is inside I feel burning around the penis just inside the entrance", etc.
The pain lasts:
"as long as he keeps trying, especially if we try forcing it in. Once he stops there is no pain."
This has been happening since:
"Our honeymoon two years ago and has continued to happen every time we try to have sex" (primary vaginismus) or "my hysterectomy eight months ago" (secondary vaginismus), etc. [Note: inform your doctor if you have been able to previously have sexual intercourse without pain.]
It feels like:
"burning", "stinging", "like he's hitting a wall", "tightness during/on entry", etc.
I have tried to reduce or eliminate the pain by:
"using lubricant, changing positions, relaxing more."
I am able or unable to:
"insert a tampon or complete a gynecological exam."
3. Mention any Past Problems:
Have you previously had any sexually transmitted diseases, yeast infections, bladder problems, or any pelvic pain outside of penetration?
4. Mention any Sexual Abuse
5. State what you think the problem is:
"I think it may be vaginismus. My symptoms are similar to those outlined in an article I read. However, I have read there are other things that can cause pain during sex, and would like to have them ruled out."
Other Possible Causes of Painful Intercourse
Some additional causes of sexual pain (other than vaginismus) are listed in the following pages. It is important to note that secondary vaginismus can co-exist with these medical conditions or continue to be present even after the condition has been resolved. If you suspect that you have one or more of these conditions make note when you see your physician:
Eczema/Dermatitis (Vulvar) - A skin condition that is often characterized by unbearable itchiness. The patches of skin often become thickened, inflamed, and develop thin cracks. There are several different types of eczema, with varying causes and treatments.
Endometriosis - A condition where tissue from the lining of the uterus (endometrial tissue) grows outside the uterus and attaches to other organs in the abdominal cavity (most often the ovaries and fallopian tubes). Symptoms may include painful menstrual periods, heavy menstrual bleeding, pain during and after sexual intercourse, and infertility. Often considered to be the most common cause of pelvic pain.
Interstitial Cystitis - The chronic, and often severe, inflammation of the bladder wall. Cause is usually unknown. Symptoms include frequency of urination, urgency, and sometimes pelvic pain.
Lichen sclerosus - A painful skin disorder that typically affects the vulva and/or anus in women. Symptoms include itching and/or burning, thinning skin, white patches of skin, sores or ulcers from scratching, and pain during sexual intercourse. If not treated can lead to fusing of the skin, atrophy, and narrowing of the vagina.
Ovarian Cyst - An ovarian cyst is any collection of fluid within the ovary. Any ovarian follicle that is larger than about 2 centimeters is termed an ovarian cyst. Symptoms may include pain or pressure in the abdomen, problems with urine flow, and pain during intercourse.
Pelvic inflammatory disease (PID) - General term for infection of the lining of the uterus, the fallopian tubes, or the ovaries. It is a common result of infection with sexually transmitted diseases.
Psoriasis - An itchy skin condition characterized by raised red patches of skin covered with silvery scales, although when located in the vulvar area the skin usually less scaly or raised.
Sexually Transmitted Diseases (STD) - Herpes, human papilloma virus (HPV) and other STDs can cause discomfort and pain during sexual intercourse.
Trauma of the vaginal canal & vulva during childbirth - Birth trauma, whether due to difficult labor and/or multiple labors, can result in internal vaginal tears, decreased estrogen levels, less lubrication of the vaginal canal, weakening of the pelvic floor muscles, tearing and scarring of the perineum, and sometimes undetermined “deep” pelvic pain. Pain during intercourse can be a consequence of any of these conditions.
Trauma due to surgery - Sometimes following vaginal surgery or pelvic surgery there can be scarring of tissues that had been torn or cut during the procedure. This can cause pain during intercourse.
Urinary Tract Infection (UTI) - Infection of the urinary tract (kidneys, bladder, urethra). Usually caused by bacteria.
Vaginal Atrophy (atrophic vaginitis) - The inflammation of the vagina due to diminishing estrogen levels resulting in thinning and shrinking tissues and reduced lubrication of the vaginal walls. Characterized by vaginal dryness, itching or burning, discomfort, and painful sexual intercourse. It typically occurs following menopause when estrogen levels are lower or in younger women immediately after childbirth or while breast feeding, but can also occur following chemotherapy or radiation, when the ovaries may not be functioning properly.
Vaginal Prolapse - “Prolapse” indicates that an organ has slipped out of its proper place. Vaginal prolapse can be due to a variety of factors including hysterectomy, menopause, obesity, difficult labor, and/or weak pelvic floor muscles. There may be symptoms of urinary incontinence, pain during intercourse, constipation, and/or vaginal heaviness or pain.
Vaginal irritation - Feminine hygiene products, douches, soaps, powders, detergents, and too tight underwear and pants can all cause irritation of the vaginal area leading to discomfort and/or pain during sex.
Vulvar Cancer - A rare type of cancer where cancer cells are found in the vulva. It is often misdiagnosed as a yeast infection.
Vulvodynia - Chronic vulvar discomfort or pain, characterized by burning, stinging, irritation or rawness of the female genitalia when there is no infection or skin diseases of the vulva or vagina that could cause these symptoms. Two subtypes of Vulvodynia are:
Vulvar Vestibulitis (also known as Vestibulodynia, Localized vulvodynia, or Vestibulitis) - This is a type of vulvodynia specific to pain on touch and/or pressure only in the vestibule, which is the area within the inner lips surrounding the vaginal opening. There is almost always pain with sexual intercourse.
Dysesthetic Vulvodynia (also known as Generalized Vulvodynia) - Pain may be present in the outer lips (labia majora), inner lips (labia minora), and/or the vestibule (area surrounding the vaginal opening). Women have also indicated pain in the clitoris, the mons or pubic mound, the perineum, and/or inner thighs. The pain can exist in one or all of these areas and can be constant or intermittent. Pain can be experienced even when nothing is touching the area.
Yeast infection (Vulvovaginal candidiasis) - Vaginal infection characterized by severe itching, vaginal discharge, soreness or irritation, burning sensation, and pain during sexual intercourse. There may be burning discomfort during urination.