Providing Hope to Vaginismus and Vulvovaginal Dyspareunia Patients

Darla Cathcart, PT, DPT, Ph.D., WCS, CLT  graduated from Louisiana State University (Shreveport, LA) with her physical therapy degree, performed residency training in Women’s Health PT at Duke University, and received her Ph.D. from the University of Arkansas Medical Sciences. Her dissertation research focus was on using non-invasive brain stimulation to augment behavioral interventions for women with lifelong vaginismus, and her ongoing line of research will continue to center around pain with intercourse. Darla is part of Herman & Wallace's core faculty and recently launched her own course Vaginismus and Vulvovaginal Dyspareunia. She sat down with the Pelvic Rehab Report to discuss working with vaginismus and vulvovaginal dyspareunia patients.

I believe one of the most important things that we as pelvic therapists can do for patients experiencing vaginismus and vulvovaginal dyspareunia is to offer HOPE!

These patients often arrive at therapy with a belief that something is uniquely wrong with them. Often, they have been to more than a handful of other doctors and care providers who are unfamiliar with pelvic floor problems causing pain with sex (which is substantiated by the research) who have maybe given them messages of "I can't find anything wrong with you" and "You just need to relax."

If I had a dollar for every time a patient told me that another care provider told them to "Just drink a glass of wine before sex to help you relax" (palm to forehead!)...These messages often cause these patients to feel as if their pain with sex is made up in their heads, or that a scary diagnosis is being overlooked.

Unfortunately, unless they have found a provider who can quickly identify that the patient has a musculoskeletal problem with the pelvic floor that needs a pelvic therapy referral, then the patient has often gone for many months, years, or even a decade or more without being properly heard or getting the right help.

When I sit down with a patient, after hearing a bit of that person's story, I typically start the conversation with "Thank you for sharing your story. I want you to know that you are not alone - a big percentage of my patients have pain with sex. I also want you to know that based on what you are telling me, you will likely get better as most of them have done."

Patients often express relief, sometimes disbelief, or both, mixed with some hope - a bit of "Ah, this person hears me and knows what I'm talking about, and says I can get better!" The belief of being able to get better, even if mixed with some doubt, is an extremely valuable start on their healing journeys.

There are many factors that the pelvic therapist could consider to facilitate conversations around pain with sex.
As with all of our patients seeking pelvic rehab, communication requires non-judgment and respecting a patient's boundaries. Asking a patient "Have you been sexually abused or had sexual trauma in the past?" can feel unnerving and alarming for a patient who is not ready to have that conversation with their pelvic therapist. However, asking a patient "Have you had any negative sexual experiences that you would like to share, that you feel may be impacting your symptoms?" allows the patient to decline until they feel ready to engage in such a conversation.

This softer approach lets the patient know that the therapist is open to a conversation about impactful events and respects that patient's autonomy in sharing that history. Putting the patient in the driver's seat is also critical. For instance, consider a patient who, theoretically, would benefit greatly from using vaginal trainers (dilators) but declines to use them. An approach of "but using trainers will be the only way to get better" may result in the patient quitting therapy, or worse, feeling traumatized from the therapy experience. Alternatively, affirming to patients that the treatments chosen are their prerogative keeps the path for ongoing healing and provider trust.

A statement of "Not using vaginal trainers is your choice, but we can always consider them again in the future if you change your mind. Let me talk you through the alternative treatments, and how their effects will differ from that of the vaginal trainer use" leaves the door open to return to that treatment down the road if the patient chooses, and also respects the choice of the patient in the moment. The key is to not be pushy about pursuing the undesired treatment down the road! It could be mentioned again, but use judgment and caution in the approach.

A final highlight is being sure to give patients space to share their story, as often they have not been heard by previous providers or their symptoms have been discounted. 

My course Vaginismus and Vulvovaginal Dyspareunia, is scheduled for March 3rd and September 14th this year and takes a deep dive into the detail of how to make the rubber meet the road to not only get treatment started but to really help progress a patient into a satisfying sex life. This course was developed so that the participant could leave this course and understand how to really approach the examination, history taking, and step-by-step procedures in instructing and using vaginal trainers and other tools for patients having painful intercourse. Additionally, this course should increase the practitioner's confidence in incorporating instructions and education related to a patient's concerns about the female sexual cycle and response (arousal, desire, orgasm), sexual positioning, lubrication, and partner integration.