Overview and Management of Vaginismus in Malaysia. Case-based discussion. 2nd National Mind and Body Seminar: Vaginismus Dare to Treat at Putrajaya, 27th October 2017.
3. Shila, 2004
• A young lady in niqab with
vaginismus, but already pregnant
• Anticipated difficulties in labour
monitoring
• Already planned for LSCS
4. Zaira was beaten by a belt, 2008
35, teacher, divorcee with depression
Reported history of physical abuse throughout her marriage but always very
vague in her story
After many sessions, revealed her vaginismus
7. Julia, 2014
• Julia, 33, teacher, married for 6 years with no
child, had have normal sexual intimacy but
started to avoid it after fertility treatment.
• Julia was referred by her gynaecologist for
dyspareunia
8. Treatment of Endometriasis
• She had recently been diagnosed with endometriosis.
• Dyspareunia started while she was on hormonal treatment for
endometriosis 6 months prior to consultation
• Dyspareunia persisted after treatment was stopped.
• History of vaginal dryness for a long time, requiring lubricants most of
the time. Able to enjoy sex and achieved orgasm sometimes.
9. In bed, mind in the
kitchen
• Julia was particularly obsessive with
housekeeping, always ensure house in a perfect
condition and sink must dry all the time.
• She was unable to ‘switch off’ her thoughts
from day to day house chores to completely
‘switch on’ for sex.
12. Chronic Pain Management Approach
• Chronic pain management approach for dyspareunia.
• Psychoeducation: concept of chronic pain - no more damaging, a ‘wrong
signal’ to the brain from hypersensitized pain nerve.
• Cognitive behavioural therapy (CBT) principles to improve her sexual
functioning.
• Cognitive modification: learn to cope and live with pain rather than aiming for
a cure.
• Behaviour therapy: Engage in activities rather than avoiding to break the
vicious cycle of pain. Relaxation techniques.
13. Julia’s progress
• Dyspareunia, after 3 sessions
• Increase frequency of sex from
2x/monthly to 1-2/weekly
• Reduced her pain score from 6/10
to 2/10.
• 4 months in the therapy sessions;
and while receiving treatment for
endometriosis; the patient has a
spontaneous pregnancy.
14. Vaginismus: Repeated Failures
• Many referrals of vaginismus
• Unsuccessful treatment
• Default
• ‘Stuck’
• Not making progress
• Asking around – therapists whom I asked had similar
experiences
26. Psychotherapy: Individual
• Focuses on identifying and resolving any underlying psychological
problems that could be causing the disorder.
• Problems related to childhood trauma
• Insecurities or fears about sex resulting from trauma and parents' attitudes
about it
27. Psychodynamic Principles
In Individual Therapy
• Address issues of trust
• Resolve repressed anger (for being dismissed and invalidated)
• Address her immature defence mechanism
• Generalization: towards all men
• Passive aggressive: vaginismus as the symbolism of power
28. Psychotherapy: Couple
• Any sexual problem should be treated as a problem for the couple as
a whole, and not just addressed as a problem for one person.
• The therapist interacts with the patients both separately and as a
couple.
• The therapist addresses both couple's sexual history and any other
problems that may be occurring in the relationship.
• Working on relationship problems.
• The couple is educated about vaginismus disorder and given advice
on the kind of activities that can be engaged in at home that may be
helpful in overcoming the disorder.
29. Cognitive-Behaviour Therapy in Couple’s
Therapy
• Unlearned the learned behaviour
• Desensitization
• Expose patient to the least threatening situation until she is in control
before moving on to the more threatening
• Studies showed Vaginismus is highly treatable
30. Model of Sexual Therapy (General)
(Jack Annon 1976)
• P Permission
• L
• I Limited Information
• S
• S Specific Suggestion
• I
• T Intensive Therapy
31. Permission (P)
• The practitioner creates a climate of comfort and gives permission to
clients to discuss sexual concerns, often introducing the topic of
sexuality, thereby validating sexuality as a legitimate health issue
(Annon, 1976).
32. Limited information (LI)
• The practitioner addresses specific sexual concerns and attempts to
correct myths and misinformation. This is reserved for relatively
straightforward, noncomplex problems (Annon, 1976).
33. Specific Suggestions (SS)
• Based on patient’s sexual history, specific suggestions to address
problems
• The patient is an active participant, with the therapist's guidance.
• The suggestions from the therapist may be very specific
• focusing on sexual sensations
• recording negative thoughts and analyzing them
• using music, candles to enhance the sexual experience (Annon, 1976).
34. Intensive Therapy (IT)
• The therapist provides specialized treatment in cases that are
complicated
• coexistence of other complex life issues
• psychiatric diagnoses such as depression, anxiety disorders, obsessive-
compulsive disorder, personality disorders, or substance abuse
• interpersonal or intrapersonal conflict
(Annon, 1976).
35. 10 STEPS THAT WORK
• Step 1 - Understanding vaginismus
• Step 2 - Sexual history review & treatment strategies
• Step 3 - Sexual pain anatomy
• Step 4 - Vaginal tightness & the role of pelvic floor muscles
• Step 5 - Insertion techniques
• Step 6 - Graduated vaginal insertions
• Step 7 - Sensate focus & techniques for couples to reduce pelvic floor
tension
• Step 8 - Pre-intercourse readiness exercises
• Step 9 - Making the transition to intercourse
• Step 10 - Full pain-free intercourse & pleasure restoration
36. Step 1 - Understanding vaginismus
• Overview of vaginismus
• Spasm, sexual pain, penetration difficulties
• Involuntary/unintentional
• Addressing myths
• Helps women to get started by being proactive about their sexual health as
understanding vaginismus is fundamental to the process of overcoming it.
• Overview on
• how diagnosis is made
• treatment methods
• relationship issues
• pelvic/relaxation techniques
• conditioned responses and muscle memories.
39. Step 2 - Sexual history review & treatment
strategies
• A balanced approach is taken to help women review and analyze their
history.
• Identify and evaluate any events, emotions, or triggers contributing to
vaginismus sexual pain
• Emotional reviews
• negative events, feelings, or memories that may collectively contribute to
involuntary pelvic responses.
• include blocked or hidden memories and how to move forward when there
have been traumatic events in a woman's past.
40. Facing The Truth: Emotions Resulting From..
• Witnessing events
• Abusive experience
• Relationship with partner
• General misunderstanding/misinformation
• Fear
• Sexually fearful upbringing
• Physical experience
• Medical condition
43. Make Declaration
• Putting The Past Behind
• Permission to be sexual & sensual
• Dispelling Negative Emotions
• Taking Control
44. Step 3 - Sexual pain anatomy
• Educates about sexual body parts.
• Distinguish what kind of pain/discomfort is normal with first-time or
ongoing sex
• Physical changes take place during arousal to orgasm in a sexual
cycles in the context of sexual pain or penetration problems.
• Anatomy areas such as the hymen and inner vulva
46. Step 4 - Vaginal tightness & the role of pelvic
floor muscles
• Role of pelvic floor muscles, especially the pubococcygeus (PC)
muscle group
• Explaining how once they are triggered they continue to cause
involuntary tightness with attempts at intercourse.
• Treatment will focus on retraining the pelvic floor to eliminate
involuntary muscle reactions that produce tightness or pain.
48. The Importance of Relaxation
“Someone says to me just relax –
and I do not know how”
49. Pelvic Floor Exercise (Kegel)
Contract PC muscles slowly for three seconds.
Hold them tight for three seconds
Then relax them completely for three seconds.
Repeat this 20 times several times throughout
the day.
Progressively increase the length of repetitions
50. Step 5 - Insertion techniques
• Techniques to allow initial entry without pain.
• In this step, women practice PC muscle control techniques as they
allow the entry of a small object (cotton swab, tampon, or finger)
• Women begin to take full control over their pelvic floor (Kegel’s
exercise with insertion)
• learn how to flex and relax the pelvic floor at will
• eliminate unwanted tightness
• allowing entry.
53. Step 6 - Graduated vaginal insertions
• Graduated vaginal insertion exercises allow women to comfortably
transition to the stage where they are ready for intercourse without
pain or discomfort.
57. Step 7 - Sensate focus & techniques to reduce
pelvic floor tension
• Helping with the transition to pain-free intercourse,
• to reduce pelvic floor tension
• to increase intimacy.
• to build trust and understanding and assist in the process to adjust to
controlled intercourse without pain.
• Couples begin to work together during this step as exercises teach how to
successfully practice sensate focus (controlled sensual touch)
58. Sensate Focus (Master & Johnson)
First stage: the couple
may touch each other's
bodies excluding
breasts and genitals.
•encouraged to be aware of
sensation
•concentrate on what they
find interesting, not on what
they think the other may
enjoy.
The second stage
increases the touch
options to include
breasts.
•Encouraged sensation about
the partner's body
Further stages include
the gradual
introduction of genitals
and then full
intercourse.
61. Step 8 - Pre-intercourse readiness exercises
• Couples review and practice techniques that eliminate pelvic floor
tension and prepare to transition to full intercourse.
64. Step 9 - Making the transition to intercourse
• Techniques used to eliminate pain and penetration difficulties while
transitioning to normal intercourse.
• positions to use to maximize control and minimize pain
• Use of lubricants
71. Challenges in treating vaginismus
• Very costly (specialist treatment can escalate to USD10K)
• Long waiting list for new clients
• Global shortage of qualified specialists or clinic
• Lack of accessibility for treatment
• Previous misdiagnosis or mishandlings resulting in distrust of medical
& other treatment professionals
• Other personal life challenges or emotions that inhibit women from
seeking treatment eg embarrassment
Mark & Lisa Carter, 2004
72. Treatment Duration: Factors
• Partner support
• Consistency of effort
• Varying level of motivations
• Professional support
• Physical health
• Complexity of other co-existing condition
