The Nervous System Is the Treatment: Rethinking Vaginismus Care

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Transcript

Welcome back to the OTs and Pelvic Health Podcast. I am so glad you're here today because I'm going to be talking about vaginismus and the inspiration behind this came from a couple people who actually flew into my DMs about two weeks ago and planted the seed regarding this incredibly important conversation. So I said that we're talking about vaginismus but I think there's a strong potential that some of you listening to this episode are thinking, okay, I am not sure how comfortable I am working with that diagnosis and some of you may be wondering where OT fits into this.

And I wanna say to you all that by the end of this episode, I think you're going to see vaginismus in a completely new light. And more than that, I think you're gonna see yourself in your OT skillset in a completely new light because here's the thing, vaginismus is not just a pelvic floor problem. It's not a dilator problem.

It's not even primarily a pain problem. What it is, is a nervous system problem and that is 100% in the OT lane. So whether you work with vaginismus, want to work with vaginismus or just wanna understand how the nervous system approach applies to the most intimate aspect of our clients' lives, this episode is for you.

Intro

All right, I'm gonna start at the beginning because I think vaginismus is one of the most misunderstood diagnoses in all of pelvic health.

That misunderstanding has real consequences for the people who suffer with it, sometimes for years, sometimes for decades. Vaginismus at its most basic level is the involuntary contraction of the vaginal muscles that makes any sort of penetration painful or impossible. That could be penetration during sex, during a gynecological exam, tampon insertion, toy insertion, and the range is wide.

Some people experience discomfort, others experience severe pain, some are completely unable to achieve penetration at all. Now, here's where most of the conversation stops, right? We identify the involuntary muscular contraction, people reach for a dilator, and that is the most public-facing solution. And that's what most clinicians are trained to do.

And to be fair, dilators have a role. I am not here to throw them out of the window, but that's what I want you to really sit with, that the word involuntary is the key to this whole diagnosis. If the muscle contraction is involuntary, can you voluntarily fix it? I don't think you can out-exercise it.

You can't outstretch it, you can't cognitively talk your way out of it, and you absolutely cannot just dilate your way through it, at least not sustainably and not without the risk of retraumatization.

Think about how we approach other involuntary responses in the body, right? We don't tell someone with CPRS to just move through the pain. We don't tell someone with fibromyalgia to just try harder. We recognize that the nervous system is running the show, and we meet it there in all of these cases.

And vaginismus is the same. At its core, it is a nervous system response. The body has learned for really any number of reasons, right, it could be trauma, it could be cultural messaging, painful past experiences, religious purity, right, medical procedures, anxiety.

For whatever that person's experience was, the takeaway message is that penetration is not safe, and the body is doing exactly what it is designed to do. It's protecting itself. This is not a flaw.

This is a feature. And when we start seeing it that way, everything about how we treat it changes. Everything about the way our clients interpret their diagnoses changes.

So when we reduce vaginismus to a dilator problem, we are minimizing a deeply complex, deeply biopsychosocial experience into something purely physical. And for the women living with it, who have been dismissed, misdiagnosed, or handed a dilator kit with very little support, that minimization is one more wound on top of many. We can do better.

And as occupational therapists, we are uniquely positioned to do so. Okay, I wanna talk for a few moments about the standard treatment trajectory and what it looks like for a lot of people with vaginismus. Because I think when we understand the gap, we understand why a different approach is so necessary.

Okay, so the typical journey often looks like something, often looks something like this, right? A woman finally musters the courage to bring up her symptoms to her provider. And let me pause here and acknowledge this alone is an incredible act of bravery. She has likely been sitting with shame, confusion, frustration, and grief for months, or years, or decades before she says a word out loud.

And when she does say it, she might be told just to relax, have a glass of wine, or try harder. She might be handed a dilator kit and told to practice. She might even get a referral to pelvic floor therapy.

And pelvic floor therapy can absolutely be part of the healing. But when even in the best pelvic floor therapy settings, the primary framework is often biomechanical. We're assessing muscle tone, coordination, strength, flexibility.

We're giving home programs. We're progressing dilator sizes. And sometimes that works.

But for many people with vaginismus, especially those with trauma histories or deeply rooted nervous system dysregulation, it doesn't work. Or it works temporarily and then stalls. Or it produces progress with dilators that doesn't translate to real intimacy, real life, real function.

And here's what that feels like for the woman on the receiving end. Demoralizing, deeply, profoundly demoralizing because she's done the work. She has done the exercises.

She's done her dilating. She has shown up to every appointment and she still feels broken. She still can't have the sex of her choice with her partner.

I can't tell you how many times a client has looked me in the eye and said she feels like her body is betraying her. So I wanna offer a reframe here, not just for your clients, but for you as a clinician. When the standard approach isn't working, it's not the failure of a client.

It's a signal we're treating the wrong thing. If you've ever worked with a client who's progressed to the largest dilator size, but still couldn't transition to penetrative sex with her partner, that gap tells you everything. The problem was never the dilator size.

It was the nervous system. The problem was the involuntary response that no amount of voluntary practice can override. And this is where OT and specifically a nervous system first approach changes everything.

Let me say it really plainly. If a client's nervous system is dysregulated when she attempts dilation or any penetrative activity, you're not going to get lasting results. You might get temporary compliance.

You might get short-term progress, but the nervous system will call it back every single time because it believes it is keeping her safe. And until you help her body learn that it actually is safe, not just tell her she's safe, but help her nervous system learn and feel and experience true safety, you're working against yourself. This is not a criticism of pelvic floor therapy.

This is an invitation to go deeper.

I want to take a moment here to celebrate occupational therapy. And I want to offer you a different perspective.

Our seat at the table is not the same seat. It's different and deeply essential. And when it comes to vaginismus specifically, it's incredibly important.

Here's what OT brings to this work. We think in occupations. We don't just think about the pelvic floor.

We think about what the pelvic floor allows someone to do, to experience, to participate in. Intimacy is an occupation. Sexual health is a meaningful daily life role.

The ability to have a gynecological exam, to wear a tampon, to feel pleasure in our own bodies, these are occupations. And when vaginismus interferes with these core occupations, the impact ripples across every dimension of a person's life. Her relationship, her identity, her mental health, her sense of self as a woman, a partner, a human being.

Being trained in the biopsychosocial model means we don't silo the body from the mind and from the environment. We understand that a woman's experience of vaginismus is shaped by her history and her nervous system, her beliefs, her relationships, her culture, her faith, and her trauma. And we have the framework to hold all of that.

We are masters of activity analysis. We can break down the layers of what is happening before, during, and after a triggering event and identify exactly where the regulation breaks down. We can trace that thread from morning to dilator session and find the precise moment when the nervous system exists and exits out of the window of tolerance.

We understand the concept of meaningful occupation as the vehicle for healing. We treat the whole person in the context of what matters to them. And what matters to a person experiencing vaginismus is always deeply relational, personal, and tied to who she is and who she wants to be.

So if you've ever felt like you don't have enough tools, like you're not medical enough, like you're not sure where you fit into pelvic health, I want you to hear this. Vaginismus may be the diagnosis that shows you most clearly exactly why we were made for this work. 

All right, let's get into the clinical meat of this because I know a lot of you who are listening and thinking are like, okay, so what does a nervous system approach first to vaginismus actually look like? 

So what does it actually look like is the last thing I said. Step one. Step one, nervous system regulation before anything else.

Before we talk about the pelvic floor, before we introduce a dilator, before we do any hands-on work, we spend time helping the client understand her own nervous system. Identify her baseline state and build a toolkit of strategies to get herself regulated. This means we're asking, is she in a hyper-regulated state where she's activated, anxious, vigilant? Is she in a hypo-regulated state, more shut down, disconnected, numb? And critically, does she know where she is? Can she feel it in her body? Can she name it? For people with vaginismus, especially those with trauma histories, body awareness can be pretty limited, not because they're not perceptive, but because the nervous system has learned that paying attention to the body is dangerous.

So the first phase of treatment is really about building introceptive awareness, helping her to develop the language that felt sense, the ability to notice when something's happening inside her before it becomes a crisis. So we're teaching nervous system strategies, breath work, grounding, movement, co-regulation with a trusted partner, and we're helping her understand that these aren't relaxation tricks. They're the actual treatment.

Regulation is the treatment. Step two is the mindset and the cognitive layer. Once the nervous system is in a more regulated state, and only then, we can access the cognitive layer.

This is where we start working with the beliefs, the fears, the frameworks that she's built up around her body, sex, and intimacy. And these beliefs are real and they're varied. Some people believe their body is broken.

Some believe they're letting their partner down. Some carry deep messages from their faith tradition about what sex is supposed to look like and what it means about them that it's painful. Some others carry medical trauma from a Guyne exam that felt violating.

Others, it could be childhood sexual trauma that lives in the body and is activated every time penetration is attempted. None of this can be addressed when a nervous system is dysregulated. In a hyper-regulated state, the brain's fear centers are running the show and no amount of cognitive reframing lands in that state.

But when the nervous system is regulated and they're in their window of tolerance, the prefrontal context is online. They can get curious. They can examine their beliefs with some distance.

They can start to rewrite the story her body has been telling. Step three, the curiosity mindset. Now, I wanna spend a moment on this because I think it is one of the most elegant and powerful clinical tools in vaginismus treatment.

The curiosity mindset is exactly what it sounds like. Instead of approaching dilation or any penetrative activity with fear or performance expectations or pressure, we invite the client into genuine curiosity. I wonder what it would be like if... What would happen if we tried this? I'm just going to notice that.

And here's why this works neurologically. Curiosity and fear cannot fully coexist in the same brain state. When we enter a genuine curiosity mindset, we shift out of the limbic, fear-based brain center and into the frontal cortex, the creative, the explorative, the open part of the brain.

And in that state, the body naturally begins to relax. The involuntary bracing begins to ease. The window of tolerance widens.

Clinically, I have definitely seen this be the turning point for client after client. Not a new exercise, not a new dilator size, a genuine, I wonder what would happen if... And suddenly, the body does something it couldn't do before.

Step four, the pelvic floor and dilation in context. So only, only after we've laid this foundation to do this work, then the pelvic floor work begins. It releases, it drops.

We do the breathing. We do the coordination strategies. And maybe, maybe we integrate the dilator as one tool within a much larger framework.

Not as the goal, not as a measure of success, but as one piece of a rich, holistic approach. And when we do it this way, when dilation is introduced in a regulated nervous system state with the curiosity mindset, with full body awareness and a toolkit of strategies, the results are different. Actual transfer to real intimacy, actual functional change, because the nervous system has come along for the ride.

Before we wrap up today, I wanna share a framework for explaining the nervous system and chronic pain to clients. And I genuinely find it beautiful because of its simplicity. Because I know that one of the challenges in pelvic health therapy is finding language that is accessible and relatable and empowering, I think it's worth spending time on thinking about how to explain this to clients so they don't feel pathologized.

Okay, here's how I want you to think about it and how I actually explain it to clients. I say something like, imagine every day the world sends you a ball of energy, okay? This could be stress, stimulation, demands, sensory input, positive and negative, all of it. That energy ball comes in through the top and has to go somewhere.

Your body has to do something with it. When we have good tools, movement, connection, rest, creativity, meaningful occupations, we can use that energy ball in ways that serve us. We process it, we metabolize it, we channel it somewhere healthy.

But when we don't have those tools or when the load is too high, that energy ball has to go somewhere else. And for a lot of us, it sinks down into the pelvic floor. And when there's a triggering event, an attempt at intimacy, a guy in exam, a moment of vulnerability, it activates as pain and bracing, and maybe as vaginismus.

The pain isn't random, it's a message. It's the body saying, I am not okay right now. I need your attention.

And that's how I start this conversation. And when clients understand this, when they stop seeing their pain as malfunction and start seeing it as communication, everything shifts. Because now the question becomes, what does my body need, not what's wrong with me? And that shift from victim of the body to partner with the body is where healing begins.

Your job as the clinician is to help her develop the strategies. To intercept that energy ball before it lands in the pelvic floor.

And to help her hear what her body is saying and respond with care instead of fear. So vaginismus is not primarily a pelvic floor problem. It's a nervous system concern.

And until we treat it as such, we're gonna keep getting partial results. The word involuntary is your North Star with this diagnosis. These involuntary responses require nervous system level intervention, not more voluntary effort.

And the curiosity mindset is magic. Teach it early, return to it often, and watch what opens up for your clients. The healing always spills over.

When we help a client understand her nervous system context in the context of intimacy, she gets better at understanding it in every context. That's the OT ripple effect. And it's the most beautiful part of this work.

Finally, for any of you who are facing vaginismus personally, I see you, this is hard, but you're not broken. Your body is doing the very best of what it knows how to do. And there is a path forward.

Please find a provider who understands the nervous system piece because you deserve care that meets you where you actually are. 

If this episode resonated with you, share it. Share it with a colleague, share it with a client, share it in your OT's community because the more we talk about this, the more people get access to care that actually works.

Thank you so much for being here.