Painful Sex and Vaginismus (GPPPD): Causes and Treatment

"Every time we're about to be intimate, my whole body tenses up." "My last doctor told me to just relax and it would get better." If you have heard advice like this and nothing improved, I want you to know that your pain is real, there is a mechanism that explains it, and there is a step-by-step way to treat it.

What is this condition called?

• Dyspareunia is the general term for pain during sex, and it applies to people of any gender.
• Vaginismus is when the pelvic floor muscles around the vagina tighten on their own when penetration is about to happen, making it difficult or impossible.
• GPPPD (genito-pelvic pain/penetration disorder): DSM-5 (2013) and DSM-5-TR (2022) combined vaginismus and dyspareunia in women into a single group, because in clinical practice they are hard to separate.

Under the GPPPD criteria, there must be at least 1 of these 4 problems, recurring for at least 6 months and causing distress:

1. Difficulty with vaginal penetration
2. Marked pain at the vaginal opening, inside the vagina or in the pelvis during penetration or attempts at penetration
3. Marked fear or anxiety about pain before, during or in anticipation of penetration
4. Marked tensing or tightening of the pelvic floor muscles when penetration is attempted

These symptoms may occur when inserting a tampon, during an internal examination or during sex.

The cycle of pain, fear and tension

The common mechanism is: pain the first time → fear of being hurt again → muscles tense involuntarily → the vagina does not relax or become moist → more pain. It goes round and round until the body "remembers" it. This is why pushing through makes things worse, and why simply being told to "relax" is usually not enough.

1. 1
   First painFrom a physical cause or an experience
2. 2
   Fear of more painAnticipating it every time
3. 3
   Muscles tenseHappens involuntarily
4. 4
   No relaxing or lubricationThe vagina isn't ready
5. 5
   More painThe body remembers the cycle

Pushing through makes it worse. Being told to just relax is usually not enough.

Causes I look for

Physical

• Dryness from lower hormones, for example around menopause, after childbirth, while breastfeeding or with some contraceptive pills. Read vaginal dryness (GSM)
• Pain at the vaginal entrance (vestibulodynia), a common cause of pain at the opening
• Infections, such as thrush or some sexually transmitted infections. Read sexually transmitted infections
• Skin conditions of the genital area, or scars from childbirth
• Deep pain in the pelvis may be related to endometriosis, cysts or pelvic inflammation

Psychological and past experience

• Anxiety, beliefs that sex is wrong, or a lack of information about your own body
• Painful or forced experiences in the past, including internal examinations that were not gentle

Relationship

• Pressure to conceive, or fear that your partner will leave
• Not enough arousal, rushing, or not feeling able to say that it hurts

Examination can be gentle

I always start by talking. A physical examination is done only when you are ready. You control the pace and can ask to stop at any time, and in some cases we start with an external look only. A good examination should make you feel safer, not more afraid.

What treatments are available?

• Treating physical causes, such as treating infection, local oestrogen for dryness, and local anaesthetic in some cases, as prescribed by a doctor.
• Pelvic floor physiotherapy teaches you to recognise and relax the muscles, with breathing and relaxation. It has good evidence for reducing pain.
• Vaginal dilators: training one size at a time, when you are relaxed and entirely in control, to teach your body again that penetration does not have to hurt.
• Cognitive behavioural therapy (CBT) and sex therapy help reduce fear and change the cycle.
• Pausing penetration for a while and coming back to closeness without a goal, such as sensate focus, can greatly reduce pressure.
• Botulinum toxin injections into the muscle have been studied in vaginismus that has not responded to other treatment. This is off-label use and must be done by an experienced doctor.

Getting to know your own body gradually helps too, and some women safely use devices as part of their practice. Read sex toys and masturbation, safely.

Treat physical causes

• Treat infections
• Local oestrogen when dry

Pelvic floor physiotherapy

• Learn to relax the muscles
• Breathing and relaxation

Graded dilators

• Practise one size at a time
• You stay in full control

Mind and partner

• CBT and sex therapy
• Pause penetration for now; sensate focus

All treatment is as assessed by your doctor, at a pace you are ready for.

If you are the partner of someone who has pain

What helps most is to believe them when they say it hurts, stop immediately when asked, do not blame, and learn together. Intimacy can take many forms that do not involve penetration. If talking is difficult, read common couple problems and how to talk them through.

When to see a doctor

• Pain almost every time, or penetration is not possible at all
• Deep pelvic pain, unusually severe period pain, or bleeding after sex
• Fever, unusual discharge or sores on the genitals
• The pain began after being forced or abused. If you need urgent help in Thailand, call 1300 (social assistance hotline) or 191 (police), and 1323 (free mental-health hotline; Thai language, ask for English support)

At Dr. Kris Clinic, we provide care with understanding, without rushing and without judgement, assessing the body, mind and relationship, and referring you to pelvic floor physiotherapy or a gynaecologist when needed. English-speaking consultations are available in person or online.