Vaginismus treatment options
You may already know what vaginismus is, and regardless of whatever the causes of vaginismus there are a number of vaginsimus treatment options. In this blog we explore some of the most well known and most easily accessible.
Vaginismus treatment options – Botulinum neurotoxin (Botox)
Although a variety of techniques have been used, most botox approaches use injection into the pelvic floor muscles (Pacik 2011). Success rates vary from 75% (Ghazizadeh &, Nikzad 2004) up to 100% (El-Sibai 2000), at completion of therapy, with many studies showing a good retention of benefits at 1 to 2 year follow up (Pacik 2011, Bertolasi et al 2008). However, many women are uncomfortable with this approach.
Vaginismus treatment options – Exercises
Although research is in its early days Pelvic floor muscles exercises have demonstrated some additive benefits to dilator therapy (see desensitisation below) (Reissing et al 2013). Sphincter muscle exercises have also been seen to be effective (Zukerman et al 2005). One study used Functional electrical stimulation (FES) a system in which a small electrical charge is applied to create muscle stimulation to help with training of the pelvic floor muscles, which when combined with desensitisation proved highly efficacious (Seo et al 2005). Pelvic floor exercises appear to be a good addition to desensitisation approaches (see below).
Vaginismus treatment options – Desensitization
Desensitisation is a process of graded exposure which can be done in real life, known as in-vivo, or can be done in the imagination, known as in-vitro. The therapist combines relaxation with the anxiety producing stimuli (in this case vaginal penetration) and through a process referred to as reciprocal inhibition the old anxiety response is over written with the new relaxation response. It is usual to start off with a relatively mild anxiety trigger (such as the thought of penetration by a very slim object) get the subject relaxed with that and then progress on to the next, slightly more, challenging trigger.
Because of the intimate nature of vaginismus often the patient will have the approach explained to them, be taught how to relax and then they will conduct the work at home with a set of vaginal dilators or their fingers. Many therapists will go through the process in the imagination in preparation for the woman to go through it in reality at home, this approach is particularly common amongst hypnotherapists.
Studies of both In vivo and In vitro approaches have achieved high levels of success. Many small scale studies obtained 100% achievement of intercourse at or before the completion of the study (Biswas & Ratnam 1995, ter Kuile et al 2007, Reamy 1982,) and larger scale studies (120ss) still producing strong positive results (93.3%, Jeng et al 2006, Schnyder et al 1998 ). Results appear to have been achieved in about 1-6 sessions (Reamy 1982, ter Kuile et al 2007) and show good levels of retention at follow up, with 100% retention at one year follow up in Reamy’s (1982) small scale (10ss) trial and 83.3% of the women in Jeng et al’s 2006 study having regular intercourse with orgasm at one year review. Schnyder et al’s 1998 study which compared women receiving in vivo desensitisation with those receiving in vitro found no statistically significant difference between the two groups, whilst repeating the trend for high efficacy 97.7% of participants were able to have sex by the end of the study, of whom all retained this ability at follow up, average 10 month follow up and over half of whom reported total freedom from symptoms. Hypnotherapy enhanced desensitisation has been tested in several studies with a high degree of success (Al-Sughayir 2005, Degun & Degun1982, Fuchs et al 1973). With all desensitisation approaches demonstrating such high rates of success it is hard to say if the addition of hypnosis to the desensitization procedure makes a significant difference or not. Al-Sughayir’s 2005 does suggest a trend towards a faster response when hypnosis is used, but nothing else.
Vaginismus treatment options – Couples therapy
Traditional couples therapy approaches appear to yield results. One study of 56 couples achieved an 80.3% success rate as defined by achieving penetration (Munasinghe, et al 2004), with another similar study achieving a remarkably similar outcome, which was sustained at a three month follow up (Hawton & Catalan 1990).
Vaginismus treatment options – Cognitive Behavioural Therapy (CBT)
CBT is a psychotherapeutic approach which encourages the examinations of beliefs, assumptions and automatic thoughts, adopting new thoughts and then testing these in real life situations. It has been demonstrated to be efficacious in treating vaginismus when targeting fear of coitus cognitions and avoidance behaviours (ter Kuile et al 2007). Other CBT therapists have combined education, both general and vagina specific muscle relaxation, and graded desensitisation (see above) via the patient’s own finger (Wijma,& Wijma,1997), which has been shown to be highly efficacious at completion of therapy with Mousavi & Farnoosh (2003) reporting a 91.42% success rate. Other studies have shown even higher success rates (100%). However, these successs have to be seen in the light of high dropout rates by patients prior to treatment, which have in some cases been as high as 50% (Kabakci & Batur 2003). This suggests that a self-selecting group has a high chance of success.
Bibliotherapy, self-directed CBT via book, with minimal contact, and group therapy CBT approaches have both produced statistically significant benefits but at a low level (Van Lankveld 2006). Engman et al’s (2010) follow study of woman who had received an average 14 sessions of CBT found after 3 years 81% of respondents (respondents = 74.6% of the original woman who responded to contact) were able to have intercourse, although only 6% reported it was pain free, however most still reported enjoying it. When hypnosis was combined with the CBT approach by Eserdag Et al (2011) in a large-scale study (460ss, receiving between 2-10 sessions each) 100% success was found at three month follow up, with similar results at the 1 year mark, although at this point not all the women were achieving orgasm, and a small number were participating in but not enjoying sex.