Pain with intercourse is a common complaint seen in pelvic health clinics. In fact, 1 in 7 women in the US is affected by pelvic pain according to the NIH. One of the most popular treatment methods clinicians use to treat this condition is vaginal dilators.
But what is their effectiveness? Do they really help? Should they be used alone or in conjunction with other treatment approaches?
There have been several studies done on vaginal dilators and their effectiveness in reducing painful penetration. Most, if not all studies conducted saw an improvement in pain with penetration and pelvic exams with the use of vaginal dilators in women with vaginismus, vulvodynia, and other pelvic pain disorders.
But as we all know, this is just one piece of the puzzle. As physical therapy shifts away from the impairment model and toward the biopsychosocial approach to patient care, we know that there are multiple other factors playing into dyspareunia. Factors such as:
- Stress
- Trauma
- Past musculoskeletal problems
- Neural tension
- Fear
- Cultural expectations
- Safety
Can all play a significant role in causing pain with penetration.
And as multiple new studies suggest, adding mindfulness in conjunction with the use of dilators can significantly increase the success of the treatment of dyspareunia.
Mindfulness is helping the client to focus on the present moment without having the mind wander to what they are going to have for dinner, who is going to pick the kids up from school, or the next project they are working on at work.
Instead, we help them to stay in the moment and accept their thoughts, feelings, and sensations during the treatment without judgment. Mindfulness may also help women to develop a greater sense of body awareness and self-compassion, which can be helpful in addressing the emotional and psychological aspects of their pain
Studies have also looked at incorporating breathing and breath work into treatment sessions with dilators. Using breath and mindfulness together can enhance relaxation and mobility of the pelvic floor which is key for insertion to occur.
We must also consider clients whose dyspareunia is related to trauma or PTSD. While treating PTSD is out of the scope of our practice, if a client comes to us with this history, it is our duty to recommend treatment with a psychotherapist or cognitive behavioral therapist trained in this kind of trauma in conjunction with physical therapy treatment approaches.
And then of course, we as clinicians must be non-judgemental, comforting, understanding, and actually listen to a client’s concerns and goals during treatment. There is no way treatment of dyspareunia is going to be successful with dilators or any other intervention if that client doesn’t feel comfortable with you.
Let’s take a deeper look at some of the latest research on combining mindfulness work with traditional treatment interventions:
Tending to painful sex: applying the neuroscience of trauma and anxiety using mindfulness and somatic embodiment in working with genito-pelvic pain and penetration disorders by Cyndi Darnell
- This 2021 article by Darnell discusses the application of neuroscience, mindfulness, and somatic embodiment in working with genito-pelvic pain and penetration disorders. The author argues that these disorders are often rooted in trauma and anxiety and that the brain’s response to these experiences can cause physical pain during sexual activity.
To address these issues, Darnell suggests using mindfulness techniques to help individuals become more aware of their thoughts, emotions, and physical sensations during sexual activity. By developing this awareness, individuals can learn to recognize and manage their anxiety and trauma-related symptoms.
The author also suggests incorporating somatic embodiment practices, such as body scans and breathing exercises, to help individuals connect with their bodies and become more present during sexual activity. This can help to reduce feelings of dissociation and disconnection that may be contributing to their pain.
Overall, Darnell’s article provides a useful framework for therapists and healthcare professionals who are working with individuals experiencing genito-pelvic pain and penetration disorders. By incorporating neuroscience, mindfulness, and somatic embodiment practices into their approach, practitioners can help individuals to better understand and manage their symptoms, and improve their sexual health and well-being.
Understanding vaginismus: a biopsychosocial perspective
- This article by McEvoy, McElvaney, and Glover (2021) offers a biopsychosocial perspective on understanding vaginismus, a condition characterized by involuntary muscle spasms in the vaginal area that can cause pain or discomfort during sexual activity.
The authors argue that a comprehensive understanding of vaginismus must consider biological, psychological, and social factors that may contribute to the development and maintenance of the condition.
For example, biological factors such as hormonal imbalances or underlying medical conditions may play a role, as may psychological factors such as anxiety, trauma, or negative sexual experiences. Social factors such as cultural or religious beliefs about sex and sexuality may also be relevant.
To address vaginismus, the authors suggest a multidisciplinary approach that incorporates medical interventions, such as pelvic floor therapy or medication, as well as psychological interventions, such as cognitive-behavioral therapy or mindfulness-based interventions.
The authors also stress the importance of addressing any underlying emotional or psychological factors that may be contributing to the condition.
Overall, the article offers a valuable perspective on vaginismus that considers the complex interplay of biological, psychological, and social factors that may be involved. By adopting a biopsychosocial approach, healthcare professionals can provide more comprehensive and effective treatment for individuals experiencing vaginismus.
Women, painful sex, and mindfulness
- This article by Pernilla et al. (2022) explores the role of mindfulness in the context of painful sex experienced by women. The authors highlight the prevalence of painful sex, also known as dyspareunia, and its impact on women’s sexual health and well-being.
The authors argue that mindfulness practices, which involve paying attention to present-moment experiences with a non-judgmental and accepting attitude, can be an effective tool for managing pain and distress related to dyspareunia.
Mindfulness may also help women to develop a greater sense of body awareness and self-compassion, which can be helpful in addressing the emotional and psychological aspects of their pain.
To support their argument, the authors present a review of the existing literature on mindfulness and dyspareunia. They highlight several studies that have demonstrated the effectiveness of mindfulness-based interventions in reducing pain and improving sexual functioning in women with dyspareunia.
The authors also suggest that mindfulness practices may be helpful in addressing other conditions that can contribute to dyspareunia, such as anxiety or depression.
Overall, the article provides evidence for the potential benefits of mindfulness in the context of painful sex experienced by women. By incorporating mindfulness practices into their approach, healthcare professionals may be able to provide a more comprehensive and effective treatment for individuals experiencing dyspareunia.
Effects of mindfulness training on body awareness to sexual stimuli: Implications for female sexual dysfunction
- This article by Silverstein et al. (2011) investigates the potential effects of mindfulness training on body awareness and sexual response in women with sexual dysfunction.
The authors argue that mindfulness practices, which involve paying attention to present-moment experiences with a non-judgmental and accepting attitude, may be helpful in improving women’s sexual functioning by increasing their awareness of bodily sensations and reducing distraction and negative self-judgment during sexual activity.
To test this hypothesis, the authors conducted a randomized controlled trial involving women with sexual dysfunction. Participants were randomly assigned to either a mindfulness intervention or a control group. (“Being mindful does not always benefit everyone: mindfulness … – PubMed”)
The mindfulness intervention consisted of eight weekly sessions of mindfulness training, while the control group received a general health education program.
The results showed that women in the mindfulness group reported significant improvements in their ability to focus on bodily sensations and reduced levels of anxiety and negative self-judgment during sexual activity. These improvements were associated with significant improvements in sexual functioning, including increased sexual desire, arousal, and satisfaction.
The authors suggest that mindfulness training may be a useful tool for addressing the psychological and emotional factors that can contribute to sexual dysfunction in women. By increasing body awareness and reducing distraction and negative self-judgment during sexual activity, women may be better able to connect with their bodies and enhance their sexual experience.
Mindfulness and Cognitive Behavior Therapy for Provoked Vestibulodynia: Mediators of Treatment Outcome and Long-Term Effects
- This article describes a study that investigates the effectiveness of a mindfulness-based group therapy intervention for women with provoked vestibulodynia (PVD), a chronic pain condition affecting the vulvar vestibule, the entrance to the vagina.
The study involves 85 women who were randomly assigned to either a mindfulness-based group therapy intervention or a wait-list control group. Results showed that women in the mindfulness-based group therapy intervention had significantly lower pain, sexual distress, and psychological distress compared to those in the wait-list control group.
Additionally, the intervention had a sustained effect over the follow-up period. The authors conclude that mindfulness-based group therapy may be a promising treatment option for women with PVD.
Another way we can help patients achieve mindfulness is through guided motor imagery.
Guided imagery allows you to explore beliefs and movement patterns that may be hindering your goal of returning to normal movement and function.
Visualization, imagined movement, or mentally rehearsing a movement activates the same sensory and motor patterns in the brain as the actual movement. This has been used for many years as a therapy for stroke rehabilitation and is now a proven method for reducing pain.
There is a new study trial due to begin in May of 2023 that will be looking at the effects of guided motor imagery on women who have pain with penetration:
The goal of this study is to look at the “effects of a Graded Motor Imagery (GMI) programme in women suffering from Genito-Pelvic Pain Penetration (GPPD) Disorder.”
The researchers are aiming to answer if graded motor imagery will significantly help to reduce pain in women with this disorder. Stay tuned for the results of this brand-new study being conducted!
Implementing these study findings in the clinic
When it comes to using mindfulness and guided motor imagery with dilators in the clinic, these are a few guidelines to help clients focus during treatment.
Mindfulness survival kit around the use of vaginal dilators:
- Connect with your breath often during the day
- Thoughts are not facts
- Take a break before you need it – do not overdo the dilator therapy
- Pace yourself, use the 2/10 guide for flares
- Notice the pleasant things
- Move slowly with the dilator
- Do mindful movement, even if only for a minute
- Relax tension
Graded exposure to guided imagery survival kit:
- Thinking: do you have negative or positive thoughts about the part that is hurting?
Eg “My vagina is flexible and slides and glides between the ligaments and muscles of my pelvis with ease.
This teaches the part of the brain that is hyper-vigilant to let go of some of the over-protection.
Use soothing words to yourself lying in the constructive rest position.
- Looking: look at the dilator – feel the reaction in your body when you see it.
Can you look at it with wonder and without fear?
Can you slow your breathing down during this activity?
- Mapping: hold your finger or dilator close to the area that is sore but not touching.
Outline the area of discomfort with your finger or dilator in the air close to the area.
- Indirect contact: allow pressure against or close to the area from the smallest dilator.
- Touching: can you touch the area that is painful?
- Moving and Doing: picture yourself doing the activity with the dilator
Outcome measures are important to help map out if progress is being achieved. These are some of my “go-to” outcome measures when working with clients with pelvic pain.
Outcome Measures
- Vaginal Penetration Cognition Questionnaire (VPCQ) (The full scale can be found at the end of the research article)
This questionnaire helps assess the thoughts and feelings a client has around their pain with penetration.
This questionnaire assesses sexual functioning in women
This article reviews all the different scales available for sexual disorders to help identity which scale is most useful for a particular disorder.
Final thoughts:
Yes. Dilators are a great resource for managing pelvic and vaginal pain and many many studies have shown them to be effective in reducing pain. But we should also be incorporating mindfulness and possibly even guided motor imagery into the treatment of these clients to fully treat the whole person and get to the root cause and underlying effects emotions and feelings can have on living with dyspareunia.
Have questions or want to share your thoughts? Bring them to the group chat or one of the mentoring sessions!
Susan