By Melinda Fontaine
Mary is an amazing story because in a matter of months, she went from not having any penetrative sex for many years to having unrestricted intercourse with her partner. When Mary was a young woman, she saw a gynecologist for a routine exam. Now, lying on the exam table with your butt almost falling off the edge, your feet in stirrups, and a physician coming at you with a cold hard speculum is enough to make anyone anxious and uncomfortable. On top of that, when the physician had difficulty inserting the speculum causing lots of pain, he rudely blamed Mary for being a prude. He exclaimed “You are the kind of girl who will make a cold wife”. Can you believe that?! This extremely rude and sexist doctor missed the perfect opportunity to educate her on the pelvic floor muscles and how increased tension can lead to difficulty with speculum exams and penetration. I wish this weren’t a common complaint that I hear. Not many doctors are as rude, but with our fast-paced health care system, the education is often missed. He screwed up, so Mary walked out of the office feeling very bad and not understanding what was going on with her body. Her future pelvic exams were all variations on this theme.
Mary became very successful in life and met and married a lovely man named Alan. She had a rousing sex life consisting of outercourse and clitoral stimulation which she really enjoyed. She developed a great relationship with her clitoris, could have orgasms, and was fully satisfied through their many years of marriage. She never attempted vaginal intercourse, in fact she never realized that intercourse was a possibility. Her husband had “found the door locked” and did not talk to her about it or try again. It also never occurred to her to examine her own vagina and figure out what it what…until she met Patrick. Patrick was her new lover and a very passionate and patient man. They shared a love of poetry and music, and their relationship grew more intimate. Good fortune shone upon them because Patrick happened to be an obstetrics and gynecology nurse in his prior career. He taught Mary that sex could involve vaginal penetration. Even before they attempted intercourse, he knew that Mary should seek help.
Mary went to see a gynecologist with a lot of experience and a friendly demeanor. This practitioner was the exact opposite of the first gynecologist Mary met many years ago. She taught Mary how to find her vaginal opening behind the set of double doors (labia majora and labia minora). The doctor taught her how the muscles around the opening of her vagina were so tight for so long, that they effectively pinched the opening closed. The good news is these changes were reversible. She recommended that Mary buy a book about vaginismus and a set of dilators, and go see a pelvic physical therapist. Check out Malinda’s blog for more on vaginismus.
When Mary first came to see me, she was 64 years old with 2 goals:
- pain free vaginal intercourse
- pain free pelvic exams
She had read the book on vaginismus and began the self-help program. She began with inserting a Q-tip in the vagina and was surprised when she saw the tip disappear inside her, and with no discomfort. She then repeated the process with the smallest dilator and the next two sizes after that. The book also told her to do Kegel exercises. When she began PT, I told her to stop the exercises because they were actually making her muscles tighter. For more information, see Why Kegels are bad for your tight pelvic floor.
I like to do a guided anatomy tour of the vulva using a handheld mirror for all my female patients, but I felt it was an extremely appropriate review in this case because part of achieving her goal was going to be becoming comfortable and familiar with her body. During the visual inspection, I mentioned that the color of the tissue in the vestibule (the area between the labia minora) was pale, almost white. It is typically a nice pink like the inside of your cheek. This pale color commonly happens when the estrogen level in the vulva is low, as happens after menopause or in young women who use birth control pills; see Dr. Gonzalez’s blog. This can also cause the tissue to become fragile, tender, dry, and stiff. Luckily, Mary’s gynecologist had noticed this as well and had prescribed her a topical estrogen cream which she had used a few times. I encouraged her to use it consistently as prescribed because it would help make for a resilient, comfortable, and flexible vagina, very useful for intercourse.
I also examined the muscles of her pelvic floor internally. I found that they were very tight, even when she was not actively squeezing them. The muscles were probably squeezing all the time without her realizing it, making it very hard to insert anything in the vagina: a penis, a finger, a speculum. Over a series of visits, I could make the muscles release with massage, verbal cues to let go of the tension, and guided meditation.
But what caused the tension in the first place, and how can we keep it from happening again? Many different things can cause muscles to tense up and try to protect themselves. It is usually something that the muscles perceive as dangerous, such as an infection or trauma, but sometimes it is not so clear. Some people carry their stress, fear, and anxiety in their muscles. You may be familiar with the phenomenon of people having tight shoulders when they are stressed out; the same thing can happen in the pelvis. Her muscles were short and tight and full of knots (trigger points). They may have been clenching for a large part of her life without her knowing. We found that any stress causes her pelvic floor to tighten up more. For example, we landed on the subject of politics during one treatment and her pelvic floor tension was through the roof! Luckily, she now knows how to reverse that, and bring her muscles back to baseline. Her history of painful pelvic exams and inability to tolerate penetration was a result of those tight pelvic floor muscles, and now she finally had an explanation for what she experienced. Mary is not alone; check out this short film about tight pelvic floor muscles, Tightly Wound.
To coax these muscles out of their holding pattern, we did internal myofascial release in the office, a dilator home program, partner education, and a lot of encouragement. After 4 months, she was able to comfortably use the largest dilator and tolerated vaginal penetration by her partner’s two fingers. After 9 months, she could tolerate vaginal penetration by her partner’s penis. With physical therapy to stretch the tissues, estrogen cream to improve the quality of the tissue, and lots of practice, Mary is now able to have comfortable penetrative sex with her partner, a HUGE difference from where she started months ago.
I asked Mary for a comment for this blog post and she said “It was hard for me to believe that, after all this time, I would actually be able to have penetrative sex, but you always encouraged me to believe that this was the case. When one is starting with a Q-tip (and at a late age), it is really important to have a conviction that one’s goal is truly achievable.” Mary is a great example for all the other women out there in similar situations.