Vaginismus and Painful Sex: Causes and Treatment (Episode 602)

Full Transcript: Episode 602

Lisa Hendrickson-Jack:

This is the Fertility Friday Podcast, episode number 602.

Today’s episode dives into an incredibly important topic that has not really been one that we’ve talked about on the podcast a whole lot. I think the only time this topic came up — the topic of painful sex — or pretty much the only time was an episode quite a while ago, and it was related to one of the lesser-known side effects of hormonal birth control, which can be painful sex. But in today’s episode, we are talking about painful sex and vaginismus with Dr. Janelle Frederick, also known as the Vagina Rehab Doctor.

One of the main themes that came out in today’s episode was how common an issue painful sex is for couples — how many couples actually struggle with this. And not just that it’s a little bit painful but you can still do it, but actually the percentage of couples for whom the issue is so severe that sex may not even be able to take place. So this is a huge, huge issue — obviously one that can be surrounded by shame and silence, something that people may be experiencing but not talking about.

So I’m really thankful to have this conversation with Dr. Frederick and to bring it out into the light, to normalize it, so that couples who are experiencing this type of difficulty know that they’re not alone, but also know that there’s hope. And I think for me especially, the message that I hope shines through is that it’s not normal for sex to be painful. And if it is, it shouldn’t be that way. There is support out there and we should be seeking that. It should never be expected that we’re just supposed to continue to endure something that is painful.

So before we jump into today’s episode, I want to share a little bit more about Dr. Janelle. Dr. Janelle Frederick, known as the Vagina Rehab Doctor, is a world-renowned pelvic floor specialist dedicated to helping individuals overcome pelvic floor dysfunction and reclaim their confidence. Recently married, she proudly embraces her new name while continuing her mission to break the stigma surrounding pelvic health issues. Originally from a small city in Alabama, Dr. Janelle brings warmth, expertise, and a passion for empowering others.

So, without further ado, let’s go ahead and dive into today’s conversation with Dr. Janelle.

I’m excited to be here today with Dr. Janelle Frederick. Welcome to the show.

Dr. Janelle Frederick:

Thank you so much, Lisa. I’m very excited to be here, and I can’t believe that I’m here. I used to listen to your podcast and I’ve heard about you for years. So, thank you so much for having me.

Lisa Hendrickson-Jack:

Oh, of course. I was really thrilled to have you because we’re going to be talking about something that I haven’t talked a lot about. I feel like if I think about all the different episodes, even over 11 years, I feel like this is not something that we’ve talked about a lot. It might have come up in passing. And so I know there’s a lot of things we can talk about today, but I did want to ask you about pain with sex, painful sex. So I’m really excited to talk about that with you. But before we get into that, I’d love to hear a little bit about your background. So for those of us in the audience who aren’t as familiar with your work, share a little bit about what you do and why you ended up focusing on this area in particular.

Dr. Janelle Frederick:

Sure. So I’m a pelvic floor physical therapist. I actually went to Oakwood University in Alabama — Huntsville, Alabama — and that’s actually where I just moved back to. So started off with my bachelor’s there, went to California, Northern California, a school called the University of the Pacific, and that’s where I did an accelerated doctorate in physical therapy. So it was just two years, super quick and stressful. But once I finished, I started doing traveling physical therapy.

And I remember vividly when my recruiter told me about a women’s health physical therapy position. And this was going to be just about bladder dysfunction — urinary incontinence, frequent urination, urgency — so feeling like you won’t make it to the bathroom. And I was only supposed to be there for three months for a contract. And I was so in love with what I was doing there that I just kept renewing it until I was there for a year. And so I was like, “Okay, this is something I need to look more into.” And so that’s when I decided to go ahead and specialize as a women’s health physical therapist.

Now, it’s no longer called women’s health physical therapy — it’s called pelvic health physical therapy, just to be more inclusive. But I then went to Chicago, and that’s where I did a residency at Loyola. I then started working at Northwestern, and that’s when I got exposed to more sexual dysfunction. So I started seeing that a lot of women were struggling with sexual pain in their relationships and intimacy. And I just really want to help women have pain-free sex. I feel that that’s something everyone should experience, especially when there is a partner involved. I mean, that can drastically influence the relationship. So instead of trying to be the expert on everything — like incontinence, prolapse, pregnancy — I was like, let me just choose something. And so that’s what I tend to focus on: just helping women to feel free and satisfied with their sex life.

Lisa Hendrickson-Jack:

Well, I mean, I’ve been following you for a while on Instagram. I feel like the content that you put out is super fun, but it hits on such an important issue. So one of the questions I wanted to ask is just about prevalence. I mean, how common is this issue?

Dr. Janelle Frederick:

Oh, it’s very common, and it actually changes based on where you’re located. So if you’re in an eastern culture — like there are certain parts of Turkey or certain parts of West Africa — where the rates of sexual pain and vaginismus, which can actually make intercourse completely impossible, are even higher. So 75% of women will at one point in their life have painful sex. Sometimes it’s not because of the pelvic floor though — it may be menopause or it may be recurring yeast infections. But the fact remains that painful sex happens to three out of four women in their lifetime. Now at one period of time, about 25% of women struggle with painful sex, which — that’s millions and millions of people.

So it’s very common. And we do sort of niche down even a little bit more to vaginismus, and we see this happening a lot with women who have waited until marriage, women who are religious, women who try to do things the right way — and they seem to struggle the most. So we see it a lot. It’s not talked about enough, but you just never know. There could be people that have babies and have not had sex. We also work with that — like they’ve had a vaginal birth, they have never had intercourse. And so this is common and you can’t just look at someone and know whether or not they are struggling in that department or not. So we absolutely love to make this more known so that women can feel comfortable getting help, talking about this, and not feeling so isolated or strange.

Lisa Hendrickson-Jack:

Well, you said a lot there. One thing I just want to touch on before I ask you more about vaginismus — you said women who’ve had a baby, a vaginal birth even, and have not had sex. Are you referring to like the IVF scenario where they’ve — okay, please explain.

Dr. Janelle Frederick:

So I want to sort of take a few steps back. We work with various types of pelvic floor dysfunction. We still get incontinence, occasionally prolapse, or someone preparing for pregnancy who wants to prepare their pelvic floor. But most — I would say 70% of the patients that we have — it’s either “I can have sex, but it hurts way too much,” or “I can’t have sex at all because nothing can get inside. He’s just hitting a brick wall.” And so when that is happening for five years in your marriage, most people are ready to have kids by the five-year mark. And if sex is impossible, you only have a few options.

IVF — many times they still have to go in. So a lot of our patients sometimes struggle with a finger, inserting a Q-tip, inserting a tampon. So there is something called the splash method, where if your partner just ejaculates around the vaginal opening, even if there’s no penetration, the sperm can just swim up. So in the charting world, we call that like a contact pregnancy — it’s kind of one of the teachings. If you want to try to avoid pregnancy, it’s like don’t let him get it on his hands. This is very interesting because I’ve never heard this as a method of conception. So that is very interesting.

Or we have some people where maybe their partner can get in very partially — just the tip of the penis can get in — and somehow they get the sperm up there, but no full penetrative sex has taken place. And so we’ve even worked with women who have three-year-olds running around, but they’re now experiencing pain-free sex for the first time after they go through our coaching program, which is pretty detailed on how to actually release those pelvic floor muscles so that intimacy is no longer hurting. So you just cannot judge a book by its cover. People are really struggling with this, but I’m glad that the word is getting out there that there are solutions, and you don’t just have to suffer through this problem.

Lisa Hendrickson-Jack:

Okay, so I want to ask: what is vaginismus, and why is this happening?

Dr. Janelle Frederick:

Okay. So vaginismus is a pelvic floor disorder that can make penetration either completely impossible or very excruciating. And the reason why this is happening is because of three primary factors.

One, there is significant pelvic floor tightness. This is a medical-grade level of tightness. We hear a lot that people think it’s good to be tight — we’re not talking about that type of tightness where your partner goes, “Oh, you’re so tight.” That’s not medical-grade level of tightness. We’re talking about hypertonicity, which means your muscles are essentially held in a kegel all day long. Like your muscles don’t know how to let go of restriction. That is the level of tension that we’re talking about — to where even a Q-tip may hurt or be painful.

After the tension, the other thing is pain. There is true physical pain. It’s not just in their head. It’s not just “I’m afraid” or “we haven’t done enough foreplay.” There is pelvic pain that is preventing insertion from being tolerated. And then also, with vaginismus, there is usually — but not always — a fear component. And what we tend to see a lot of is women who are scared of pain. They’ve been told that it’s going to hurt, there’s going to be bleeding, they’re going to rip their hymen — just prepare to grit through it and hold on. So a lot of women come with either fear of pain or a history of sexual trauma that has created some anxieties with sex. And so it’s like a cocktail of things contributing to either impossible intercourse or extremely painful intercourse. So that’s vaginismus.

Lisa Hendrickson-Jack:

That just makes me so sad to hear. And one in four religious women have it. One in four. So part of it is — and you kind of already said this — it’s beyond just not enough foreplay. But is this related to sometimes a lack of information about female anatomy and how it works, or even a lack of understanding of the sexual process?

Dr. Janelle Frederick:

Yes, it is that. But also we see that anyone can have vaginismus. While we do see it more common in more conservative cultures, more religious women, we’re also seeing it in women who didn’t grow up going to church, and maybe their parents were pretty liberal and they’re sex positive — and they can’t have sex. It also happens to women who have very high sex drives. So it’s not one thing, but I would say a common thread that I’m seeing is a lot of avoidance — to where you wait until marriage and you try and have sex on your wedding night, but literally nothing has been tried before then. You haven’t tried to insert a finger, you haven’t gotten a pap smear, there’s never been a tampon put in. So those muscles have essentially been unused for about 25 or 30 years. That’s one of them.

The other factor is poor sex education — where some people don’t know where their vagina is at all. They think that this process of intercourse doesn’t even make sense. How is that penis going to fit inside my small vagina? Why is this not going to be painful? Oh, it has to be painful. So there’s a lot of that.

And then there’s a lot of religious silencing where just in your upbringing, you just didn’t talk about it. Sex is dirty. Sex is nasty. You can’t do it until you’re married. And then all of a sudden when you’re married, you’re supposed to be able to just go for it. So it’s definitely a lot of factors involved. But sometimes there’s no trauma in the background, no conservative religion. Some women don’t know why they have it. Some women develop it after very stressful life events. But the fact remains that those muscles just don’t have the mobility required to allow comfortable intercourse. And then sometimes there’s fear and anxiety where we have to work with them on calming their nervous system too. And it’s not just the physical. So it is an amalgamation of things.

Lisa Hendrickson-Jack:

Working over the years with women of reproductive age — in their 20s, into their 40s, even into their 50s — sometimes when I’m working with a younger population and the sex is not the primary thing I’m talking about with clients, it’s usually about the menstrual cycle and charting. But obviously, if you’re using the method for pregnancy or avoiding pregnancy, we need to be able to talk about when the sex is happening. And so naturally that lends itself sometimes into these types of conversations. I’ve seen many situations where you just kind of get into conversation and they kind of mention that sex is painful sometimes. And it seems to be a situation where they’re not saying anything. Like the sex is painful, but they’re not saying anything. And it’s like once you have a conversation and you talk a little bit about how the body works — how long it takes for the vagina to relax and lengthen, lubrication, all that kind of stuff — then the lights start to go off.

Dr. Janelle Frederick:

Exactly. I see a lot that women don’t feel like they have a voice, and there are these expectations on us that we want to fulfill — like we want to be able to say that our partner is pleased in the sexual department. Or maybe they feel like they are being needy if they’re complaining that something hurts or they need to stop sex early. I think there was a study that showed 40 to 50% of women who deal with painful sex haven’t even told their partners.

And I remember a very clear situation — this is when I used to work in person at Northwestern in Chicago. There was a woman in her mid-40s. She came in for pelvic floor therapy for painful sex. And when I tell you, her vagina was so tense and tight I could barely get my finger inside to do the assessment and release her pelvic floor muscles — because she’s been married for like seven years and she said she’s been having sex the whole time. She goes on to say that she was having sex with her husband because she felt like it was her job — like she had to do that in order to be married. And we can judge her, but a lot of women feel that same way.

Lisa Hendrickson-Jack:

What you were saying — you could barely insert a finger, but she felt like it was her duty to have sex. I mean, we have so much work to do. But what’s the solution? Like, from my perspective and my views and values, sex is something very special. It’s the most intimate you can be with someone in many ways. And in the context of a loving relationship, it can be such a beautiful thing. So it’s sad to think of married couples going almost a decade without being able to fully enjoy it — for both of them to fully enjoy this, and for one partner to feel like it’s just a duty they have to do and not even realize it’s supposed to be enjoyable.

Dr. Janelle Frederick:

Oh, yeah. I think there are so many layers to the work that needs to be done. On my side, being a pelvic floor physical therapist, I’m really in the trenches of the actual physical healing work, right? The nervous system and the pelvic floor muscles, and women knowing that those muscles even exist and that they can be causing someone’s pain. But I think even further than the physical and clinical work is the education that we get. What are we being taught about our bodies? And what are we being told as women?

Is sex about pleasing your partner? If you’re a wife, is it about just submitting and making sure that your husband is happy? Or is it a mutual experience where both people should feel safe and satisfied and not in pain? Because it’s only taboo if we talk about it for women. If a man comes to you and says, “I’m in excruciating pain during sex,” you would think something is very wrong with him. But we don’t think that way for a woman. We think that she should be bleeding, it should be painful her first several times. And women are confused — they’re waiting for this first-time sex pain to go away because we’ve been told that if you’re a virgin, you’re just supposed to be in a lot of pain.

So it’s a lot of myths. There’s a lot of antiquated stories that we’re still holding on to, and we’re not teaching women to be the agency owners of their bodies. Even as a religious woman — God created pleasure. He doesn’t want me to be in pain. So I think speaking from all angles, whether religious or clinical, we need to empower women and couples to know that sex is a beautiful, pleasurable thing. Not just done to please one person, not just done for reproduction — it’s also done for bonding and feeling close and connected to your partner.

Lisa Hendrickson-Jack:

So now I want to shift into more of the solutions. Where does someone start when they have these types of issues?

Dr. Janelle Frederick:

Great question. One of the best places to start is just believing that they can heal, because we work with a lot of women who have had this problem chronically or their whole life — they’ve never been able to insert a tampon, or the pap smear was causing them to jump off the table. Someone like that who knows pain more than they know comfort and pleasure — it starts with just believing that your body doesn’t have to stay this way. Because we can give you the best clinical treatment, but if your mind is still stuck in “I’m never going to get better,” then it won’t work.

So that’s where it starts. But then it also goes to relearning new narratives about your body. Yes, you may be experiencing pain now, but just like any other muscle in your body, those muscles can be retrained. The same way we can strengthen our butt muscles, we can get more flexible — we see people learning how to do the splits at 35 years old. So it’s similar for the pelvic floor.

These are muscles that are some of the strongest muscles in the body. They can be trained to release tension and pain, but that is a process. So in that process, as a pelvic floor physical therapist, we’re looking at how much tension is being held inside — because many times there is internal work that needs to be done. The same way if you have a tight shoulder, you may go to a massage therapist and they’re almost digging into the muscle to release that knot — the muscles inside the vagina can be so restricted that a stretch or just breathing is not enough.

And so we teach our patients — because we do everything remotely — how to use tools at home. Dilators: they’re cylindrical tools that look like small penises. It starts from a really small thing that looks like maybe a finger. And we show them how to use these tools, how to use them to release pain and tension. There are also pelvic wands, which are tools that help more with the angle, because the pelvis is not a straight line. So we’re teaching women how to use their own hands, how to use tools, and how to include other exercises and nervous system calming methods that help them to not be so afraid of their body — because a lot of this is also learned fear because it has always hurt. So that is typically the route we go: address the nervous system, and also help with the actual muscles.

Lisa Hendrickson-Jack:

I mean, how can the partner be involved in this?

Dr. Janelle Frederick:

I find that it doesn’t really go well when the woman feels she has to sort this out on her own. I will say that culture plays a big role in how comfortable the man is with this healing process. In my experience, I’ve seen that some husbands are a little more closed off to this process — they sort of just want to go and have sex. They don’t want to use dilators. They don’t want to see their partner struggling to get pain out of her vagina. And so sometimes I’m saying, if the man is not willing to help you use dilators or go to the physical therapy session, we at least need him to just be supportive. Because culture does play a big part in how people see things.

We also do offer couples coaching. So if someone actually wants to do each and every session with their partner, we will show their partner how to aid their partner in releasing the pain — hands-on tactics where they can physically help their partner relax. But generally, if it is the woman we’re helping in each session, we do eight sessions typically. By visit five, six, seven, we start prescribing partnered homework — we want you to do some foreplay first with your partner, then we want them to use the dilator with you. And here are the strategies that we want your partner to use so that you can start relaxing, start feeling more unity sexually, and feel prepared to make the transition to actual sex. While it’s not required, it is definitely a bonus when your partner believes in you and is willing to help out.

Lisa Hendrickson-Jack:

One other question — the hope piece. So for women who have identified this issue, they’re willing to jump in and figure it out, they’ve got their dilators, their partner’s on board — typically how long do you see it take before these women start to feel relief and actually start to be able to enjoy sex again?

Dr. Janelle Frederick:

This is where I get extremely geeked out and happy. When I used to work in person, it would take me maybe six to eight months to help women overcome this. Currently, our average amount of time is eight to ten sessions, which equals out to just about two to three months. And we always say two to three months because we’re women — we have periods, maybe we get sick, maybe we travel. So I don’t like to say only eight weeks. But we really only need that length of time if someone is coming every single week and doing the homework. Your body is created for this. We’re not teaching you how to fly. We’re teaching you how to do something that your body was made to do.

And in person, if someone went in person, the average time is about six to eight months. So don’t give up. Even if it’s taken you longer, it doesn’t mean you can’t get better. It just may mean you need a new approach or a different style of therapy.

I think it’s three major things that make the difference with our program. One is that we just understand the condition better — vaginismus means spasm of the vagina, and that has now actually been debunked. It’s now lumped into a condition called genital pelvic pain penetration disorder. Number two, we’re showing women how to take ownership over their healing by teaching them hands-on tools they can do at home — instead of lying on a table while the provider does everything to you. We’re seeing more ownership, more accountability. And then lastly, we’re able to include more non-clinical things: pleasure, sex positivity, pain science. So women are feeling more coached and guided with our program instead of just being told to go home and do exercises. It’s very hands-on, very actionable, and women are able to learn how to feel like the CEO of their body.

Lisa Hendrickson-Jack:

Based on everything you’ve experienced, what suggestions do you have for how one finds support and doesn’t feel discouraged if they’ve tried to seek support and not received the help they need?

Dr. Janelle Frederick:

I would say a big one is to have both social support and expert support. Not everyone who has a white coat is an expert in painful sex or vaginismus. When you go to your doctor and they start recommending things you could hear from a group chat — have a glass of wine, relax, use more lube — that’s not really skilled advice. So once you realize that’s the most advice you’re getting from your doctor, look and do some research. Can you work with a pelvic floor therapist who actually focuses specifically on vaginismus or sexual pain? Because that is the number one proven expert to treat sexual pain. It’s the most non-invasive route — no surgery involved.

And then on the other side, don’t just do the clinical. Is there a support group? Is there a friend or girlfriend you can talk to who is not going to shame you or act like you’re just this weirdo? Someone who can provide emotional support more than just your partner. Even if you can’t afford pelvic floor therapy, doing some pelvic floor stretches and pelvic floor relaxation exercises can drastically help and reduce pain. So there’s something that everyone can do regardless of their economic level or capacity. Just do something.

Dr. Janelle Frederick:

And the last thing I wanted to say is: don’t forget about your pelvic floor as you pursue pregnancy and as you think about your fertility — because generally fertility planning and trying to grow your family does involve sex. And it’s after pregnancy too. Your pleasure matters before you get pregnant, during, and even after as you become a mom. You’re going to eventually want to return to sex, right? So don’t forget about that piece. We’ve seen so many women get pregnant soon after finishing treatment because now they can actually get through the act. And so remember that your comfort matters. It’s not just for your partner — it’s for you. And there is healing available. There is hope, and you can do this.

Lisa Hendrickson-Jack:

That is amazing. This is a really big issue, and it has the potential to tear apart relationships. But there’s a solution. It doesn’t have to be this way. So happy that you’re out there healing the world one vagina at a time. So why don’t you share with us where people can go to learn about you?

Dr. Janelle Frederick:

Sure. So if you want to learn more about me and what I do, I am most active on Instagram, also on TikTok, with the same handle: vagina rehab doctor. Everything is spelled out — no abbreviations. And then if you are interested in one-on-one coaching with us, you can set up a free consultation at vaginarehabdoctor.com. And again, everything is spelled out.

Lisa Hendrickson-Jack:

Amazing. Well, we will make sure to link all of those places in the show notes. Thank you again for being with us today and enlightening us on vaginismus. Everything you said made so much sense. So thank you for enlightening us and for giving hope, especially for couples who have been struggling with this.

Dr. Janelle Frederick:

Yeah, thanks for having me, Lisa.

Lisa Hendrickson-Jack:

I hope that you enjoyed today’s episode with Dr. Frederick as much as I did. I mean, wow. I have heard of a lot of issues in my time, but I’m still going to need a minute to kind of digest what she said about the splash method. Don’t even think that if a person has had a baby — even a vaginal delivery — that they have actually had sex before. Because there are couples for whom sex is such a significant issue, challenge, problem — causes such significant pain — that there’s an actual quote method of conception that doesn’t involve penetration, so that couples can still conceive even if they’re not able to have penetrative sex. That was certainly new to me.

This is important for women to know, for couples to know. Education is so important. But it’s also important for practitioners to be aware of this. And this is one of the themes that often comes up in FAM, which is: I always say you can’t assume anything. When you’re working with a couple, you never want to just assume things. You don’t want to assume that, for example, if they say, “Oh, yeah, I use condoms” — you don’t want to assume that means they know how to use them correctly. You want to investigate that a little bit more. And even a reminder that if you’re working with couples who have fertility challenges, you don’t want to assume anything. Sometimes you have to actually get down to the nitty-gritty: is sex happening, when is it happening, and how is it happening? Because there’s an actual real issue of a small percentage of couples who are really not having penetrative sex for one reason or another.

I think the bottom line biggest takeaway that I had from today’s episode is that of course there’s hope — and it’s really important not to suffer in silence. If you’re having certain challenges, it’s really important to seek out support. And what I always say for specific issues: you will have the best results when you’re working with someone who truly specializes in that issue, where this is what they do all day long. I’m glad that Dr. Janelle is out there supporting couples and she’s really fun to follow on Instagram, because she really just puts this issue out there in the open and addresses it with humor, with grace, and with the intention to really destigmatize these topics. She gave some pretty heavy stats. This is more common than we would think, and it’s so important to be breaking those barriers and bringing this knowledge to women and couples.

So with that said, I hope you have a wonderful weekend whenever you’re tuning into the show. And of course, as always, until next time, be well and happy charting.