Multidisciplinary approach ‘crucial’ to treating vaginismus

‘Whenever my boyfriend and I started to have penetrative sex, it felt as if there were razor blades inside me.
 
‘At first I laughed it off, but soon I became terrified of intercourse. My body would freeze with fear as my clothes came off.’
 
That is London-based journalist Kate Lloyd, describing her experiences with vaginismus in a story for The Guardian.
 
While Ms Lloyd describes her physical experiences as painful, the advice given to her by her GP upon discussing this issue compounded the problem.
 
‘When I first went to my GP, the advice I got was to “try and relax”,’ Ms Lloyd wrote. ‘It was about as helpful as telling someone having a panic attack to “just chill out”.’
 
Dr Alex Polyakov says such advice is damaging.
 
The senior lecturer at the University of Melbourne and consultant obstetrician, gynaecologist and fertility specialist at the Royal Women’s Hospital in Melbourne told newsGP that when it comes to vaginismus, there are a lot of ways to treat the condition.
 
‘But what is completely not helpful, and is in fact detrimental, is to say “just relax and it will go away”,’ he said. ‘That makes the situation actually worse by not acknowledging that there is a problem.’
 
Dr Polyakov believes Ms Lloyd’s experiences with both the condition, and the way she was treated by health professionals, is not unique.
 
‘All the experiences that were described [in the article from the UK], I’ve seen patients who’ve had very similar experiences here,’ he said.
 
He says when he was training to be an obstetrician and gynaecologist in Australia, there was ‘very little’ emphasis on issues with a psychosomatic component, such as pelvic pain and vaginismus.
 
‘If that is the case for consultant obstetrician/gynaecologists, I think it’s even more so for GPs,’ he said.
 
‘Unless you have a keen interest in this particular area through your own learning and finding resources, it would be pretty unlikely for most doctors to actually know how to approach this problem in an appropriate fashion.’
 
GP and Chair of the RACGP Specific Interests Sexual Health network, Dr Amy Moten, agrees.
 
‘Sexual and reproductive health is not really covered well in medical school,’ she told newsGP.
 
‘In general practice [training] it is part of the core curriculum but [how much is taught] depends on your training organisation provider.
 
‘Also, a lot of general practice training is on the job training, so you’re seeing the kind of patients your supervisors are seeing.’
 
That means if a trainee’s supervisor is not seeing many patients with sexual health issues, registrars are not exposed to this issue.

Obstetrician and gynaecologist Dr Alex Polyakov says it is ‘pretty unlikely’ for most doctors to approach the topic of vaginismus appropriately.

According to the article in The Guardian, research audited by Dr Leila Frodsham, lead consultant in psychosexual medicine at Guy’s and St Thomas NHS trust in London, recently found that only 13% of trainee gynaecologists felt that they had adequate training in psychosexual problems, despite a fifth of referrals to gynaecology clinics being for sexual problems.
 
‘I can’t think of another area where we don’t train people for something that common,’ Dr Frodsham said.
 
‘It leaves doctors anxious when they see a person with a sexual problem. No healthcare professional ever sets out to upset patients. They can sound dismissive because they don’t know how to manage it.’
 
Dr Frodsham believes psychosexual training should be mandatory.
 
‘Every single doctor, nurse and physio who does intimate examinations should be able to manage [someone saying] “I’ve got a problem with sex”,’ Dr Frodsham said.
 
Dr Polyakov believes it is common for women with vaginismus to not receive a diagnosis, or effective treatment plan, which can lead to worsening symptoms.
 
‘Pelvic pain in general is a difficult area to address and that is the reason why many women go through years of seeing doctors without being diagnosed with endometriosis, for example, [and] vaginismus is very similar,’ he said.
 
‘Unfortunately because a lot of it might well be psychological in nature, if it’s not addressed early, just as the women described in that article, it actually gets worse.
 
‘So there is rising level of anxiety with penetrative intercourse and eventually it simply becomes impossible to do.’
 
Dr Moten is also concerned about patients with vaginismus receiving adequate care.
 
‘I would hate to say that people are being brushed off, but I do think if [a GP] doesn’t know how to help someone or where to refer them to, it becomes very difficult to offer any further advice,’ she said.
 
She says that can lead GPs to then tell patients they are unable to help them manage their condition.
 
‘That’s where patients feel cut off and isolated from their healthcare professional,’ she said.
 
Dr Moten believes most GPs are aware of the condition, but have limited education on how to manage it effectively.

Dr Amy Moten recommends establishing a network in the area comprised of health professionals who can aid in managing vaginismus.

‘It’s unfortunately one of those reproductive health conditions that many GPs have heard of, but don’t necessarily have the tools and training to deal with,’ she said.
 
‘Often it’s a case of they may have heard of something like vaginal trainers or dilators, but they don’t know how to assist the patient in using them.’
 
And yet, with effective management, Dr Moten says the condition is ‘definitely treatable’.
 
‘The longer a person has had the symptoms, the harder it can be to treat sometimes,’ she said.
 
‘But with ongoing support and a multidisciplinary team it is absolutely something that can be treated and improve somebody’s life.’
 
That multidisciplinary approach is crucial.
 
‘A single GP wouldn’t necessarily be able to treat this kind of chronic pelvic pain without support, because even specialised GPs in pelvic pain have a big referral network of other health professionals, psychologists, pelvic pain physiotherapists, pain specialists and gynaecologists,’ Dr Moten said.
 
Rather than trying to equip GPs with all the tools to be able to treat vaginismus on their own, Dr Moten prefers to encourage clinicians to become more familiar with ways to seek further help.
 
‘It’s actually more about helping GPs be educated about the condition, find information resources to guide their patients and even if they don’t have skills to treat it, being able to find someone who they can refer on to,’ she said.
 
She recommends establishing a network in the area comprised of health professionals who can aid in managing vaginismus, including psychologists, physiotherapists, specialised gynaecologists and sexologists.
 
Dr Moten also recommends accessing resources from the Pelvic Pain Foundation of Australia, which she says is a not-for-profit organisation that has information for patients and doctors, including referral pathways, and from the Jean Hailes Foundation.
 
Additionally, Dr Polyakov says it is important to remember vaginismus is not purely a physical condition, but one with a ‘significant’ psychological component that also needs addressing.
 
Without addressing both components, Dr Moten says women with vaginismus may develop health avoidance and miss out on procedures such as cervical screening programs.
 
The condition can also adversely affect intimate relationships, which Dr Moten says has a ‘massive psychological consequence’.
 
Ms Lloyd wrote about such consequences.
 
‘Some days, I would feel so ashamed that it was hard to think about anything else,’ she wrote.
‘Other days, I’d feel an overwhelming sense of loss for the carefree woman I had been.’
 
Thankfully, Ms Lloyd has now utilised a number of strategies that have helped treat the condition.
 
‘For me, taking the pressure off penetrative sex really helped,’ she wrote.
 
She says she also tried a combination of dilators, along with getting support from a counsellor and the use of massage.
 
‘I discovered that with the right psychological and physical help, my vaginismus was easily controlled,’ Ms Lloyd wrote.
 
‘Now, I feel like a different person.’
 
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