When women confide in Bijal Patel about vaginismus, a type of pelvic floor dysfunction most are reluctant to talk about, she understands.
The pelvic health physical therapist suffered from the condition herself.
In fact, it’s one reason she chose this career path more than a decade ago.
Patel, who practices at Novant Health Rehabilitation Center - Midtown in Charlotte, didn’t know the condition’s name when she was unable to tolerate a routine pelvic examination as a teenager. “I didn't get any feedback,” she said. “I had a lot of questions and was too scared to ask.”
Too apprehensive to discuss it with anyone, she Googled her symptoms and diagnosed herself – correctly – with primary vaginismus, a condition in which the pelvic floor muscles are so tight that inserting anything into the vaginal canal is difficult, painful or even impossible.
Most people – including some healthcare providers – have never heard of vaginismus. Patel learned that firsthand, which is part of what inspired her to specialize in pelvic health — “to help bridge that gap and make sure others feel seen and supported.”
Vaginismus has gotten more attention since singer Meghan Trainor went public on NBC’s “Today” show about it. “I thought that every woman walking around was always in pain during and after sex,” she said.
Many may be. Patel said vaginismus, like many pelvic floor dysfunctions, is “common but not normal.” It’s a sign that the muscles need support and retraining.
Patel, who also supports patients with many other pelvic health concerns, calms patients’ fears right away. She often tells them, “When you’re in this space, there’s no such thing as TMI,” using the acronym for “too much information.”
Next step? Once you talk with your ob-gyn, ask them about a referral to a physical therapist who specializes in pelvic health in your region.
Care women can rely on at every stage of life.
With every patient, she’ll use a pelvic model and walk them through their anatomy. “There are actually three layers to the pelvic floor, just like a three-layer cake,” she explained. “They form a sling or hammock from the pubic bone to the tailbone. Just like any other muscle in your body, they contract or tighten, relax or lengthen. Most people aren’t aware of these muscles or how vital they are – until something is off.”
One of the main muscles involved with vaginismus is a superficial pelvic floor muscle called the bulbocavernosus. Patel described it as the vagina’s “bodyguard muscle.” It can tighten up protectively to keep anything from entering the vaginal canal.
What not to do
Most women have heard of Kegels – pelvic floor exercises that strengthen the muscles that support the bladder, uterus and bowels. And many assume they’re the answer for anything related to the pelvic floor. But in this case, kegels are the opposite of what’s needed. If you're already tight and you do kegels, you may make things tighter – and any related condition worse, Patel explained.
“We want the pelvic floor to be strong, in order to support all the organs above it and prevent unwanted urinary, bowel and gas leakage while providing pelvic stability,” she explained. “But it should also be flexible enough to relax and allow for urinary, bowel and sexual function without pain or strain.”
To help a tight pelvic floor relax, she said, trained physical therapists use several strategies during treatment sessions, including diaphragmatic breathing, relaxation techniques, stretching and internal pelvic floor muscle releases.
Vaginal dilators can also help. They’re a set of smooth, cylinder-shaped tools that gradually increase in size. Patel advises consulting with a pelvic health therapist before buying a vaginal dilator set.
Meet your pelvic floor!
Patel first introduces patients to their pelvic floor, core and diaphragm. She then explains how they’re related and how breathing can influence the pelvic floor. “A big part of pelvic floor treatment is to first have the awareness and connection to these muscles,” she said.
Before beginning treatment, Patel asks patients to lie down in a comfortable, relaxed position and begin diaphragmatic breathing, which focuses on breathing using the diaphragm and expands the abdomen rather than the chest.
When the patient is ready, Patel will ask them to insert the smallest dilator. If the patient can tolerate that, the dilator should remain in place for up to 15 minutes to allow the muscle tissue to stretch around it.
Once the muscles have released and the patient can fully insert the dilator without discomfort, they can “graduate” to the next size.
It’s a gradual process. Treatment moves at the pace each patient is comfortable with. Every case is different. Patients will likely need multiple PT visits plus an at-home program of exercises and dilator use.
Vaginismus is highly treatable. With appropriate care, it can greatly improve or fully resolve, providing lasting relief and confidence.
“Patients who have been through pelvic floor therapy often have a new awareness of these muscles and recognize if they’re becoming tight again,” Patel said. Many women find it helpful to continue using dilators as needed to maintain comfort and flexibility, especially before intimacy.
Who’s susceptible?
While the limited public attention the condition receives has focused younger women, vaginismus can hit beyond teen years and the 20s.
Sometimes, sex can become difficult or painful after childbirth, even if it wasn’t before. This can be triggered by the vaginal delivery itself, tearing or postpartum hormones. That can lead to a condition called secondary vaginismus. (See the sidebar below to learn about a patient of Patel’s who developed vaginismus after having her third child.)
Secondary vaginismus occurs when pelvic floor muscles that once allowed comfortable insertion start to tighten, making insertion difficult. In addition to childbirth, it could be a result of pelvic or gynecological surgery, radiation, hormonal changes, trauma or psychological factors.
(Pregnant patients who see an OB at Novant Health may meet Patel during or after their pregnancy. She created and teaches a class called “Pelvic Health Considerations: Pregnancy and Postpartum” that’s part of Novant Health’s maternity education.)
‘I’m here to help’
Most patients are referred to Patel – a lot of insurance plans require a referral – but some find her on their own.
Faith White, whose story is in the sidebar below, became a believer in pelvic floor physical therapy.
“I would send anyone with this condition to Bijal in a heartbeat,” she said. “I loved the book ‘Completely Overcome Vaginismus’ by Mark and Lisa Carter, but Bijal can do so much more than the book can.”
That’s bound to be due, in part, to Patel having overcome the condition herself.
For women who’ve summoned the courage to see her about such a deeply personal issue, it’s surely comforting to hear her say, “You’re not by yourself. I've been through it, and I'm here to help."
Late-onset vaginismus: One woman’s journey
Faith White, who became a patient of Patel’s, already had three children when sex suddenly and inexplicably became painful.
“When my husband and I would try to have intercourse, it was like a wall,” said the 48-year-old Charlotte resident. The condition puzzled the couple, who’d married in 2000, had their first son in 2001, their second in 2003 and their third in 2005.
White, who works as a virtual personal assistant, already had her hands full when she developed major chronic health issues – including two types of Lyme disease and the Epstein-Barr virus – when her youngest was just a year old.
While contending with a host of health problems, she miscarried in 2008 and was soon diagnosed with vulvodynia, a chronic condition marked by a burning pain in the vulva, the external part of female genitalia. Its exact cause is unknown, but contributing factors may include nerve damage, inflammation, hormonal imbalances, allergic reactions and autoimmune disorders. The last two applied to White.
Her only relief – and even that was minimal – was wearing skirts without underwear. That became her uniform for nine months.
When she finally saw her OB-GYN, her timing was impeccable. Her doctor hadn’t known much about the condition. But just the day before, he’d read an article about it. He prescribed Elavil, a nerve pain medication taken orally.
“It took care of the pain, but it made me zone out, which isn’t good when you’re in charge of three little people,” she said. “I tried different ointments and eventually started using a calendula cream that helped a little. But basically it was just zero contact in the area.”
She also discovered she had some food triggers. Carrageenan, a seaweed extract in things like brownie mix and Carnation Instant Breakfast, was one. Giving that up helped.
So did having an understanding husband. “Thank goodness I married a patient man,” she said. “There were times we both wanted to be intimate, but it just wasn’t happening.”
Her bout with uncontrolled vulvodynia lasted about 18 months. Problems with painful sex lasted even longer. “For probably three years, every time we had intercourse, it was painful,” she said. “For it to work, I had to be totally relaxed, have zero interruptions, no external noise. The babies had to be asleep. Conditions had to be perfect.”
She did her own research, which led her to the book, “Completely Overcome Vaginismus” by Mark and Lisa Carter, which she called “hands-down, the best resource” prior to finding Patel. The book led her to her accurate self-diagnosis of secondary vaginismus. The vaginismus came on because the pain response to vulvodynia basically taught those muscles to shut down for protection.
White found her way to Patel in late 2022. It took about six months of treatment before she saw “definite improvement.”
The two children the couple have had since all this started are proof White overcame the condition. Their fourth child – a daughter – was followed by another son.
And here’s proof that White must be effective at keeping her clients’ lives organized: She has five children ranging in age from 24 years to 18 months old. Anyone who can manage all that has to be efficient.
To learn how vaginismus impacted one woman’s life, watch the 10-minute, animated film, “Tightly Wound.” The filmmaker, Shelby Hadden, shares on her website: “There is life on the other side of this, and I wish you the best of luck on your healing journey!”
