European Journal of Obstetrics & Gynecology and Reproductive Biology 258 (2021) 189–192

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Do women with vaginismus have a lower threshold of pain?

çe Sevincb , Sultan Tarlacıc
Suleyman Eserdaga,* , Tug
a
Altınbas University, Feculty of Medicine, Department of Obstetrics and Gynecology, Turkey
b
Üsküdar University, Department of Clinical Psychology, Turkey
c
Üsküdar University, Faculty of Medicine, Department of Neurology, Turkey

A R T I C L E I N F O A B S T R A C T

Article history: Objective: Vaginismus and dyspareunia are together categorized as a genito-pelvic pain and penetration
Received 11 November 2020 disorder. We aimed to evaluate the threshold of pain and the pain sensitivity in women with vaginismus.
Received in revised form 22 December 2020 Study design: In this prospective case-control study; 32 women with vaginismus and 29 healthy women
Accepted 31 December 2020
were enrolled. Sociodemographic Information Form, Female Sexual Function Index (FSFI), Pain Beliefs
Available online xxx
Questionnaire (PBQ), Revised Fibromyalgia Impact Questionnaire (FIQR), The Lamont Scale of Vaginismus
were applied. Threshold of pain was measured with algometer in terms of Newton (N).
Keywords:
Results: The pain thresholds vaginismus and control group were as follows; left posterior superior iliac
Vaginismus
Dyspareunia
crest (40.3 N, 84.9 N respectively;p < 0.001), right posterior superior iliac crest (42.9 N, 76.1 N
Sexual dysfunction respectively;p = 0.007), left lateral trochanter (42.0 N, 69.8 N respectively; p = 0.015), right lateral
Algometer trochanter (43.8 N, 75.3 N respectively; p = 0.003), left anterior superior iliac spine (29.2 N, 51.2 N
Pain threshold respectively; p = 0.003), left insertion of gracilis muscle (27.3 N, 45.2 N respectively; p = 0.038), left
medial vastus muscle (37.0 N, 52.4 N respectively; p = 0.025) and the pain thresholds were significantly
lower in the vaginismus patients.
Conclusion: Women with vaginismus have a lower threshold of pain, and the pain threshold decreases in
higher grades of vaginismus. The pain may aggravate the avoiding behavior of women from sexual
intercourse
© 2021 Elsevier B.V. All rights reserved.

Introduction are excluded as differential diagnoses, psychologic etiology of

Vaginismus is a sexual dysfunction which affects approximately
0.5–1 % of women [1]. Vaginismus was previously defined as
recurrent or persistent involuntary spasm of the outer muscles
surrounding the vagina with the sexual intercourse [2]. Separately,
dyspareunia was defined as recurrent or persistent genital pain
associated with sexual intercourse [3]. According to Diagnostic and
Statistical Model of Mental Disorders Fifth Edition (DSM-V),
vaginismus and dyspareunia were categorized together as
genito-pelvic pain and penetration disorder [4]. This entity is
recently defined as fear or pain of penetration regardless of pelvic
muscle spasms. The inclusion of vaginismus and dyspareunia in
the same category also raised concerns; because dyspareunia could
be caused by several etiologies [5]. In the etiology of dyspareunia,
organic causes and/or psychogenic (hysterical) factors are respon-
sible [6,7]. Nevertheless, when organic causes of dyspareunia
* Corresponding author at: Hera Klinik, Valikonagi Cd. No:52/7, Nişantaşı,
_
Istanbul, Turkey.
E-mail address: suleyman@eserdag.com (S. Eserdag).
dyspareunia emerges.
From our aspect, most of the women with vaginismus have an
exaggerated information that the first sexual penetration would
cause intensive pain. Therefore they perceive pain because of the
involuntary pelvic contractions in their first intercourse. Each
unsuccessful attempt consolidates the ‘negative conditioning’ and
increases the anxiety for the fear of pain in genital area during
intercourse. In other words, pain enhances contractions and
contractions enhance the pain in a vicious cycle. So any attempts to
genital area rather than sexual intercourse, such as gynecologic
examination, use of vaginal tampons etc. are also perceived as pain.
In conclusion, pain caused by the insertion of any objects into the
vagina has both psychological (anxiety or fear of pain) and
biological (muscle contractions) factors.
To the best of authors’ knowledge, the pain thresholds are not
evaluated in women with vaginismus with an algometer. Since the
vaginismus and dyspareunia are two arms of the GPPPD, the
disclosure of pain sensitivity of the women with vaginismus takes
importance for better understanding of the subject. Therefore, in
current study, we aimed to analyze the pain thresholds of women
diagnosed with vaginismus.

https://doi.org/10.1016/j.ejogrb.2020.12.059
0301-2115/© 2021 Elsevier B.V. All rights reserved.
S. Eserdag, T. Sevinc and S. Tarlacı European Journal of Obstetrics & Gynecology and Reproductive Biology 258 (2021) 189–192

Material and method

The study was performed in a private practice clinic which was

specialized on treatment of sexual dysfunctions between January –
March 2020. The study was approved by the Ethics Committee of
Uskudar University with the number 61,351,342-/2019 294 in 31/
05/2019. A written and verbal informed consent was obtained from
all participants.
A total of 32 women who were diagnosed with primary
(lifelong) vaginismus after a detailed anamnesis and gynecological
examination were included in the study group. Twenty-nine
healthy and non-vaginismic women with no known psychological
or psychiatric disorder and sexual dysfunction were included in the
control group. All the women who were included in the study did
not have diabetes, cardiovascular or neurological disorders and a
history of drug use which could affect the sensitivity and threshold
of pain.
Sociodemographic data of all participants were recorded. All
the women took the surveys; the Female Sexual Function Index
(FSFI), Pain Beliefs Questionnaire (PBQ), Revised Fibromyalgia
Questionnaire (FIQR). The grade of vaginismus was decided
according to the classification on Lamont, which classifies
vaginismus in four grades, considering the muscles of the patient’s
reaction during the gynecological examination [8].
The FSFI has 19 questions which evaluates the desire, arousal,
wetting, orgasm, satisfaction and pain domains in previous 4
weeks [9,10]. The PBQ was developed by Edwards et al. and has two
subgroups which evaluates the organic beliefs in 8 steps and
psychologic beliefs in 4 steps [11,12]. The FIQR has 21 questions in 3
sections, in which the first evaluates the function in previous 7
days, the second evaluates the global effect of fibromyalgia and the
Fig. 1. The locations where the algometer was used.
third evaluates the symptoms [13,14].
Algometer was used to analyze the sensitivity for pain, caused
%) had a job while 5 (17.2 %) women were house wives and the rest
by the pressure and the threshold of the pain can be represented by
of the women had a job with an income.
a numeric value by the algometer. In this study, Wagner Pain
In vaginismus group, 8 (25 %) women declared they had no
TestTMModel FPK Algometer was used for the evaluation. The
previous sexual knowledge while 19 (59.4 %) had inadequate and 5
locations where the algometer was used are shown in Fig. 1.
(15.6 %) had sufficient knowledge before marriage. In control
group, 10 (34.5 %) stated to have no sexual knowledge while 12
Statistical analysis
(41.4 %) had inadequate and 7 (24.1 %) had sufficient knowledge.
Five (17.2 %) women were doing masturbation in control group
Statistical analysis was performed out by SPSS (Statistical
while this rate was 46.9 % (n = 15) in vaginismus group. Experience
Package for the Social Sciences) for Windows 23 (SPSS Inc.,
of orgasm was reported in 14 (48.3 %) women in the control group
Chicago, IL). The distribution of parameters was analyzed by the
and 22 (68.8 %) women in the vaginismus group.
Kolmogorov-Smirnov test and the Shapiro-Wilks test and the
The results of the FSFI total scores did not have a statistical
frequency analysis. For the numeric variables with normal
significance between groups (p = 0.063). When the FSFI results
distribution, Independent Samples’ t-test was used. Pearson’s
were considered regarding the presence of sexual dysfunction
Chi-Square Test and one-way ANOVA test was performed for the
(scores <26.55); significantly more women had sexual dysfunction
analysis of categorical variables. P values <0.05 were considered
in vaginismus group than control group (90.6 % vs. 65.5 %
significant.
respectively; (p = 0.017) When the subgroups of FSFI results were
evaluated, the scores for desire and arousal did not have a
Results significant difference between groups while the scores for
lubrication (p = 0.014), satisfaction (p = 0.008), orgasm
A total of 61 women were recruited; the study group (n = 32) (p < 0.001) and pain (p < 0.001) were significantly lower in women
and the control group (n = 29) were similar in terms of age with vaginismus. The PBQ and FIQR scores did not reach to a
(27.1  3.2 years, 33.8  6.4 years respectively; p = 0.076). All the statistical significance in women with vaginismus. The comparison
patients in the vaginismus group had primary/lifelong vaginismus. of the scores of FSFI, PBQ and FIQR surveys are listed in Table 1.
All of the patients were married, the mean duration of marriage The results of the analyses of thresholds of pain are given in
was 10.4 months (3–74 months). Table 2. The main thresholds were found significantly lower in the
In the control group 17.2 % graduated from primary/secondary most of the measurements in women with vaginismus. The pain
school, 37.9 % from high school, 44.8 % from college/university. thresholds were found significantly lower in vaginismus group
Education levels of the vaginismus group were as follows: 3.1 % than the control group in the following measurements: Left
secondary school, 21.9 % high school and 75 % college/university. posterior iliac process (40.3 N vs. 84.9 N respectively; p < 0.001);
None of the women in the vaginismus group had pregnancy history right posterior superior iliac process (42.9 N vs. 76.1 N respectively;
while 25 (86.2 %) women in the control group had children. In p = 0.007); left lateral trochanter (42.0 N vs. 69.8 N respectively;
vaginismus group 3 (9.4 %) women were house wives and 29 (90.6 p = 0.015); right lateral trochanter (43.8 N vs. 75.3 N respectively;

190
S. Eserdag, T. Sevinc and S. Tarlacı European Journal of Obstetrics & Gynecology and Reproductive Biology 258 (2021) 189–192

Table 1
Scores of the FSFI, PBQ and FIQR tests.

Study group (n = 32) Control group (n = 29)

Age (years) 27.1  3.2 33.8  6.4 0.076
FSFI scores total 17.44  7.478 24.86  5.091 0.063
Presence of sexual dysfunction according to FSFI 29 (90.6 %) 19 (65.5 %) 0.017
FSFI subgroups
Desire 3.41  1.31 3.248  1.14 0.606
Arousal 3.15  1.56 3.538  1.15 0.291
Lubrication 3.58  1.50 4.448  1.12 0.014
Orgasm 3.26  1.70 4.331  1.28 0.008
Satisfaction 3.20  1.86 4.634  0.93 <0.001
Pain 0.82  1.33 4.662  1.55 <0.001
PBQ total 8.13  1.51 7.77  1.53 0.655
FIQR total 20.938  9.5535 16.690  9.5004 0.722

Table 2
Comparison of pain thresholds.

Study group Control group (n = 29) P

(n = 32)
Left posterior superior iliac process 40.3  13.1 84.9  25.7 <0.001
Right posterior superior iliac process 42.9  42.9 76.1  26.8 0.007
Left lateral trochanter 42.0  15.3 69.8  24.5 0.015
Right lateral trochanter 43.8  15.1 75.3  26.2 0.003
Left anterior superior iliac spine 29.2  9.9 51.2  20.7 0.003
Right anterior superior iliac spine 29.7  11.2 48.3  16.5 NS
Left insertion of gracilis 27.3  10.9 44.8  16.9 0.038
Right insertion of gracilis 28.6  10.8 45.2  17.0 NS
Left gracilis muscle (medial part) 28.2  13.0 44.1  17.2 NS
Right gracilis muscle(medial part) 28.4  12.1 42.4  12.4 NS
Left medial vastus muscle 37.0  13.4 52.4  22.7 0.025
Right medial vastus muscle 34.9  16.4 49.5  19.5 NS

p = 0.003); left anterior superior iliac spine (29.2 N vs. 51.2 N
respectively; p = 0.003); insertion of left gracilis muscle (27.3 N vs.
44.7 N respectively; p = 0.038) and left medial vastus muscle
(37.0 N vs. 52.4 N respectively; p = 0.025). However, in right
anterior superior iliac spine, insertion of right gracilis muscle,
medial part of left and right gracilis muscles and in right medial
vastus muscle, the thresholds of pain did not have a significant
difference between groups.
When the patients were classified according to Lamont
classification system, there were 4 women with grade 1, 10
women with grade 2, 17 women with grade 3 and 1 woman with
grade 4 vaginismus [8]. The pain thresholds tended to decrease as
the grade of vaginismus increased. The change of the algometer
scores are given in Table 3.
Discussion
We have evaluated the FSFI, PBQ and FIQR surveys and, pain
thresholds of 32 women diagnosed with vaginismus and compared
their results with 29 women who can have a painless sexual
intercourse. The pain thresholds were measured in both right and
left sides from several points and the pain thresholds of women
with vaginismus was found significantly lower than women who
have painless intercourse. Furthermore, the pain thresholds
decreased in points close to genital organs with the increasing
grades according to Lamont classification system [8]. Women with
vaginismus are generally anxious patients, therefore we may
assume that higher expectation of pain may lead to more intense
feeling of pain. On the other hand, the PBQ and FIQR scores of the

Table 3
Algometer measurements according to the Lamont classification.

Grade 1 (n = 4) Grade 2 Grade 3 Grade 4 p

(n = 10) (n = 17) (n = 1)
Left posterior superior iliac spine 56.5  9.3 37.9  12.7 38.6  12.0 26.9 0.044
Right posterior superior iliac spine 60.2  12.1 40.1  15.2 41.3  17.3 30.1 0.156
Left lateral trochanter 56.0  13.1 38.7  15.4 41.7  14.2 25.6 0.177
Right lateral trochanter 62.5  11.3 40.5  14.6 42.3  13.8 30.3 0.047
Left anterior superior iliac spine 43.5  6.9 27.7  5.2 27.2  10.2 20.6 0.011
Right anterior superior iliac spine 32.9  11.0 28.3  10.5 30.  12.5 25.9 0.908
Insertion of left gracilis muscle 41.6  10.3 27.1  10.1 24.3  9.6 23.6 0.033
Insertion of right gracilis muscle 38.5  9.2 28.6  10.7 26.0  10.6 33.5 0.209
Medial part of left gracilis muscle 37.8  10.7 27.4  13.3 27.1  13.2 18.8 0.432
Medial part of right gracilis muscle 38.1  11.0 28.8  11.8 26.2  12.4 21.8 0.343
Left medial vastus muscle 46.5  6.1 40.7  14.8 32.4  12.8 39.7 0.191
Right medial vastus muscle 53.1  18.5 36.2  19.0 29.0  10.8 50.9 0.035

191
S. Eserdag, T. Sevinc and S. Tarlacı
two groups did not have a significant difference while the FSFI
scores revealed that the rate of presence a sexual dysfunction was
higher (90.6 %) in the vaginismus group compared to the controls
(65.5 %) according to <26.55 cut-off point of total FSFI scores. The
similarity of the PBQ and FIQR scores of the vaginismus and control
groups supported our hypothesis of increased pain thresholds in
women with vaginismus as our measurement locations were in the
genito-pelvic are and in supporting muscles, while similar pain
perceiving was observed in two groups except the genital pain.
According to the recent classification of DSM-V, vaginismus is
defined as a gentio-pelvic pain disorder together with dyspareunia.
In literature, the pain component of vaginismus is mostly ignored
or underestimated and this topic is not commonly evaluated by
studies. Pain is an important component of this disorder and this is
either caused by the feeling or the fear of pain. Therefore, the pain
component of the vaginismus needs to be evaluated in detail with
both physical and psychological aspects.
Pelvic muscle tension was evaluated in several studies.
Previously, when vaginismus was accepted as a spasm-based
disorder, Reissing et al. evaluated the pelvic muscle tonus of
women with vaginismus and compared them with patients with
dyspareunia due to vulvar vestibulitis syndrome and with healthy
controls [15]. They found the vaginal spasm and pain measures
were similar between women with vaginismus and women with
dyspareunia while the women with vaginismus had a higher
vaginal/pelvic muscle tonus and lower muscle strength. Therefore,
they recommended in 2004, vaginismus should be defined
multidimensionally regarding the pain/fear of pain, pelvic floor
dysfunction and behavioral avoidance, additionally to vaginal
spasm. Concurrently, our data showed similarity to the aforemen-
tioned study with the lower pain thresholds and sexual dysfunc-
tion rate in women with vaginismus. Van der Velde et al. reported
the pelvic muscle tone and voluntary contractions in women with
vaginismus did not have significant difference from healthy
controls in evaluation with electromyography [16].
The pain sensitivity of women with life-long vaginismus was
compared with women who have superficial dyspareunia with
respect to vulvar vestibulitis syndrome by Ter Kuile et al. [17]. The
results of the study revealed that both pain with touch (98 % vs. 69
%, respectively), erythema (94 % vs. 77 % respectively) and, pain and
erythema (92 % vs. 56 %) were more frequently seen in women with
dyspareunia than women with a lifelong vaginismus. Nobre et al.
reported that pain accompanied up to 59 % of the women with
vaginismus [18]. They concluded that pain was complementary for
vaginismus. Engman et al. evaluated pain in women with partial
vaginismus with or without vulvar vestibulitis and reported pain
after intercourse was more common than pain during intercourse,
up to 70 % of patients had pain during micturition [19].
The rate of sexual dysfunction was significantly higher in
women with vaginismus when the FSFI score were evaluated
supporting the results of the Reissing et al. [20]. However, our
results diverted with some of the subgroup results. The scores of
orgasm were similar between vaginismus and control groups in
the study of Reissing et al. while the scores for desire were
similar between groups in our study [20] Similar results on
lower scores in subgroups of FSFI in women with vaginismus
was reported in several other studies [21,22]. We have also
observed lower thresholds of pain with the increasing grades of
vaginismus. These results may be interpreted as development of
a ‘muscle memory’ in genital area due to enhanced anxiety
caused by the unsuccessful intercourse attempts in time among
women with vaginismus. However, larger patient series and
comparison of post-treatment results are needed to support this
hypothesis.
European Journal of Obstetrics & Gynecology and Reproductive Biology 258 (2021) 189–192
Conclusion
Women with vaginismus have a lower threshold of pain, and
the pain threshold decreases with the grade of vaginismus. These
findings may lead us to comment that the pain may aggravate the
avoiding sexual behavior of vaginismic women from sexual
intercourse.
Declaration of Competing Interest
All authors declare no conflict of interest regarding the
research, authorship and publication of this article. The authors
received no financial support for the research, authorship, and
publication of this article.
References
[1] Fugl-Meyer A, Fugl-Meyer KS, Fugl-Meyer KS, Fugl-Meyer A, Meyer K, Sjogren
K, et al. Sexual disabilities, problems and satisfaction in 18-74-year-old
Swedes. 1999.
[2] Association AP. Diagnostic and statistical manual of mental disorders, DSM-III.
Washington DC: American Psychiatic Association; 1980.
[3] APA E. Diagnostic and statistical manual of mental disorders. Washington, DC:
Text Revision (DSM-IV-TR); 2000.
[4] Association AP. Diagnostic and statistical manual of mental disorders (DSM-
51 ). American Psychiatric Pub; 2013.
[5] Reissing ED, Borg C, Spoelstra SK, Ter Kuile MM, Both S, de Jong PJ, et al.
“Throwing the baby out with the bathwater”: the demise of vaginismus in
favor of genito-pelvic pain/penetration disorder. Arch Sex Behav 2014;43
(7):1209–13.
[6] Binik YM. Should dyspareunia be retained as a sexual dysfunction in DSM-V? A
painful classification decision. Arch Sex Behav 2005;34(1):11–21.
[7] Arıkan I,_ Barut A, Harma M, Harma MI, _ Gezer Ş. The results of diagnostic
laparoscopy examinations - an 8 - years experience. Gynecol Obstet Reprod
Med. 2011;17(2):87–9.
[8] Lamont JA. Vaginismus. Am J Obstet Gynecol 1978;131(6):633–6.
[9] Rosen CB, Heiman J, Leiblum S, Meston C, Shabsigh R, Ferguson D, et al. The
Female Sexual Function Index (FSFI): a multidimensional self-report instru-
ment for the assessment of female sexual function. J Sex Marital Ther 2000;26
(2):191–208.

i’nin Türkçeye Uyarlaması. Turk Klin J
[10] Aygin D, Aslan FE. Kadın cinsel işlev ölçeg
Med Sci 2005;25(3):393–9.
[11] Edwards LC, Pearce SA, Turner-Stokes L, Jones A. The pain beliefs question-
naire: an investigation of beliefs in the causes and consequences of pain. Pain
1992;51(3):267–72.
[12] Hös Berk, Bahadır G. Kronik ag
ri yaşantisi ve ag

ri inançlari: ag

ri inançlari
ölçeg
i’nin türkçe geçerlik ve güvenirlik çalişmasi. 2021.
[13] Bennett RM, Friend R, Jones KD, Ward R, Han BK, Ross RL. The revised
fibromyalgia impact questionnaire (FIQR): validation and psychometric
properties. Arthritis Res Ther 2009;11(4):R120.
[14] Ediz L, Hiz O, Toprak M, Tekeoglu I, Ercan S. The validity and reliability of the
Turkish version of the revised Fibromyalgia Impact Questionnaire. Clin
Rheumatol 2011;30(3):339–46.
[15] Reissing ED, Binik YM, Khalife S, Cohen D, Amsel R. Vaginal spasm, pain, and
behavior: an empirical investigation of the diagnosis of vaginismus. Arch Sex
Behav 2004;33(1):5–17.
[16] van der Velde J, Everaerd W. Voluntary control over pelvic floor muscles in
women with and without vaginistic reactions. Int Urogynecol J Pelvic Floor
Dysfunct 1999;10(4):230–6.
[17] Ter Kuile MM, Van Lankveld JJ, Vlieland CV, Willekes C, Weijenborg PT. Vulvar
vestibulitis syndrome: an important factor in the evaluation of lifelong
vaginismus? J Psychosom Obstet Gynaecol 2005;26(4):245–9.
[18] Nobre PJ, Pinto-Gouveia J, Gomes FA. Prevalence and comorbidity of sexual
dysfunctions in a Portuguese clinical sample. J Sex Marital Ther 2006;32
(2):173–82.
[19] Engman M, Wijma K, Wijma B. Post-coital burning pain and pain at
micturition: early symptoms of partial vaginismus with or without vulvar
vestibulitis? J Sex Marital Ther 2008;34(5):413–28.
[20] Reissing ED, Armstrong HL, Allen C. Pelvic floor physical therapy for lifelong
vaginismus: a retrospective chart review and interview study. J Sex Marital
Ther 2013;39(4):306–20.
[21] van Lankveld JJ, ter Kuile MM, de Groot HE, Melles R, Nefs J, Zandbergen M.
Cognitive-behavioral therapy for women with lifelong vaginismus: a
randomized waiting-list controlled trial of efficacy. J Consult Clin Psychol
2006;74(1):168–78.
[22] Cherner RA, Reissing ED. A comparative study of sexual function, behavior, and
cognitions of women with lifelong vaginismus. Arch Sex Behav 2013;42
(8):1605–14.
192