The Patchy History of Vaginal Pain Treatments
Moments after climbing onto the examination chair and splaying her legs during her first gynecologist appointment, Noa Fleischacker knew something was wrong.
"I was in so much pain," remembered Fleischacker, now a 30-year-old living in Chicago. "I couldn't handle getting a pelvic exam or Pap smear. I couldn't handle any insertion with a speculum."
Her gynecologist, however, was unfazed.
"You're just nervous," the medical professional assured her before handing her a prescription for sedation pills to take before her next appointment.
But when Fleischacker returned for her second-ever gynecological exam, the experience was just as painful. The doctor had a solution for this, too: more sedatives.
"She never entertained the idea that there could be a real medical condition," Fleischacker noted.
Vaginal pain is curiously and consistently absent from histories of pain and modern medicine, which was built on a model where the male body is the default.
Her gynecologist was the first in a series of medical professionals to dismiss, misdiagnose or propose unhelpful solutions for her vaginal pain. Fleischacker's experience—both of suffering from pelvic pain and having that pain downplayed—is common.
"I hear these stories every day," said Fleischacker, who now hosts a storytelling podcast about chronic vulvovaginal and pelvic pain conditions called "Tight Lipped." She said the podcast receives daily messages from people who've been told to deal with their vulvovaginal pain with dismissive solutions, like "Use more lube" or "Maybe you don't like your partner."
According to Hannah Srajer, a doctoral student who studies healthcare and social movements at Yale University and works on the Tight Lipped team as an organizer, the problem is not a new one. She said vaginal pain is curiously and consistently absent from histories of pain and modern medicine, which was built on a model where the male body is the default.
"Part of it is the stigma associated with vaginal pain," Srajer said. "A lot of people who have it don't talk about it publicly."
Classical and late antiquity: The wandering womb
As misunderstood and dismissed as these conditions are, here's what we do know about how vulvar and vaginal pain were treated over the ages.
The ancient Greeks had a fairly straightforward explanation for all pain and illnesses afflicting women: a semen-hungry uterus. Ancient Greek physicians Hippocrates, Plato and Aretaeus wrote of the "wandering womb," which they believed had a tendency to move "hither and thither" about the body, causing everything from pain to sluggishness.
To "cure" a wandering womb, ancient doctors applied sweet-smelling fragrances to the vagina to lure the womb back to its rightful place. Physicians also prescribed frequent sex to sate the sperm-ravenous womb. Ancient Greek doctors were also known to treat gynecological conditions with a process called succussion, which involved tying patients to a ladder, flipping them upside down and shaking them to jiggle the womb back to its proper place.
18th and 19th century: Hysteria
During the 18th century, hysteria, from the Greek word "hystera," or womb, became a catch-all diagnosis for a variety of ailments, including everything from emotional outbursts to increased or decreased sex drive, "menstrual difficulties," uterine contractions, and pelvic pain and inflammation.
Today, historians believe hysteria may have been improperly diagnosed cases of endometriosis, a common gynecological condition where tissue similar to the lining of the uterus grows on other parts of the body, causing pain, cramps and excessive menstrual flow.
Another treatment popularized in the mid-19th century was the "rest cure," which involved bed rest and strict avoidance of all physical and intellectual activity.
19th century: Vaginismus
In 1861, controversial American gynecologist J. Marion Sims coined the term "vaginismus," defining it as involuntary muscle spasms that made sex impossible. In the case of vaginismus, "the gentlest touch with the finger, a probe, even with a feather, produces the most excruciating agony," he wrote.
Sims, who later became infamous for performing gynecological experiments on enslaved women without anesthesia, came up with a "cure" for vaginismus that involved surgically expanding the vagina, then having the patient use a glass dilator several hours a day while healing from the surgery.
Sims also relied on ether—surgical anesthesia—to treat vaginismus. Ether was used not only to anesthetize patients for surgery but also to make sexual intercourse possible. Sims, as well as other gynecologists during this time period, anesthetized patients they suspected of having vaginismus so their husbands could have sex with them while they were unconscious.
Another treatment for vaginismus popularized around this time was cocaine, which was applied to reduce spasms and make penetration possible.
20th century and beyond
According to Srajer, it was around the early 1900s when the medical community began to cast vaginal pain as psychological, citing conditions such as the Oedipal complex, castration complex and penis envy as the root of the problem. Early psychoanalysis believed women with vaginismus experienced involuntary muscle spasms upon attempted penetration because of a subconscious desire to capture the penis.
Reframed as easily cured mental disorders, vaginismus and vaginal pain disorders were treated predominantly by psychotherapy for most of the 20th century, Srajer said.
This trend continued into the 1970s when sexuality researchers William Masters and Virginia Johnson introduced a method of psychological therapy for vaginismus that involved sex therapy for couples, direct behavioral exercises and sensate focus. Therapists also used a treatment called systematic desensitization, which involved the gradual insertion of vaginal dilators of increasing sizes.
"The idea is that you systemically desensitize contact with the painful vagina to the point where your anxiety response lowers to the point where you can have sex," Srajer said. "It was all about thinking that this condition is about fear."
'There's a whole slew of things that people are prescribed and treatments that people go through that don't really have any clinical evidence behind them.'
Srajer added that while therapists claimed the systematic desensitization technique cured up to 100 percent of their patients, a review of the system calls into question its efficacy. In 2012, the Cochrane Database of Systematic Reviews of interventions for vaginismus found "no statistically significant difference between systematic desensitization and any of the control interventions."
Long classified as an easily treated psychological problem, vaginismus was only recently removed from the newest update of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Still, clinical and cultural understanding of pain continues to be shaped by decades of "easy cure" claims, Srajer explained.
That isn't to say there aren't effective treatments out there. Srajer and Fleischacker, both of whom have been diagnosed with pelvic floor dysfunction, have found pelvic floor physical therapy to be helpful. Some people have found surgery to be the most effective option, while others have responded well to injections of botulinum toxin (brand name: Botox).
"The biggest problem we have is that there is not enough clinical evidence on any of these treatments," Srajer said. "We do know that pelvic floor physical therapy is very helpful and does have a higher success rate than many of the other treatments. We also know that Botox can be pretty helpful. But there's a whole slew of things that people are prescribed and treatments that people go through that don't really have any clinical evidence behind them."