Using Botox for the Treatment of Vaginismus
Botox has become a powerful tool for the treatment and cure of vaginismus. Vaginismus is characterized by extreme fear of any form of vaginal penetration and like any phobia can be disabling because of its severity. The fear of vaginal penetration results in involuntary and uncontrolled spasm of the vaginal muscles and in the more severe cases of vaginismus intercourse is impossible. Almost to a patient the history is the same: “It’s like hitting a brick wall” they say. The majority of my patients have had vaginismus for many years, often four to seven years, though some of my patients have been afflicted with vaginismus for over 20 years. As they get beyond childbearing age they no longer have the opportunity to raise a family.
The failure of conservative therapy for vaginismus.
Vaginismus patients are often either undiagnosed or misdiagnosed. Health care providers, be it a nurse or doctor, are often unfamiliar with vaginismus and therefore even the diagnosis of vaginismus is often delayed for many years. Most of my patients made their own diagnosis by researching the internet. Once the diagnosis of vaginismus is made, most physicians still don’t know what to do. They need to make some referral so the first choice is often a psychologist or sex therapist and off the patient goes to what begins the frustration of one to three years of “talk”. You CANNOT talk a severe vaginismus patient into a successful outcome. They listen politely and make no progress. Much time, money, effort and emotion is wasted. A resource article about this can be found on my web site by linking to: “Too Much Talk”
After this fails as a treatment for vaginismus, the patient is told to buy dilators, to do Kegel exercises and progressively stretch the vagina by dilating. My vaginismus patients dutifully buy the dilators with renewed hope that they will now be able to get beyond this terrible condition, however the patients with the severe forms of vaginismus often are not able to open the box of dilators, let alone use them. They read books and continue to fail. Once again they feel that they are running out of hope for any type of cure. Time is marching on; mounting pressure is affecting both themselves and their relationships. They begin to feel “less than”, ashamed (“women have been doing this for years, why can’t I?”), frustrated, and worried that their partner will leave them, or seek greener pastures.
Someone gets the brilliant idea that they should try hypnotherapy. So it’s off to yet another therapist; more time, more money and more frustration. Many of my patients have tried hypnotherapy and once again the failure rate is high especially in the more severe forms of vaginismus. I have a number of case histories speaking to the failure of this form of therapy.
There are other treatments that have been tried by my patients: these include physical therapy, anti-depressants and other forms of medication, topical anesthetics, lubricants and sedatives. Some patients resort to binging on alcohol, or overdosing on sedatives and anti-depressants. Some have even gotten pregnant, but still no sex life.
They now return to their GYN with a diagnosis and multiple failed attempts at treatment. The GYN says “Perhaps we should do a hymenectomy” and it’s off to the OR for the procedure. They don’t know that the hymen is not intact because often vaginismus patients are unable to tolerate an exam by the GYN. A hymenectomy is done, or more often the remnants of the broken hyman are removed, the patient recovers for six weeks and is told she can now have intercourse. Guess what? Not possible. I have a number of patients that have had this procedure for vaginismus and not one success. Back to the drawing board. “Let’s do a vestibulectomy” says the GYN. Once again the patient is scheduled for surgery and in pure vaginismus patients without external pain, with pain ONLY on attempted entry; the procedure again fails, as it has in a number of my patients. Vestibulectomy (the removal of the lower cuff of vagina, and reconstruction by advancing the remaining vagina to fill in the surgical defect) has a high rate of failure in pure vaginismus because these patients have generalized spasm of multiple vaginal muscles and these additional areas of spasm are not addressed by simply cutting away the lower portion of the vagina.
Vaginismus: It’s impact on relationships.
By now many of my patients have spent years seeking therapy for vaginismus, and the severe degrees of vaginismus patients are no further ahead. You can see how time consuming all these treatments are, and most of my patients report years of multiple failed therapies. The condition of vaginismus becomes disabling not only to the woman but also her mate. They both become more and more frustrated, arguments about small things erupt, bickering becomes commonplace and the relationship continues to deteriorate. Sometimes the husband asks for a divorce, but often they remain together as brother and sister or as “roommates” as the husband of one of my patients told me. Sometimes, in the longer cases, they separate for a period of time and get together once again because they love each other and are soul mates.
Even playful non-penetrative sex is a problem for many of my patients. They are unable to relax because they fear that it will lead to attempted intercourse and more frustration. As they distance themselves from sexual involvement my vaginismus patients often become less aware of what “turns them on” resulting in “sexual underdevelopment” for both the woman and the man. It is for this reason that I recommend sex counseling AFTER successful treatment of vaginismus with Botox injections. It is at this time that the woman is able to be receptive to being more comfortable with herself and with her partner.
Why Botox for Vaginismus?
Botox injections for vaginismus have been used since 1997, but these reports have not been widely disseminated and so most physicians, including gynecologists, are unaware of these reports. Botox has the capability of relaxing muscles and also relieving painful conditions with a wide range of uses. It has been used extensively to weaken facial muscles, to control muscular spasm in patients with cerebral palsy and stroke, migraine headaches, excessive sweating and Raynaud’s Disease to name just a few of the uses. Botox for vaginismus is not yet FDA approved, and actually most conditions that respond to Botox are not yet approved by the FDA. The process of approval is very time consuming and laborious. It is for this reason that physicians are able to use Botox as an “off label” drug which means that the physician may use the drug if there is a reasonable expectation that the patient will be helped. NOTE: FDA approval was received 8/11/10 to continue my study using Botox injections for vaginismus (IND 109343) and progressive dilation under anesthesia.
Our own approach to treat severe vaginismus patients has developed with time and become more sophisticated since I first used Botox in 2005. The treatment is more than just injecting Botox for vaginismus. It has become a comprehensive program of injecting Botox under anesthesia, progressively dilating the vagina during the same anesthetic, and leaving a dilator in place that the patient wakes up with in the recovery room. The dilator is coated with a topical anesthetic and in addition a series of long acting local anesthesia injections (bupivacaine) are administered so that the patient is numb in the vagina when she wakes up. She is therefore unable to feel the dilator in place. Waking up with a dilator in place is monumental for my patients who have never had any form of penetration. They spend the next three hours in recovery working with the dilators and then sleep with the dilator that is comfortable. They are then seen again each day for the next 1-2 days to continue working with the dilators. All this takes place before the Botox has had a chance to work. Once the Botox becomes effective (2-10 days) the process continues to get easier. We stay in constant contact with our patients to help them advance through the dilators and to help them transition to intercourse. Our success rate is in excess of 90 percent and as of January 2012 no patient has had to return for more Botox injections.
Though many treatment plans fail prior to treatment, of especially the more severe forms of vaginismus, I find that referral back to their therapist(s) AFTERBotox treatment is useful. Once the patient is comfortable using dilators, and has progressed to intercourse, the sex therapist, physical therapist or hypnotherapist can help make the recovery easier. Often relationship issues that have evolved can be improved and additional stretching by a skilled physical therapist will continue to make intercourse easier.
Literature References for the use of Botox to treat vaginismus:
A number of articles have been written about the value of using Botox injections to treat vaginismus. My own experiences were published in the December 2009 issue of Plastic Surgery & Reconstructive Surgery and the 2011 issue of Aesthetic Plastic Surgery. You can link onto the following educational resource article “Botox for Vaginismus: References” for more information.
Touching stories of patients treated with Botox for Vaginismus:
Patients are so grateful that they are finally cured that they want to shout out their success to the world. The problem is that most of my patients have maintained “A wall of silence” and not even their families or close friends know about their condition. Several of my patients made the courageous decision to “go public”, to help inform their sisters that treatment is possible, that a cure is likely, and that they can have a normal relationship and also give birth to a child vaginally.
Rachel was our “first heroine” and wrote “The Blessing of Botox”. In September 2009 she delivered a healthy baby boy named Kaden. She wrote me that she delivered vaginally in 14 minutes!! Most of my “normal” patients take much longer!
Another patient wrote about her own journey, not only flying to us from England, but also her many failed treatments. Her journey is chronicled in “Khadija’s Story”.
A husband and wife stories also appear on this website as “David’s Experience with Vaginismus” and “Rachel’s Experience with Vaginismus”. These stories are heartwarming and a must read.
More stories can be found on our website VaginismusMD.com