From the time she got her first period, Ashley*, now 29, knew she wasn’t like other girls—at least when it came to using tampons. “I remember how challenging it was to put one in,” she says. “I spent many hours crying in the bathroom and eventually gave up.” She didn’t date anyone in high school and avoided going to the gynecologist since she was afraid of getting an internal exam and the pain it might cause.

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Despite her anxiety, she was determined to have sex once she met someone she felt comfortable with.

Four years ago, Ashley’s wish came true. She began seeing a guy and, as the relationship got more serious, she told him she was a virgin. When the couple first tried to have sex, things turned disastrous. “It felt like he was hitting a brick wall,” she says. “I thought there was something physically wrong with me, like I was mis-formed.” The couple tried again and the same thing happened.

That’s when Ashley began researching what might be going on in the hopes of getting some answers. She discovered the Women’s Therapy Center, a sexual health practice in Plainview, N.Y. and booked an appointment with the two therapists there. Ashley had vaginismus—a painful condition in which the pelvic floor muscles tense up in anticipation of penetration, effectively closing off the vagina. After 10 sessions with the therapists, in which Ashley gradually began inserting her finger into her vagina and eventually began using dilators of varying sizes, she was able to have intercourse. “At first it was scary, but my therapists kept telling me that my body was designed to do this,” says Ashley. “They told me this was happening because my pelvic floor was tensing up, and I just needed to train my body not to.”

Like other women who have vaginismus—a condition whose causes aren’t fully known, but it’s been linked to trauma (such as sexual or emotional abuse), anxiety and guilt over having sex—Ashley was unable to have a pelvic exam, use tampons or have sex, until she got help.

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Vaginismus, which affects one to seven percent of women worldwide, breaks down into two categories—mild and severe. If you have a mild case and find a doctor who is knowledgeable about the condition, you may receive sex counseling and try using dilators, hypnotherapy and physical therapy. Mild cases tend to respond well to a variety of treatments, explains Peter T. Pacik, M.D., a physician in Manchester, N.H., who specializes in vaginismus. “The more severe cases that involve a high level of anxiety about penetration are more difficult to treat,” he says. “I think of it as a protective reflex. The patient believes intercourse will cause her pain and then the body creates a protective mechanism by causing those entry muscles to go into spasm and not permit entry.”

In addition, vaginismus presents in two different categories—complete vaginismus, meaning a woman can’t tolerate any penetration at all, and situational vaginismus, meaning a woman can tolerate a tampon or finger penetration but nothing more. “A woman usually discovers she has vaginismus when she can’t get a tampon in or she can get it in but can’t get it out,” Dr. Pacik explains.

What worries physicians is that there are health consequences to vaginismus since sufferers tend to put off checkups with their gynecologist. “Many women make appointments and find an excuse to cancel,” he says. “This happens year after year so they may go 15 to 20 years without having a Pap smear or pelvic exam.”The bottom line: If you think you have vaginismus, it’s important to find an experienced physician (or therapist) who won’t tell you to “just relax.”

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Here, six approaches that can help:

Biofeedback. For women with less severe vaginismus, biofeedback can help them learn how to lessen pelvic floor tension, according to Pacik. The process involves the placement of a sensor in the vagina so you can learn when your pelvic floor muscles are tensed and when they’re relaxed. The idea is that you can eventually learn to induce this relaxed state.

Botox. Reserved for severe cases, intravaginal Botox (which received FDA approval in 2010 for a study led by Pacik) is administered during anesthesia and appears to help prevent involuntary muscle contractions. Pacik developed a program that includes progressive dilation under anesthesia while the pelvic floor muscles are relaxed. “This sets the stage for stretching the muscles even before the Botox takes effect,” he explains. “The patients continue with their dilation, which gets progressively easier with time and practice. The Botox keeps the muscles relaxed. During the four months the Botox is active, the muscles are unable to go into spasm and the dilators help stretch the muscles to a degree that permits intercourse.”

Counseling. During these sessions, a therapist addresses issues of fear or anxiety surrounding sex. He or she may also pass around speculums so participants can feel them, hold them and, eventually, insert them into themselves. “I feel we have to demystify speculums, which are terrifying to women with vaginismus,” Pacik says. “I show my patients how safe they are, that the sides are blunt, that these are safe instruments.”

Dilators. Used to help stretch the vaginal opening, women use different sized dilators depending on their treatment, often graduating to dilators of increasing size. Dilator therapy must be done in conjunction with counseling by a therapist who can set an appropriate treatment plan.

Kegel exercises. To help relax the pelvic floor, women are encouraged to practice regular Kegel exercises, in which you squeeze the same muscles you clinch when you’re urinating. “Kegels can be useful in conjunction with other types of therapy, such as helping with the use of dilators,” explains Pacik. “As a result of repetitive Kegels, the pelvic floor fatigues, sometimes allowing easier insertion of dilators.”

Hypnotherapy. Hypnotherapy, which is best for less severe cases of vaginismus, is geared towards helping women overcome the fear and anxiety of vaginal penetration.

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