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If you or someone you care about is experiencing vaginismus, chances are you're wondering, "Why is this happening?" "What can I do to stop it?" And "How can I go on to manage and reach my goals in the future." I'm Amanda Olson. I'm a doctor of Physical Therapy, and a certified pelvic floor rehabilitation specialist. I'm the president of Intimate Rose, where we create solutions for common pelvic health issues that are highly sensitive but fixable. And today we're going to be discussing vaginismus. In this course, you'll learn what it is and why it occurs, what you can do to manage it on your own and in conjunction with other healthcare providers, and some exercises that can be done at home to help alleviate pain and some of the issues that you're having to help you reach your goals. Let's start with "What is vaginismus?" Vaginismus is an umbrella term that describes issues with penetration. That can be penetration with a tampon, during a medical exam, or with penetration during sex or a sexual-type activity. Vaginismus is broken up into a primary and a secondary classification. Primary vaginismus describes people that have never been able to have penetration. And that penetration may be that they simply cannot tolerate anything inside them, or that it's extremely painful and extremely difficult. So, for people with primary vaginismus, they've never been able to use a tampon or have never been able to tolerate the speculum during a medical exam. Also, they may have never been able to have penetrative intercourse, or be intimate with a partner. Oftentimes this is accompanied by pain. Secondary vaginismus describes someone that, perhaps, was able to use a tampon, or have a medical exam, or have penetrative sex, and then something happened that changed their ability to tolerate that later in life. That something could be a medical event, like having a baby. Or experiencing cancer; oftentimes treatments with cancer, like chemotherapy and radiation, can cause changes to the vaginal tissue and the pelvic floor muscles that prevent someone from having pain-free penetration. Other events that might occur may be a stressful or traumatic event. So, and this holds true for people with all forms of vaginismus, when something happens, like abuse or trauma or a stressful event that maybe even isn't related to sex, oftentimes the pelvic floor muscles, and we'll go over what those are in a moment, respond by clenching and guarding around the urethra, where the urine comes out, around the vaginal opening, and around the anus. And it happens subconsciously. Oftentimes the person is not aware that it's happened, and those muscles clench and that creates a barrier. And that can happen during times of stress, or when there is some sort of perceived threat. That person may have experienced rape or sexual trauma or abuse, and then have gone on to be in a safe, comforting relationship or engaging in safe, comfortable activities, but their pelvic floor muscles are still in that guarding reflex. So, those are some of the events that can occur that might result in vaginismus of any form. Determining the underlying "why it's occurring" is often really helpful in determining how you're going to go about managing it. But most people with vaginismus are going to respond to a well-rounded program to help re-train the pelvic floor muscles, and to help gently stretch and mobilize the tissue around the vagina, and also to participate in mind/body relaxation-type exercises that are going to allow them to be conscious and aware of when those muscles are contracting and when they are not. Let's talk about what the pelvic floor muscles are, with regards to vaginismus. So, this is a model of the pelvis. Everything you see in white are bones, and we have the organs inside. So, for people with vaginas, there is a bladder in the front, and then a vagina and a uterus in the middle, and then a rectum in the very back. So, as you can see, these organs are very closely connected sitting in this bowl. For some people, perhaps the uterus is gone. But still remains the rectum and the bladder. For this reason, people with vaginismus may experience pain or difficulty with having a bowel movement, so maybe some constipation or pain with bowel movements. They also might experience difficulty emptying their bladder, or pain when their bladder is full. As you could see, they were all snug as a bug in a rug here, in the pelvic bowl, which means that, with the pelvic floor muscles supporting them, if the pelvic floor muscles are tight, sometimes there can be compression on those organs, there can also be underlying inflammatory processes in place. The pelvic floor muscles consist of three layers. What you see on the outside here, in red, is the superficial layer. This is the pubic bone, and this back here is the tailbone. So, here's the front of you, and here is the back. In people with vaginas, we have the urethra in the front, the vagina in the middle, and the anus and the rectum down below. And then we have this nice superficial layer of pelvic floor muscles surrounding and supporting them. Then we have a layer of fascia, and then a deep layer of pelvic floor muscles that are thicker and span all the way out to the side here. And you can see where the bladder would sit in the front, the uterus and vagina in the middle, and the rectum in the back. With vaginismus, oftentimes what's occurring, as I mentioned prior, the pelvic floor muscles are contracting and guarding and creating a wall. A lot of times my patients will report to me if they're trying to have sex. It feels like the penis is hitting a brick wall. Or if they're trying to use a tampon, it feels like there is no hole or opening; the tampon simply won't go in. So, what happens is, again, oftentimes the person is not even aware that those muscles are clenching and binding up and preventing penetration there. So, for this reason, it's really important to be working with a comprehensive team of people to help, and be performing some exercises on your own. And we'll go over the details of that in the second chapter here. But I do recommend that people see their physician to ensure that there is no other underlying more dangerous or serious medical diagnoses. Oftentimes, that may involve getting some further testing done or further examination by a doctor. And then I always recommend that people work one-on-one with a pelvic health physical therapist who is knowledgeable and trained and certified in pelvic health. That person is going to do, also, a very thorough examination of the posture and of your breathing and of your hip muscles and how your spine is moving, and of the pelvic floor muscles themselves, to help determine what your unique needs are to reach your goals. There's a lot that you can do at home, though. So we are going to be going over some breathing exercises and stretches in the final chapter of this course. Our next chapter, I'm going to go over how you can start to manage this condition at home on your own. I'll see you there. Welcome back. We're now going to talk about what can you be doing at home to help manage the symptoms of vaginismus, overcome the issues with penetration so you can reach your goals. As I mentioned previously, it's very important to start with discussing this with your medical provider. That could be your doctor, nurse practitioner, gynecologist, family carer. If when you go to talk to your healthcare provider about these issues, you don't feel like you're being listened to, or they're writing you off or telling you, "You just need to relax" or "Try having a glass of wine," those are not solutions to managing vaginismus. It's really important to find someone who's listening to you and is going to be helpful in managing and being part of a team to help you overcome this. So, keep looking for a provider until you find one that is listening to you. Additionally, I recommend seeing a pelvic health physical therapist for a complete evaluation as well, and to help determine what your unique needs are in managing your symptoms. The first thing that I always educate my patients in is their anatomy, as I just did, and getting aware of your own individual, unique and beautiful anatomy. A lot of people with vaginas have never actually looked down there, and it's important to know what structures are, and where they are, so that you can be gaining better coordination and control of them. Because the underlying undoing of vaginismus is going to come down to the coordination of those muscles so that you can relax them when it's appropriate, to be able to have that penetration, whether it's with a tampon, during a medical exam or with penetrative sex. So, the first thing that I recommend is that you get a handheld mirror and find a comfortable position, whether it's lying on your back in bed or in a squat in the bathroom. Sometimes people even feel good lying on their side with their top leg up. What you're going to be doing is using your mirror to get a good look at your anatomy. Taking note of the vulva, the outside vaginal tissue, which is on the outside there, find your urethra and clitoris. It's really important to be familiar with where that is. And then the vaginal opening, and then find the anus. There may be a lot of hair. There may be not very much hair. But just getting a look around, and familiarizing yourself. The next thing that I want you to do is to imagine that you are trying to shut off the flow of urine. In order to shut off the flow of urine when we are in this still position, not on the toilet, the pelvic floor muscles are going to contract. When the pelvic floor muscles are coordinated and working well, what you should see is a little bit of a pucker or the clitoris area hood coming down and the anus closing, almost like a wink, closing up. You should see the vaginal opening closing and lifting in towards you a bit. So when we're upright, the pelvic floor muscles contract and lift upward, almost like an elevator, or like one of those claws that come in and get a toy in those arcade games. That is the activated or contracted position. This is also called a Kegel. This is only for your reference. Oftentimes, people that are experiencing vaginismus have muscles that are indeed too tight, and Kegels are not going to be a treatment or a remedy for them. In fact, what I'm going to be teaching you how to do is quite the opposite. You're going to be learning how to drop and relax. But first I want you to know what "up" is. You may find, too, that your muscles are already so tight that you cannot feel a good contraction, and that's okay. The next thing you want to do is imagine that you're gently going to pass gas. So, right where you are, still using your mirror to help provide that reference, imagine that you are going to pass gas gently. This involves a little bit of a bear down, and what you should see is a dropping or opening around the vaginal opening, and then also, likewise, a little dropper or bulge around the anus. You may also notice this soft tissue area, in between here, coming down and towards you. If you are trying to do this and the pelvic floor muscles are not working, or you're not seeing any changes, don't give up, and don't get frustrated. I promise you it will get easier. A couple of different visual cues that are helpful are to imagine that you're trying to blow a bubble out of the vaginal opening or out of the anus, or that you're trying to pass an egg through, as if you were a chicken. So you're just imagining a gentle dropping and bulging downward from that pelvic floor. Another cue that works well for some people is to imagine that the vaginal opening is a rosebud and you want to make the rose bloom downward and outward. That's a series of cues; find the one that works best for you. Different visual cues resonate differently with different people, and that's why I like to give several, so that gives you the opportunity to find what you like, find what works best for your brain and your body. If after practicing this for a few days you're just finding it's simply not working, this is where the value of seeing a pelvic physical therapist comes in. They have a lot of different tools, like biofeedback, and different cues and different manual techniques that will help you learn this. But the name of the game is going to be learning to, on command, get the pelvic floor muscles to drop and relax. What happens is that the drop and relax allows to open the vagina so that something can pass through. Other tools that are useful for this are vaginal dilators or wands. There's a lot of different types of tools on the market. There are dildos, there are different types of vibrators of different sizes and shapes. Dilators, like these for example, they are Intimate Rose, often come in sets that range from very, very small, the size of my pinky, up to larger. What this does is this allows you to start if you're having significant issues with penetration, you're learning to do that drop-and-relax. If you imagine this is the vaginal opening, and you're dropping and relaxing, and learning to tolerate without pain having something in there, and performing gentle mobilization to train the tissue in the vagina and around it for pain-free penetration. This allows for a gentle, step-wise progression as you graduate and learn, to be able to get where you need to be. So, for example, if your partner is roughly this large, but you're currently not able to use a tampon, that's where this step-wise progression is really helpful. With the dilators, I always recommend that you use them for roughly 10 to 20 minutes, one to two times a day. The goal is to train the concentration and coordination between the brain and the pelvic floor muscles to gently drop and relax to allow for penetration with no pain. Penetration should not hurt. So, with these, for example, they are a nice smooth silicone, so they allow for a really gentle and easy use in. They come in a lot of different materials on the market, but a lot of people will agree that having a gentle, flexible silicone is more forgiving, especially when you have significant challenges with penetration. I always recommend, find a lubricant that works best for you: water-based, silicone-based, natural lubricants. Find one that you like. With medical-grade silicone, such as these dilators here, it's important to use a water-based lubricant. When you're using your dilator, I recommend you put down a towel and you start to engage in some breathing exercises which we'll go over in the next chapter, focusing on breathing in and out, feeling your pelvic floor drop and relax, getting good practice in there. And then, being very generous with your lubricant, one to two tablespoons even, and some of it's going to go on the dilator, and some of it you'll just gently place around the vaginal opening here, this is also called the introitus, and you place it in there and then just inside the vaginal opening. Take your time, especially when you're first learning. You're going to be practicing your breathing, focusing on staying relaxed. Do that drop and bulge; whether you're imagining that you're blowing a bubble, or imagining that the vagina is a rose blooming. Bring the tip of the dilator to the vaginal opening, and just rest there for a moment. If having something touching your vaginal opening is sparking pain or some emotional issues, or if you're struggling, sometimes it's helpful to start with the dilator in an innocuous place that has nothing to do with your vagina. You can even start with it on your arm, and practice breathing, and using self-talk, using something like, "This dilator is here to help me," "I am helping myself feel better," or "I am worthy of reaching my goal," whatever works for you. Using that pulls us out of that fight-or-fly mode, which often happens with vaginismus, and into a more here-and-now, which allows you to focus on what the muscles are doing. So, we're working on staying out of panic, out of a feeling of threat or harm, and in our body, so that we can control those muscles around the vaginal opening. After you've mastered your arm, you can move it to your abdomen and practice the same thing. "This is the dilator. It's here to help me. I am working on feeling better," or whatever your mantra is. And then you can bring it to your inner thigh, and work on that so that you're just slowly but surely getting proximity to the vaginal opening. Once you're able to get the dilator all the way in, and that could be on day one or it could take a month, it could take more, depending on what your circumstances are, depending on if you've had radiation after cancer, or if you've experienced a significant threat or harmful event, you may be working in tandem with a counselor or other clinical psychologist that's helping through this program as well. So, keep in mind, everyone's different; there's no protocol that is going to match every single person. So, day one may be easy peasy, day one may be even something slightly larger, and day one might be just on your arm. Be gentle with yourself; give yourself grace. But once you are able to get the dilator all the way in, you're then going to be gently mobilizing the tissue around in preparation of graduating up to the next size. So, if this is the vaginal opening you've gotten in, imagine that the vaginal opening is a clock where this is 12 o'clock, and this is 6 o'clock. You're gently going to come press down into 6, then move to 7, then 8, then 9, 10, 11... The 12 o'clock area is one that you may want to be very careful with or avoid when you're first starting. The 12 o'clock area is right underneath the urethra, that's where the urine comes out; it's a tissue that tends to be highly sensitive. For many people pushing a dilator up into that tissue through the vaginal canal is not going to feel very good. For some people it's not going to be noticeable, and for some it will be intolerable. When you're first starting, I recommend avoiding pushing up into the 12 o'clock position, but you can go into 11 o'clock and 1 o'clock, repeating through. Then you can start to work on holding it for a little more, like 30 seconds, down into that tissue, then rotating. I call this the clock method. Once you have mastered that, and it's pain-free, you're then ready to start moving up and trying the next dilator in your set. I also recommend doing different position changes. We'll go over this in the exercise portion of this course. But you don't always just have to be lying down on your back, and in fact I recommend, when you're using dilators or a wand, which we'll go over next, that you try different positions: lying on your back, being on hands and knees, lying on your back with your feet up the wall, a deep squat, all of these position changes allow for a change in your anatomy, a change in the tissue, and if your goal is to have pain-free penetration, it allows you to learn how to control your body in those different positions, because sex doesn't always just happen on your back, and it allows you to be more comfortable with variability, which is going to make that sex more enjoyable and more fun. So, as you progress through, you're working on still maintaining your breathing and mobilizing that tissue, recognizing that it may take time in between to get to where you need to go finally. Some people like to include their partner in their dilator use, and that's great! If you have a partner that is really patient and understanding, and is a positive part of your healing process, having them observe or even having them gently learn how to participate in using the dilator is a wonderful, wonderful thing, and that's very personal. It's 100% up to you. I've also had patients that really didn't want their partner involved until they were... Kind of, like, the curtain goes up, and it's the finished product. And that was what works best for them. They didn't want their partner to be part of that rehabilitation journey. Decide what works for you, and decide what works best between you and your partner. Open communication is key, and I think, ultimately, once you two decide together what's going to work best for you, you're going to thrive in that environment. So, just use communication with them; show them this video, even. I have patients that bring their partner into therapy sessions or into their appointments so that their partner can hear from me what we're working on in therapy, and I can help introduce anatomy. So, it's a really wonderful thing to have somebody who's willing to learn and be by your side during that journey. If you don't have someone that's like that, don't worry, you can do it by yourself. There's more than one way to wrap a present. So finding what works best for you is going to be what gets you to where you need to go. So those are dilators. Another tool is a wand. One thing that can happen is, when the muscles have been clenching for a very long time, knots can develop in them, or tender points, or sometimes referred to as trigger points. Just the same way you would get a knot in your shoulder or your neck that can give you kind of a headache, kind of a throbbing sensation, you push on it and it zings up and over your head, knots like that can occur in the pelvic floor muscles. After all, they are muscles just like everywhere else. They have nerves, blood vessels, they can be sensitive, and they can be too tight, they can be too weak, and they can have those tender points. Those tender points can be located anywhere within the muscle belly. Usually they are located along the sides, which are very difficult to release using just a finger or a from-the-outside approach. They can also be near the tailbone, and up even under the pubic bone, near the bladder. Having a thorough evaluation by a pelvic physical therapist often shows where these are located on your body. One of the ways to release them independently is to use a pelvic wand. This is actually the wand I designed to be able to release those tender points in various parts of the pelvic bowl. This one can be used vaginally or rectally. Sometimes those tender points are better accessed through the rectum. That can be really hard for a lot of people, so most of the time you can reach most of them through the vagina. So, either end can go in the vagina or the rectum. This short little hook makes it easy to just come into the vagina and hook into the muscles, right under the pubic bone, while the longer end makes it easy to sweep through, and provide more of, like, a massage sensation to the length of the muscle, or to come in, and hook and get those tender points that live on the deep far side of the pelvic bowl. This is called the obturator internus. That muscle often feels like hip pain. A lot of my patients are often very shocked when they feel a sensation of hip pain, we evaluate their pelvic floor muscles and, lo and behold, it's just a big trigger point in the obturator internus on this side. Once we release that, they feel much better, and their hip pain is suddenly gone. So that's the beauty of using a wand or another device to be able to perform gentle mobilization of the pelvic floor. One of the things that's really important, regardless of what you're using to work on your pelvic floor muscles, whether it's your finger, a dilator, a wand, another toy, whatever it is, using the concept that I call tomato touch. If you were at the supermarket trying to choose a tomato that was ripe, because you needed to use it that day, you would gently check the firmness of the tomato. You would come in, assess its pliability, and then come off. You wouldn't squeeze your tomato and smush it. And, likewise, you wouldn't push your thumb in so hard that your thumb punctured through the tomato. That is the same respect that you want to show your muscles and your tendons and your ligaments in your body and in your pelvic floor. So, when we're using a wand or a dilator or a finger, you're checking your tomato for ripeness. You're never going to push any harder than you would use to check that tomato for ripeness. Using plenty of lubricant is really beneficial, and always, always, using plenty of lubricant when you're starting to engage in sex. Additionally, you can use balms on the vulva, here, that help moisturize if you're experiencing irritation or redness. Using organic balms can be really helpful, just the same way as Chap Stick on the lips, and helping make sure that that tissue is really healthy and really pliable, which is really helpful for penetration. In our next and final video, I'm going to take you through some breathing exercises, and we're going to go over some pelvic floor muscle relaxation stretches, positions and exercises that you can use at home to help guide you on your journey. Welcome back to the exercise portion of the vaginismus course. When I say "exercises," I mean a lot of different things. The first thing I'm going to teach you is the importance of breathing and maintaining an easy, steady breathing pattern when you're doing your stretches, and learning how to coordinate your pelvic floor and using your dilators, and also when you start to incorporate penetration in sex. So, in addition to breathing, I also recommend that you engage in some form of cardiovascular exercise that is joyful to you. That could be going for a walk for 10 to 15 minutes; it could be running, Zumba, dance party in your kitchen. Whatever it is. But those types of activities help to improve circulation, which is good for all of your muscles, including your pelvic floor. And it's also good to help produce some endorphins, which is best for overall health and wellness. I'm also going to show you some stretches that you can use. I always recommend to my patients that you pick the one that works best for you, and use that one on a daily basis. So, of the three or four that I'm showing you, pick the ones that you like and use them. And then, finally, I'll teach you some different positions that you can use when you are using a dilator, a wand or even a toy to help your pelvic floor learn how to better tolerate penetration. The first thing that we're going to do is start with breathing. You can practice breathing in a variety of different positions. You can sit criss-cross like this, you can lie down on your back, and I'll demonstrate that in a moment. But the first thing that I want you to feel is the sensation of what your pelvic floor does when you're breathing, because that's going to help you understand why. Breathing is, of course, paramount to living. If we are living, then we are breathing. But a lot of people with vaginismus are breathing very shallow in their chest, which means that they're not getting good oxygenation to the rest of their muscles. And that can also further drive the gripping or guarding sensation in the pelvic floor. Our diaphragm works in beautiful harmony with our pelvic floor when we have good coordination. So that looks like a piston, actually. When we inhale, our diaphragm drops down, and so does our pelvic floor. So, it looks like this. As we inhale... and then exhale, the diaphragm comes back up, and so does the pelvic floor. These are the natural mechanics of our trunk. So, when we are breathing really shallow, oftentimes we're not getting good mobility in the pelvic floor. Breathing is actually a really passive way to get a little bit of mobility and stretch on the pelvic floor in a pain-free manner. So, the first thing I'd like you to do is place one hand on your chest and one on your belly. Take a deep breath in. And determine where you feel your hand is moving when you breathe. Try it lying down too. You can have a pillow. One hand on your chest, one on your belly. And inhale. See if you can get your hand on your belly to rise up towards the ceiling. I'm showing you this movement, almost like balloon, ìn through the belly, And then easily let it down by breathing through your mouth. So, inhale through your nose, exhale through your mouth. Do that for a period of one to two minutes. So, keep breathing, and let yourself fall into a rhythm while you're breathing. Now bring your hands onto your ribcage. You can do it like this, you can do it like this, or even like this. What we also want to be doing is expanding into our ribcage as if it were an umbrella. Keep breathing. I'm going to demonstrate that upright. So, when we breathe in, we want good mobility, not just in the up-and-down frame, not just through your belly, but through the ribcage, as if it were an umbrella expanding front, back, and through the sides. Almost like bucket handles coming out. So, inhale... and then exhale. So, feeling good mobility in the abdomen and the ribcage. Next, I'm going to show you some positions for pelvic floor release. During these, I recommend that you continue with that nice, easy breathing. And one thing I always tell my patients is, of all of these different positions or stretches I'm about to show you, pick the one that feels best on your body, because that's the one that's going to be the most beneficial. So, you don't have to do all of them, though you certainly can. If there are some that you like more than others, use that in your daily routine. For each position, I recommend that you hold it for two to three minutes, enough time to fall into a nice, easy breath cycle, and allow for a nice, easy release of the pelvic floor. The first one is lying on your back, and it's called happy baby. So, for this, you're lying on your back. You're still doing your breathing. And your feet are up towards the ceiling, and your knees are wider than your hips. For this, you can come back behind the knees, and support them, and fall into the stretch like this. You can reach forward to the big toes, if you're feeling fancy and you have enough flexibility in your hips. Or you can even use a towel, or a belt, behind your knees here, and use that to hold on to for support if you are having low back or hip stiffness, and you're not quite able to come into this position here. And then you're just working on directing your feet up towards the ceiling with a little bend in your knee, and then again breathing and feeling that release in through the pelvic floor. The next position is called figure 4, and it's going to stretch the hip. You'll remember that the hip backs up to the pelvic floor. So by stretching the hip we also gently provide a release or stretch to the pelvic floor. So, for figure 4, you put your ankle over your knee, and pick the whole thing up. You can support in the back, and you can use your hand to gently press that knee away here. You could also put your foot against the wall, and you can also have it towards you for a bit more of a stretch in through the hip. So you're finding a position that feels like a little bit of a stretch in through the hip or in through the back, you might feel it wrapping around the sides, and then feeling the release of the pelvic floor as you're breathing through. For this one, you'll need to switch and do the other side so you can have good symmetry between the right and the left. The next position is child's pose. But I like to use a variation. If you're familiar with child's pose as a stretch, you might be familiar with it as a crouch down, with your knees bent, arms over head here, or even arms back here, like this. I like to recommend using a pillow in two different places as variation. That helps to release the pelvic floor more gently. The first one is to place the knees slightly wider than the hips, put the pillow in the fold of the hip, and then reach forward with the arm here, breathing into the pelvic floor. If your shoulders are tight, you can certainly bring one or both back, here, to allow for a gentler position here. The next variation is to take your pillow and place it in the fold of the back of the knee. This position allows a little bit more opening around the vaginal canal. A lot of patients feel a lot more release in that area there. So, you're just coming back forward in that position. Gently breathing in and out. The next one is a mobilization. It involves more movement of the back and the hip, and oftentimes it provides a nice release, especially if you're feeling stiff in your back or your hips. It's an alternation between cat and camel. So, you'll start on your hands and knees, and press up into cat, rounding the pelvis down, tailbone down, head down, breathe into the sides of the ribcage, and then release, and point the tailbone and the head gently upwards. So, a little arch here. Play with that position to feel what feels best for you. For some, a lot of extension feels okay. And for others staying a little bit more neutral is going to feel better on the back. But the focus is on breathing and maintaining a nice, easy flow between the movements. So you'll repeat ten to twelve times. Cat and camel. The next is a deep squat. There's a lot of different variations for deep squat to help it feel better. I like to recommend using a kitchen counter or a chair or, if it feels good and you have enough balance to do it, free form. So, it looks like this. You're focusing on dropping and relaxing the pelvic floor. The benefit of using a kitchen counter or a chair is that you can hold on for stability, and also get a stretch through the back and through the shoulders all the way down to the tailbone, which is really beneficial for most people. But you can alternate between the two. A lot of folks are going to have difficulty achieving this position. You could always use a little pillow underneath as well, for deep squat. That concludes the stretches and pelvic floor release positions. I'm now going to show you a couple of variations on body position to help when you're using the dilators or a wand or a toy in hopes of integrating into intercourse. As I mentioned, changing the body position often allows for different people to feel more secure or to experience a different release in the pelvic floor. Also, it helps to prepare you for sex, that often takes place in different positions. Most people think about practicing with a tool or a toy lying on their back here. I like to recommend that, in addition to supporting your head, you get extra pillows, fluffy, big pillows or one to two pillows, and place one under each knee, support it, to allow the legs to be able to just open and relax and support it without jarring the hip too much, and then you're using the tool or the toy in this position. Another variation is to be lying on your back, with your feet supported on the headboard, or on a wall if you're down here on the floor. In this position here, with the feet supported, oftentimes you can relax the muscles in your legs. You can window-wipe them out so that you can have a little bit more space to move, and then you're using the tool. The other thing is oftentimes it allows the position of the hip to open up a little bit, so for some people this is going to feel better. Another alteration is side-lying. So, you would lie on your side, with your head positioned, and then get another big pillow or a sleeping bag and prop it here, kind of under the lower part of the leg, into the knee a little bit, so a sleeping bag would even have you up here, and then you're supported and using the tool in this position. For a lot of people, side-lying is a nice supportive position that feels a little less vulnerable. So, mess around with that position, especially if you have a history of trauma, that might feel more comforting to you. The next one is hands-and-knees position. For this, you'll be on hands and knees, stabilizing with one hand and then using the other hand with the tool. And you can go from a back approach or a front approach, depending on how long your arms are. This does require a little bit more strength at the shoulder girdle. You don't have to be in that position for too terribly long, because the arm will fatigue, but just trying it for a minute or two can be really helpful. And then finally the deep squat position we just talked about. You can back up against a wall so that it's supporting your back as you're in this position, and then using the tool in that nice, open deep-squat position. You can also be using the kitchen counter for support, or a chair. Find what works best for you. Try some variations, especially once you're towards the latter stages of using the tools and getting ready for pain-free penetration. I hope you've enjoyed these exercises. Use them daily, use them as needed, two to three minutes, five, six times a day, with the exercises, and then ten to twenty minutes using dilators or wands, daily, if you can. Take a day of rest if you need it. Also, engage in some sort of cardiovascular exercise that feels good to you and brings you joy, whether it's just going for a walk or a run or a dance party in the kitchen, something to get your heart rate up. This helps improve circulation, which is good for rehabilitating all of your muscles and joints and tendons, but especially for the pelvic floor. It's also good to spark endorphins, which is really great for overall wellness. The key take-homes for this course are to recognize that vaginismus is overcomeable and curable. You can do it. It will take time. You do want to find what works best for your body, oftentimes using a variety of different approaches and different healthcare practitioners and different counselor types to help you on your journey to reach your goals. Find a healthcare provider who listens to you, and will help you on your journey. Also, be kind to yourself. Give yourself grace. This process does take time, but you can do it.