Feed Your Body Good

Feed Your Body Good

Avoiding foods that cause pain

YOUR DIET

Your diet is a huge factor affecting inflammation in the body. As we discussed in “You feel what you eat,” if you eat foods that cause inflammation, you will have more pain. Avoiding all inflammation-causing foods seems logical but would be very difficult. So the idea isn’t to remove these foods from your diet entirely, but to reduce your general intake.

Some of the foods that may cause you inflammation and pain:
Gluten
Refined carbs
Fried food

Processed meat
Red meat
Margarine, shortening, lard

We’re not really sure how all of these foods cause inflammation, but the effects on the blood and body stress chemicals have been revealed through a number of scientific studies.

Gluten

Gluten is a protein found in wheat, barley, and rye. It gets a really bad rap, but scientists think it may be the underlying problem is that gluten is “housed” in many foods considered “simple carbs.” Yet, however consumed, scientific study shows that gluten-containing foods are inflammatory.

As of late, you can find gluten-free foods in almost any grocery store. There are enough gluten-free substitutes these days to replace just about all of your favorite foods. Although, the tricky thing about gluten it’s in a lot of foods you might not suspect, e.g. soy sauce and mixed spices. You need to read ingredient lists and look for wheat, barley, rye, “modified food starch” and/or a disclaimer like “processed in a facility that processes wheat.” The latter is probably okay to eat, unless you are allergic to gluten.


Refined carbs

Refined carbs are any type of sugar or starch-containing food that has been processed. Unrefined carbs are the carbohydrate-containing foods in nature, such as an unprocessed sweet potato or corn kernel. When you take these carbs and grind, heat, or change them in any way, it “processes” them. The more processed the food, the more refined.

Processed carbs are easier for your body to digest, but their digestion produces inflammation. A (very) short list of foods to avoid are:

Table, brown, and confectioners sugar
Most syrups (e.g., corn, agave)
Fruit juices
Anything labeled instant (e.g., instant oatmeal, white rice)
Anything labeled starch (e.g., cornstarch, potato starch)


Fried food


Putting anything into hot oil makes it bad for you. This is due to the heated oil. Most of the oils used to fry foods are hydrogenated vegetable oils, containing trans fatty acids, which increase inflammation.

When you eat too much trans fatty acid, it results in toxins that permeate the bowel wall and cause trouble. So “Just say No!” to french fries, potato chips, and deep fried Twinkies.

Processed meat

Bacon lovers beware. Meat processing causes the chemical advanced glycation end products (AGEs) to be released. AGEs activate the human immune system, which alters your cells’ make-up. Which is bad for your gut and for you. So hang up your bacon, step away from the hot dogs, retire the jerky and avoid the sausage.

Red meat

The effects of red meat are a little more debated in some medical circles. It is thought to cause inflammation in the same way that processed meat does, through AGEs. However, the problem may lay in the way we cook meat. Charring a steak may be tasty, but it releases AGEs. The more cooked the meat, the higher the AGEs. As such, red meat cooked any way contains AGEs, so it’s best to limit your intake as much as possible.

Margarine, shortening, lard, and saturated fats
These processed oils are removed from their respective foods using a chemical that is a component of gasoline. Yuck! The processing causes the foods to have a high content of trans fatty acids. See “Fried Food” above to learn why this is bad for you! Saturated fats would include cheese, heavy cream, butter, fatty meats, sausage, etc...

References: 

Lee Y, Park K. Irritable bowel syndrome: Emerging paradigm in pathophysiology. World J Gastroenterology. 2014;20(10):2456-2469.

Basu A, Devaraj S, Jialal I. Dietary factors that promote or retard inflammation. Arterioscler Thromb Vasc Biol. 2006;26:995-1001.

Fritsche K. The science of fatty acids and inflammation. Adv Nutr. 2015;6:293S-301S

Okada Y, Tsuzuki Y, Ueda T, Hozumi H, Sato S, Hokari R, Kurihara C, Watanabe C, Tomita K, Komot S, Kawaguchi A, Nagao S, Miura S. Trans fatty acids in diets act as a precipitating factor for gut inflammation? J Gastroenterol Hepatol. 2013;28(S4):29-32.

Uribarri J, Woodruff S, Goodman S, Cai W, Chen X, Ryzik R, Rong A, Striker G, Vlassara H. Advanced glycation end products in foods and a practical guide to their reduction in the diet. J Am Diet Assoc. 2010;110(6):911-916.

You Feel What You Eat

You Feel What You Eat

You’ve heard the saying “you are what you eat,” right? Well, you also “feel what you eat”. If you eat foods that cause inflammation, you’ll have more pain. Your diet is a huge factor affecting inflammation in the body. And inflammation is a context in which your brain thinks pain signals are more important. Inflammation makes your pain sensing nerves more sensitive and jumpy.

The way certain foods cause inflammation is not completely understood, but it is certain that many foods affect the gut microbiome (the mix of good bacteria and microbes that are supposed to be in your gut) This allows toxins to be released into the bloodstream. The toxins causes the immune system to rev up and release additional unnecessary proteins, which causes inflammation. All this activity is picked up and communicated with your brain.

So we “feel what we eat” because food-caused inflammation increases pain

But what can you do about it?

The most effective way to slow down the immune system and reduce inflammation is to change your diet. Yep, it’s that simple. Changing what you eat will significantly improve your pain.


The second way is to add back and support good bacteria with probiotics and prebiotics. (Probiotics are strains of good bacteria. Prebiotics specifically feed the good microbes in the gut.) Taking probiotics has been shown to reduce inflammation and symptoms of several pain syndromes including irritable bowel.

The third thing you can do is to avoid taking antibiotics, unless absolutely necessary as decided by your healthcare provider.

The fourth and theoretically the most fun is to get regular exercise. This helps in digestion, and also helps support the gut microbiome.

Step ONE

I cover all these steps in detail in my e-book, When It Hurts Down There, but here I’ll just briefly expand on Step One.


To slow down the immune system and reduce inflammation you simply need to avoid the foods most linked to inflammation-related pain. These are gluten, refined carbs, fried foods, processed meats, red meat, and processed fats. 

Again, we’re not really sure how all of these foods cause inflammation, but the effects on the blood and body stress chemicals have been shown in multiple scientific studies.

I understand that avoiding all of these foods completely would be very difficult. So, the idea isn’t to remove them from your diet entirely, but to reduce your general intake. The body is meant to have some amount of inflammation reaction to fight off infections, but you want to lower the unnecessary activation of the system. A thoughtful diet without foods that trigger trouble in your gut can lead to less pain, a healthier lifestyle, and a happier you!



References:

Lee Y, Park K. Irritable bowel syndrome: Emerging paradigm in pathophysiology. World J Gastroenterology. 2014;20(10):2456-2469.

Basu A, Devaraj S, Jialal I. Dietary factors that promote or retard inflammation. Arterioscler Thromb Vasc Biol. 2006;26:995-1001.

Fritsche K. The science of fatty acids and inflammation. Adv Nutr. 2015;6:293S-301S

MacDermott RP. Treatment of irritable bowel syndrome in outpatients with inflammatory bowel disease using a food and beverage intolerance, food and beverage avoidance diet. Inflamm Bowel Dis. 2007;13(1):91-96.

Moloney RD, Johnson AC, O’Mahoney SM, Dinan TG, Greenwood-Van Meerveld B, Cryan JF. Stress and the microbiota-gut-brain axis in visceral pain: relevance to irritable bowel syndrome. CNS Neurosci Ther. 2016;22(2):102-117.

Tillisch K. The effects of gut microbiota on CNS function in humans. Gut Microbes. 2014;5(3):404-410.

El-Salhy M, Gundersen D. Diet in irritable bowel syndrome. Nutrition Journal. 2015;14:36.

You're not alone! Pelvic pain is really common

The Puzzle of Pelvic Pain

I've fairly recently been invited to join a Facebook group of people suffering from pelvic pain problems. One of my patients invited me to the group, and let me tell you, it's an amazing cadre of women. They lift each other up, give encouragement, and point each other in the right direction for getting a diagnosis etc... I feel kind of like an outsider in there because as much as I'd love for it to be possible, I can't diagnose over the internet. It's really a puzzle figuring out where your pain is coming from, and a hands on exam is absolutely necessary. That's actually the most fun part of my job. I've always loved working puzzles.


Anyhoo, joining this group has helped many women realize they're not alone in the fight against pain. There's a sense of loneliness in pelvic pain patients, feeling like you're the only one out there dealing with this. And it's so not true!

You Are NOT Alone!!

Chronic pelvic pain is a really common issue. The guesses for how many people suffer with this is between 4% and 90% of women worldwide. I can’t even find numbers for men. That’s a pretty wide range, so narrowing down the type of pain to whether it’s with periods only, with sex only, or totally random, we can get a little better idea. With menstrual period pain, it’s around 30-40% of women worldwide. Pain with sex is probably closer to about 20%, although in the US it’s particularly high, at about 45%. Random pain is pretty common too; about 20% of the world’s population has this.

So, if you have pelvic pain, know you’re not alone. Some of the best statistics say that probably 1 in 3 women have pelvic pain, and that it’s chronic in about 1 in 7. Look around you at work sometime. If there’s more than 7 women in your office, guess what? It’s probably not just you!

If you are one of the hundreds of thousands of women world-wide dealing with pelvic pain, I can help. I love doing these kinds of puzzles! You can make an appointment with me at Nurture Womens Health.

Reference:
Latthe P, Latthe M, Say L, Gülmezoglu M, Kahn K. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health. 2006;6:177.

Queefing- the feminine way to pass gas

UM, PARDON ME?

I've been seeing a lot of questions lately in my office and online about "queefing". Whomever came up with the term queefing, in my humble opinion, is an absolute genius! So, what exactly is the definition of queefing? According to Dictionary.com:

NOUN: Slang: Vulgar. an expulsion of air through the vagina.

Anybody else a little irritated with the use of the word "vulgar "there? As if women are trying to be sexual about passing gas through the vagina. Truth be known, there's not a real term for passing wind from the vagina. "Why," you ask? Probably because men don't do this, so it's never been added to the "non-slang" dictionary. In medical literature the phenomenon of farting from your lady parts is known as either "vaginal wind", or "vaginal air." There are only a few literature articles on the subject, listed in the wee tiny print below. Some of the info here is collected from those articles, some of it's just from my experience, both personal, and with patients. (Yes, I queef on occasion. As you'll find out, most women do!)

Queefing FAQs

Since there seems to be a lot of confusion about queefing, so let's tackle the most common questions.

How common is queefing?

In the general population, we just don't know for sure. One literature review, says it's between 1 and 69%. The single article I could locate on the topic of prevalence found that 69% of women pass gas via the vagina at least twice a week. Let's go with 69% as the best number we've got. Asking around my office and my female friends, most women will admit they've queefed before, even if it isn't a regular problem.

How does the air get in there?

Vaginal air can come from two places. First, it can get in the vagina from something called a fistula. A fistula is a little opening between the bowel and the vagina, most often seen after traumatic prolonged vaginal delivery, or after vaginal/pelvic surgery. This can be diagnosed in your doctor's office or with imaging, like a CT or MRI.

The most common way for air to get into the vagina is from outside the body. The classic time is during sex. With repeated penetration, the penis pushes air from outside up into the vagina. After sex queefs are by far the most common. Air can also get inside the vagina during exercising, especially activities like yoga where your bum is up in the air. Some people suck air up inside the vagina while shifting around in their chairs at work, or while moving around in their sleep. When you're sitting or lying down, the pelvic floor tends to be less tight, and allows for air to seep up in there. Then when you stand up, it comes out.  This is particularly the case in ladies with tight pelvic floor muscles. The tightness of the muscles seems to help suck in the air, and keep it trapped.

Does a queef smell bad?

If a man farts in the forest, and no one is there to appreciate it, does it smell? Depends on how you think about it. In order for something to smell, a nose must be there to inhale the chemicals that produce a signal in the brain of a particular odor. When you pass flatus (that's the actual medical term for rectal gas) most of the time it has little or no odor. Rectal gas is a combination of swallowed air and byproducts of the microbes living in your gut. Certain foods notorious for gas (like broccoli and milk) are partly broken down by bacteria in your gut, which produces hydrogen sulfide. That chemical is what gives smelly farts their odor.

Is queefing dangerous?

Nope. Not in the least. If it's associated with a fistula, it'll need to be fixed. But classic passage of vaginal air that's trapped is common, and normal. It doesn't hurt, and is not dangerous. But it can be embarrassing. Many times a queef makes a noise similar to a fart. That sound can draw attention, obviously, and women with regular queefs tend to feel shameful about it. 

Is there anything I can do to reduce or stop it?

There's no literature on this. These recommendations come from experience and from a little medical logic. If you queef mostly after sex, using a good lubricant can help. When the penis slides more easily, it doesn't push as much air up in there. Good lubricants are generally either water or silicone based. You'll need to use one that's pH balanced. The lubricants I recommend to my patients are "Good Clean Love", "Desert Harvest Glide", and "Uberlube". If you're one that queefs after sitting too long at work, getting up regularly will reduce the likelihood of having the sound.

What's next?

If you queef more than twice a week, you may have a pelvic floor issue. You can always come by my office to talk about the sensitive topics like this. We'll figure out if your queefs are concerning or just the garden variety "gentle wind". You can make an appointment with me at Nurture Womens Health. 

https://www.ncbi.nlm.nih.gov/pubmed/28494270

https://www.ncbi.nlm.nih.gov/pubmed/26241266

https://www.ncbi.nlm.nih.gov/pubmed/14677001

Christmas hurts! Why pelvic pain flares during the holidays.

Holiday Heart attacks

Ok, this blog is supposed to be about pelvic pain...why are we talking heart attacks? Work with me here, and we'll get to the pelvic pain in a minute.

There's a really disturbing thing that happens, specifically on Christmas day and New Years. It's not the weird red-clad man climbing into strangers homes, dropping off gifts, and stealing cookies. It's the rate of sudden cardiac death. More people die of heart attacks on Christmas day and New Years than any other day in the year. Seriously? Yes. And it's not just old people who have no one to celebrate with. It's across the board.

For many of us, Christmas is fun, and exciting. But it's also a little stressful, right? Having to plan gifts, parties, buy the right ugly sweater to impress what's-his-name from the office. We have to deal with crazy uncle Ed who always makes the most inappropriate remarks during dinner. There's also the many out there that don't like Christmas because of lack of social support, or the memory of the loss of a loved one. The stress of the holidays is problem #1. The food of the holidays is problem #2.

Problem #1: STRESS

There's these chemicals called catecholamines that are the way your body responds to stress. Ones you might have heard of are norephinephrine and epinephrine. These chemicals activate the sympathetic nervous system. They're made in your body naturally, and can also be created from some of the foods we eat. They're what make your heart race and give you the feeling of shortness of breath when something startles you. It's an activation of the fight-or-flight response. During the stress of the holidays, these chemicals tend to run amok. They're at high levels in your blood. Whether that's from uncle Ed embarrassing you in front of the new boyfriend, or the stress of getting the right gift for mom.

Those stress hormones aren't good for your blood pressure and heart rate. They give you the necessary jolt to run away from a bear, if you live in Alaska. But if you're in Cedar Rapids, Iowa, it's unlikely you're being chased by a bear. And raising your blood pressure and heart rate isn't good for long periods of time.

Problem #2: The FOOD

Taking in excess amounts of alcohol and certain foods puts you at increased risk of a heart attack due to an enzyme in the foods that prevents the breakdown of catecholamines. The levels of stress hormones rise when they're not broken down properly, leading to sustained rises in blood pressure and heart rate.

What the heck does all this have to do with Pelvic Pain??

When you're in acute pain, like from slicing your finger while cutting potatoes, your sympathetic nervous system gets activated. The fight or flight response gets you to quickly move the knife away and grab the bleeding finger to slow the blood loss. This is a good deal, because sympathetic activation lets your brain know that the pain signals are important. They make you move the knife instead of continuing to cut.

When you're in chronic pain, elevated sympathetic nervous system chemicals make it hard for your brain to decide if pain signals are important or not. On the side of caution, the elevated catecholamines lead the brain to think that pain signals are important, so they're processed more rapidly.

When your sympathetic nervous system is all amped up for long periods of time, you get increased processing of pain signals. In patients with fibromylagia, the higher the activation of the sympathetic nervous system, the higher the magnitude of pain.

Holidays = stress + foods that prevent catecholamine breakdown

Stress + high catecholamine levels = high sympathetic nervous system activation

High sympathetic nervous system = increased pain processing

You're not crazy if you feel like your pain is worse around the holidays. It really is!

Do I just suffer through the holiday season, then?

ADD PIC

No, ma'am, you need not suffer. There's some good techniques to lower the sympathetic nervous system. The sympathetic nervous system has an arch enemy called the parasympathetic nervous system. Its whole deal is to lower blood pressure, lower heart rate, and calm you down. It's at its best when you're chilling, like taking in rays on the beach. Now, most of us don't have a beach nearby. If you do, I'm jealous. For the rest of us land-lubbers, we can activate the parasympathetic nervous system a few other ways. Doing something super relaxing, like getting your nails done, or having a massage can work wonders.

Other options include deep breathing and meditation. Deep belly breathing will trigger your parasympathetic system. Deep breathing involves taking slow deep breaths through your nose, pretending they're going into your stomach instead of your chest. Hold the breath for a few seconds, and then release it slowly. Meditation is also very good at triggering the parasympathetic system. Meditation is getting your mind to clear. That sounds super hard, but it really isn't. There's a few apps that you can get on your phone that will help you learn how to meditate. "Headspace" is a good one for newbies. 

As Always

If you're having worsening pelvic pain during the holidays, I may be able to help with some of my techniques too. I'd love to see you for an exam and treatment at Nurture Womens Health. You can make an appointment to see me and we'll figure out how to lower your pain, and your risk of heart attack!

Rescources

https://www.ncbi.nlm.nih.gov/pubmed/22678655

https://www.ncbi.nlm.nih.gov/pubmed/26816852

https://www.ncbi.nlm.nih.gov/pubmed/25963185

https://www.ncbi.nlm.nih.gov/pubmed/25786044

Why having sex is good for your vagina

Listen up, Ladies!

First, I'd like to commend my colleague, Dr. Jen Gunter, for gracefully addressing all of the media coverage of her vagina recently. Reading her rebuttal to all the men who had the gall to critique her vaginal aroma was the highlight of my month! One phrase she used in discussing vaginal health was "the vagina is a self cleaning oven." I've used this phrase with my patients too. There's a lot of confusion out there about vaginal odors due to the entire section of Walgreens dedicated to it. I agree that this whole section of the store should be removed. Another catch phrase I use a lot with my more mature patients is "The vagina is a use it or lose it kind of organ" You'd be surprised at the reactions I get. Most women either raise an eyebrow, or full out laugh. Beautiful ladies, I'm serious. The vagina needs to be used regularly when you're heading into menopause or you'll lose the ability to use it, potentially forever.


I've uttered "the vagina is a use it or lose it kind of organ" to an average of two women per week lately. As a pelvic and intimate pain specialist, one of the more frequent sexual issues I see is vaginal atrophy (dry vagina). I deal with this all the time. Women entering the end of their fertile years are at risk for "dry vagina." This is a frustrating and potentially disfiguring disorder of the vagina near to and in menopause. Up to 80% of women aged 65+ have problems with sex mostly due to dryness!

Sex and Midlife Estrogen

When you enter into the menopausal change, your ovaries start to poop out. They slow and eventually nearly stop the production of estrogen. Estrogen is the hormone that is responsible for keeping your lady parts moisturized. It also helps keep the vagina stretchy enough to allow your partner to enter. About 50% of women that are post-menopausal have vaginal atrophy with dryness. This typically starts within a few years of finishing your periods, but it can start when your periods get irregular and start spacing out, even years before they completely stop.


With reduced estrogen, there's less cells at the surface of your vagina. This causes problems with a host of things including lubrication, vaginal elasticity, thinning walls, and increased risk of tearing with sex. Ugh! There's also a change to the good bacteria in your vagina which leaves you at risk for discharge and bad bacterial overgrowth.

Why sex hurts in menopause

With a dry vagina, having sex begins to get uncomfortable. When your vaginal elastic qualities start to diminish, as you can imagine, putting an erect penis in there starts to hurt. If you don't have sex regularly, it hurts all the more because eventually the reduced elasticity turns in to a narrowing vagina. This isn't easy to fix once it's happened. It can get so bad that the vaginal entrance becomes tight and stiff, and the lips can even get stuck together!

Low estrogen = dry vagina and smaller opening = painful sex.

How, exactly, do I need to use my vagina?

This is a topic of some debate. The first thing to consider is that once the vagina starts to narrow, it's hard to stretch it back out. If you're in a relationship where his penis can be used to keep things stretched, then by all means that's an option. But only about 25% of women are able to orgasm with penetration, and orgasm helps with all this dryness stuff too. If you're not in a relationship, then consider obtaining a "sexual enhancement device." This is my politically correct term for a BOB (battery operated boyfriend), also known as a vibrator. The vibrator is much more likely to encourage orgasm with clitoral stimulation. Having orgasms regularly seems to help with the dryness, as it pulls in extra blood flow to the area. You may find it's a little more difficult to obtain orgasm after menopause, and that's ok. Keep working at it.

How do I get this treated?

Using your vagina regularly won't prevent it from being dry in menopause. That's an estrogen issue. What can be done to treat this? The best way to improve your vaginal dryness is with prescription estrogen. You'll need your doctor to discuss this with you, because there's a handful of medical conditions that make it dangerous to use estrogen. A history of breast cancer is one of the biggies. Other than estrogen, there are a few things that can help with dryness. DHEA vaginally is one thing that's being studied. There's also a few over-the-counter meds and prescription ones that help with dryness.


If you have vaginal dryness and aren't using your vagina, you're in a bad spot. Please get in to talk to your doctor about estrogen replacement. If you don't have a doc to do this for you, I can see you in my office! Please go to Nurture Womens Health and make an appointment to talk about vaginal dryness and painful sex. And buy yourself a fun Christmas present this year! A BOB will fit nicely in your stocking.

References:
https://www.ncbi.nlm.nih.gov/pubmed/28885410
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4389697/
https://www.ncbi.nlm.nih.gov/pubmed/28885410

Sex Hurts!!! Part 5- Vaginismus

"Sex is impossible- my vagina just won't cooperate!"

It's not an uncommon problem, sadly, to have an uncooperative vagina. Remember my "dreaded speculum exam" post? This is it...the most common cause of a painful speculum exam. Now, as you've seen in other posts, it's not the only reason. But it can cause some serious issues in your relationship, and obviously may make sex painful or impossible.

What is Vaginismus?

Vaginismus is when your vaginal muscles tighten up spontaneously, without your intentional help. This makes penetration with sex, or even placing a tampon, painful or almost impossible. It can also push things out of the vagina after they've been placed there.

For some people this happens with the very first time of trying to have sex. It can lead to what we call unconsummated marriages and is pretty common in some cultures. It can also start after having had no issues in the past. 

Primary Vaginismus

This is when you've never successfully had sex. Nothing, or at least a penis, has ever been in there. The partner may say it feels like there's some type of barrier when he tries to penetrate, or that "the hole is too small." Sometimes other muscles get in on the action and tighten up. Women often hold their breath. Primary vaginismus is often caused by societal ideas, family expectations, personal thoughts about sex, or cultural practices. But it can also be related to unusual anatomy or sometimes a history of abuse. 

Secondary Vaginismus

This is when you've been able to perform before without problems, but now you're getting painful vaginal tightening. Something almost always triggers this. It could be something as awful as rape, or as simple as a urinary tract infection. It's really common with marital issues, especially cheating. Once the trigger problem is treated and fixed, like antibiotics for the infection, the vagina may continue to tighten. This is a "knee jerk" type reaction that has been programmed. It's like Pavlov's dogs that salivated when a bell was rang because they associated the bell with food. If your brain associates pain with sex, it may tighten the vagina up without your conscious permission.

What does it feel like?

For you ladies, it can feel anywhere from mild discomfort, burning with tightening, to severe tightness, or a complete inability to allow anything in there. If something is forced inside it will cause severe pain. For your partner, it feels like a barrier, a wall, or a really tight vaginal opening. I've seen cases so bad that I couldn't get a single finger in for an exam.

What can be done for this?

If this seems like an awful diagnosis, I can assure you it's treatable. But, it requires some work on your part. There's some psychology that's in play with this diagnosis, so counseling is usually involved. It can be on the fun side, like a sex therapist, or more intellectual like counseling. The most important first step is education. Other therapies include dilators, medications, and injections.

Techniques for treatment include:

1. Education about your body, the vagina, and the muscles in the pelvic floor.
2. Physical therapy to teach you how to relax the muscles
3. Vaginal dilators. These you can purchase online and use at home. You start with a really small dilator and place it inside for 10-15 minutes every day. Once you can insert it without pain, you go up a size. It can take months to get up to the size you'll need to be able to have pain-free sex, but the work is worth it! You'll need to continue dilating for a while, usually 6-12 months to get full effect.
4. Injections of botox. This is obviously done by a trained expert.
5. Therapy- either sex therapy, or counseling, or both.

As Always

As always, if you have questions, or think you might have vaginismus, please make an appointment to see me at Nurture Womens Health.

Resources:

https://www.ncbi.nlm.nih.gov/pubmed/24894201
https://www.ncbi.nlm.nih.gov/pubmed/28363809