What if the pain you feel isn't a signal from damaged tissue - but your brain's best guess about what might be dangerous?
Jo Gipson is a pelvic health physiotherapist (Instagram @jogipsonphysio, jogipsonphysiotherapy.com) with a particular interest in the neuroscience of pelvic pain. This is part two of a two-part series. In this episode, Jo explores the pain science behind vulvodynia and vaginismus: how pain is generated by the nervous system as a protection response rather than always as a readout of tissue damage, how past experiences and current beliefs shape that response, and why the anticipation of pain can be enough to trigger it.
Pain as a protection response: what the neuroscience shows
The understanding of how pain works has shifted significantly in the last two decades. Pain is not a simple signal from damaged tissue reaching the brain unchanged - it is the brain's output, a protective response generated when the nervous system assesses a situation as threatening enough to warrant attention. The level of pain does not map neatly onto the level of tissue damage: past experiences, current beliefs, emotional state, and perceived threat level all influence how much pain is produced.
For people with vulvodynia or vaginismus, this understanding is both unsettling and liberating. Unsettling because it means the pain is real - it is being generated by a nervous system doing what nervous systems do - but is not necessarily a reliable indicator of what is physically happening in the tissue. Liberating because it means the pain can be addressed by working with the nervous system's threat assessment, not only by treating the tissue directly.
"Pain is a really important part of our neurology and our neurophysiology - it's the way that our brain communicates with us that we're in danger or that we're under threat. People who don't experience any pain at all often die earlier, because they don't have this alarm system."
How beliefs and past experiences shape the body's responses
The nervous system learns. Experiences of pain during penetration, medical examinations, or any other context leave a trace - a set of associations and predictions that the brain uses to anticipate what will happen next. These predictions are protective: they allow the body to prepare for anticipated threat before it arrives. But in the context of vaginismus and vulvodynia, where the original triggers may no longer be present or may have been treated, those learned predictions can continue to generate pain and protective responses independently.
This is the mechanism behind the anticipation effect: the brain generates the protective response - muscle guarding, pain sensitisation, withdrawal - in response to the prediction of threat rather than the presence of it. Understanding this mechanism changes what treatment needs to do: it needs to update the prediction, not just address the tissue.
"Even if they tell you exactly what they're going to do, your nervous system cannot 100% trust that they are going to do exactly what they said they were going to do... Therefore you don't 100% feel safe, and the body responds accordingly."
Why anticipating pain can make it worse - and the cycle this creates
The relationship between pain anticipation and pain experience is self-reinforcing. Anticipating pain activates the threat-detection system, which increases muscle guarding, which increases the likelihood of pain or discomfort, which confirms the prediction, which strengthens the anticipation for next time. This cycle can persist long after the original cause of pain has been addressed - and understanding it is essential for understanding why progress can feel so slow even when treatment is working.
Jo discusses why this cycle is common and what approaches begin to interrupt it: graded exposure, working with context and safety, building new non-painful experiences that give the nervous system different data, and the role of skilled physiotherapy in guiding that process. The goal is not to force the nervous system out of its protective response but to give it sufficient evidence that the threat assessment needs updating.
"There's also just a lot of normalization of pelvic pain within certain settings. And sometimes that can creep into the idea that this is how things are supposed to feel. And that normalization can actually delay people recognising that what they're experiencing isn't normal or acceptable."
Why even trusted partners can unknowingly trigger protective responses
One of the more nuanced points in this episode is the observation that protective responses can be triggered by people who are trusted and loved - not because the person is doing anything wrong, but because the nervous system has associated them with the context in which pain has occurred. A partner who has been present during painful attempts at penetration can, without any negative intent, become a trigger for the protective response simply by virtue of that association.
Jo discusses how understanding this - and talking about it with a partner - changes the relational dynamic of treatment. It also explains why partner involvement in pelvic pain treatment is not optional but central: not because partners cause the problem but because they are part of the environment in which the nervous system is learning, and can be active participants in creating the conditions for new, safer experiences.
