Vulvovaginal Discomfort

Vulvovaginal discomfort is a widespread condition affecting women of all ages, characterized by pain, burning, itching, or irritation in the external and internal genital areas. While the causes range from infections to chronic pain conditions, many women experience significant relief through proper diagnosis and treatment.

Table of contents

• Understanding the Vulva and Vagina
• Common Symptoms
• Main Causes of Vulvovaginal Discomfort
• Diagnosis
• Treatment Options
• Self-Help Strategies

Understanding the Vulva and Vagina

Many women are not familiar with the difference between the vulva and the vagina, which can make it difficult to describe symptoms accurately. The vagina is the internal tube that connects the uterus (womb) to the outside of the body. The vulva is the general name for the outside parts of the female genitals, including the inner and outer lips (labia), the clitoris, the urethral opening where urine comes out, and the vaginal opening^[3].

Pain and discomfort can occur in either the vulva or the vagina, or both areas at the same time. Understanding which body part is affected helps healthcare providers make an accurate diagnosis^[3].

Common Symptoms

Vulvovaginal discomfort can present in many different ways. The pain often feels like burning, irritation, stinging, rawness, soreness, throbbing, or stabbing sensations^[1][2].

The discomfort may affect all or part of the vulva, or it may come and go. Some women experience pain only when the area is touched, such as during sexual intercourse, when inserting a tampon, or during gynecological examinations. For others, the pain starts on its own without any obvious trigger^[4][13].

Additional symptoms can include vaginal itching, vaginal discharge that may be abnormal, vaginal odor, and painful urination^[5]. The pain may also extend to other areas, such as the inside of the thighs or around the anus^[4].

Vulvovaginal discomfort can have a significant impact on daily life, affecting sleep, concentration, work performance, and sexual relationships. Many women also experience depression and anxiety as a result of persistent symptoms^[2].

Main Causes of Vulvovaginal Discomfort

Infections

Infections are among the most common causes of vulvovaginal discomfort. Vaginitis is inflammation or infection of the vagina or vulva that causes symptoms including vaginal discharge, itching, burning, and pain during intercourse^[5].

The most frequent infectious causes include bacterial vaginosis, which results from an imbalance between good and bad bacteria in the vagina. This condition may produce a thin white or gray discharge with a strong, fishy odor, especially after sex^[6].

Yeast infections, usually caused by a naturally occurring fungus called Candida albicans, produce thick white discharge that can look like cottage cheese. The discharge is often watery and may have no smell. Yeast infections typically cause the vagina and vulva to become very itchy and red^[6][18].

Sexually transmitted infections such as trichomoniasis can also cause vaginitis. Symptoms may include itching, burning, soreness, and gray-green discharge with an unpleasant odor^[6].

Vulvodynia

Vulvodynia is a type of long-term pain or discomfort around the outer part of the female genitals that lasts at least three months and has no clear cause. The pain, burning, or irritation can be so uncomfortable that sitting for long periods or having sex becomes very difficult or impossible^[1].

There are two main types of vulvodynia. Localized vulvodynia means pain is felt in one specific spot, such as the area surrounding the opening of the vagina (called the vestibule). Generalized vulvodynia means pain is felt throughout the entire vulva or in different areas at different times^[2].

The exact cause of vulvodynia is not known. It may be related to damage, irritation, or over-sensitivity of the nerves in the vulva, previous vaginal infections, changes in hormone levels such as estrogen, or weak pelvic floor muscles^[4][13].

Skin Conditions

Several skin disorders can affect the vulva and cause discomfort. Dermatitis causes chronic itching with a rash and can result from direct contact with irritants such as strong soaps, spermicidal creams, and feminine hygiene products, or from allergic reactions to substances like latex in condoms^[8].

Lichen sclerosus is a condition that causes itching, tenderness, and painful sex. The vulvar skin becomes thin, wrinkled, and can split or tear. Postmenopausal women are most likely to develop this condition. Without effective treatment, lichen sclerosus is linked to an increased risk of vulvar cancer^[8].

Lichen planus causes pain, bleeding, a burning sensation, and painful sex. Other skin conditions that can affect the vulva include psoriasis, eczema, and folliculitis, which appears as small, red, sometimes painful bumps caused by bacteria that infect a hair follicle^[7][8].

Hormonal Changes

Reduced estrogen levels during menopause can lead to thinning, drying, and inflammation of vaginal tissues. This condition, called atrophic vaginitis or vaginal atrophy, results in vaginal dryness, itching, and discomfort. Symptoms include painful intercourse, genital itching, burning, and urgency with urination^[5].

Other Causes

Bartholin gland cysts occur when the small glands located on either side of the vaginal opening become blocked. This creates a swollen bump near the opening of the vagina. These cysts usually are not painful unless they become infected and form an abscess^[7].

Some women experience allergic reactions or irritation from certain products, including detergents, soaps, lotions, latex condoms, vaginal sprays, douches, spermicides, or fabric softeners. This can lead to vaginal discomfort, itching, or irritation^[5][6].

Diagnosis

If you have pain or discomfort in your vulva that does not go away or keeps coming back, you should see a healthcare provider. It is important to seek medical attention even if you feel embarrassed or if there are no visible signs of a problem^[1].

During your appointment, your healthcare provider will ask detailed questions about your symptoms, including how long you have had the pain, what it feels like, and what makes it better or worse. They may also ask about your medical and sexual history, any previous infections or skin conditions, and whether you have had any surgeries^[1][12].

A physical examination typically includes checking your outer genitals and vagina for signs of infection or other problems. Your provider may use a moistened cotton swab to gently touch different areas of your vulva to identify where the pain is located and how severe it is. This is called a cotton swab test^[10][12].

Tests may be needed to confirm the diagnosis. A sample of cells from your vagina might be taken to test for infections caused by yeast or bacteria. The sample is examined under a microscope, and the vaginal pH may be measured. In some cases, if the skin of the vulva looks unusual, your doctor might remove a small sample of tissue for laboratory testing, which is called a biopsy^[10].

Blood tests may be done to check hormone levels such as estrogen, progesterone, and testosterone^[10].

Treatment Options

Treatment for vulvovaginal discomfort depends on the underlying cause. For many women, a combination of treatments works best. It can take time to find the right approach, and recovery may take weeks, months, or longer^[15].

Treating Infections

Bacterial vaginosis is treated with antibiotics, which may be given as pills to swallow or as cream or gel applied inside the vagina. During treatment, it is recommended to use condoms during sex or avoid sex altogether^[6].

Yeast infections are usually treated with antifungal creams or medicines placed inside the vagina. Over-the-counter treatments are available, but it is important to be sure you have a yeast infection and not another type of condition. Even if you have had yeast infections before, it is a good idea to contact your healthcare provider before using over-the-counter treatments^[6][18].

Trichomoniasis is usually treated with a single-dose antibiotic. Both you and your sexual partner should be treated to prevent reinfection^[6].

Treating Vulvodynia

Because vulvodynia has no single known cause, treatment focuses on relieving symptoms. An individualized, multidisciplinary approach is often most effective^[12].

Medications used to treat vulvodynia include antidepressants or anticonvulsants, which can help ease long-term nerve pain. Some types of antidepressants are available as creams that can be applied to the skin. Local anesthetics, such as lidocaine cream or gel, can be used to numb the area and provide temporary relief^[10][16].

Pelvic floor physical therapy helps many women with vulvodynia. This therapy includes stretching, massage, and exercises to relax the pelvic floor muscles, improve circulation, and increase mobility. Research shows that nearly 76% of women report improvement in pain with intercourse and increased sexual satisfaction after pelvic floor physical therapy^[16].

Cognitive behavioral therapy (CBT) is a psychological treatment that aims to reduce pain and associated distress, improve sexual function and satisfaction, and strengthen intimate relationships. CBT strategies target unhelpful thoughts, emotions, and behaviors associated with pain. Research shows improvements in sexual pain with CBT, particularly when mindfulness training is included^[16].

Other treatments for vulvodynia may include vaginal trainers (tampon-shaped objects used to gently widen the vagina), muscle relaxants such as transvaginal diazepam or botulinum toxin injections into the pelvic floor muscles, and in rare cases, surgery to remove the painful part of the vulva if other treatments have not worked^[10][16].

Treating Skin Conditions

Treatment for vulvar skin conditions depends on the specific diagnosis. Contact dermatitis is managed by avoiding the source of irritation and using measures to stop itching so the skin can heal. Ice packs or cold compresses can reduce irritation, and a thin layer of plain petroleum jelly can protect the skin. Medication may be needed for severe cases^[7].

Lichen sclerosus and lichen planus are often treated with topical steroid creams. Regular medical monitoring is important, especially for lichen sclerosus, because of the increased risk of vulvar cancer if not treated effectively^[8].

Treating Hormonal Changes

Vaginal dryness and atrophic vaginitis resulting from low estrogen levels may be treated with topical estrogen applied to the vulva or vagina, or with combined estradiol and testosterone. These treatments can result in significant improvements in symptoms^[16].

Self-Help Strategies

While seeking treatment, there are many self-help measures that can relieve symptoms and prevent further irritation. These guidelines are recommended even when symptoms are under control as a preventive strategy^[19].

Clothing and Laundry

Wear loose, all-white cotton underwear and avoid pantyhose (use thigh-high or knee-high hose instead). Wear loose-fitting pants or skirts. Remove wet bathing suits and exercise clothing promptly. Use dermatologically approved detergent and double-rinse underwear and any clothing that comes into contact with the vulva. Do not use fabric softener on undergarments^[19][26].

Hygiene

Use soft, white, unscented toilet paper. Do not use bubble bath, feminine hygiene products, or any perfumed creams or soaps. Wash the vulva with cool to lukewarm water only. Do not clean inside the vagina (douching). Rinse the vulva with water after urination. Use lukewarm or cool sitz baths to relieve burning and irritation. Avoid getting shampoo on the vulvar area^[4][13][19].

Urinate before the bladder is full and prevent constipation by adding fiber to your diet and drinking at least 8 glasses of water daily. Use 100% cotton menstrual pads and tampons, or try using pads instead of tampons during your period^[4][19].

Sexual Intercourse

Use water-based lubricants during sex. Do not use contraceptive creams or spermicides. Ask your physician for a prescription for a topical anesthetic such as lidocaine gel. Try different positions when having sex. Apply ice or a frozen gel pack wrapped in one layer of a hand towel to the vulva for 15 minutes to relieve burning after intercourse. Urinate and rinse the vulva with cool water after sexual intercourse^[4][19][26].

Physical Activities

Avoid exercises that put direct pressure on the vulva, such as bicycle riding and horseback riding. Limit intense exercises that create a lot of friction in the vulvar area and try lower intensity exercises such as walking instead. Use a frozen gel pack wrapped in a clean thin towel to relieve symptoms after exercise. Try to avoid stress through activities like yoga and mindfulness, which can help you relax^[4][13][19].

Everyday Living

Do not sit in the same position for long periods. Try using a donut cushion for long periods of sitting. If you must sit all day at work, intersperse periods of standing. Do not have hot baths; make sure the water is cool or lukewarm. Learn relaxation techniques to use during the day^[4][13][19].