Vulvovaginal Pain
Vulvovaginal pain is a chronic condition that affects thousands of women worldwide, often lasting for months or years without a clear cause. This persistent discomfort can significantly impact daily activities, relationships, and quality of life, yet many women struggle to receive an accurate diagnosis and effective treatment.
Table of contents
- What Is Vulvovaginal Pain?
- Symptoms and How It Feels
- Types of Vulvovaginal Pain
- Who Is Affected
- Possible Causes
- Diagnosis
- Treatment Options
- Self-Help Strategies
- Impact on Daily Life
What Is Vulvovaginal Pain?
Vulvovaginal pain, commonly known as vulvodynia (pronounced vul-vo-DIN-ee-a), is chronic pain or discomfort in the vulva that lasts for at least three months without an identifiable cause[1][2]. The vulva is the outer part of the female genitals, including the opening of the vagina, the inner and outer lips (labia), the clitoris, and the urethral opening (where urine comes out)[3].
This condition is different from vulvar pain caused by infections, skin disorders, or other specific medical conditions. Vulvodynia is considered a diagnosis of exclusion, meaning it is diagnosed only after ruling out other possible causes[4]. The pain may occur in the vulva, vagina, or both areas[3].
Women with vulvodynia typically have a normal-looking vulva, with no visible signs of infection or irritation[5]. However, the pain can range from mild to severe and may be so debilitating that sitting for long periods, using tampons, or having sex becomes difficult or impossible[1][5].
Symptoms and How It Feels
The main symptom of vulvovaginal pain is persistent discomfort in the vulvar region. Women describe the pain in various ways, and how it feels can differ from person to person[2].
The pain is often described as burning, stinging, irritation, rawness, or soreness[1][6]. Some women also experience aching, throbbing, swelling, itching, or sharp, knife-like pain[1][2]. The discomfort may feel like the area is raw or overly sensitive to touch[4].
The timing and pattern of pain varies widely. For some women, the pain is constant and present all the time[2]. For others, it comes and goes unpredictably over several months[2]. The pain might start suddenly with no obvious reason, or it may only occur when the vulva is touched or during certain activities[1][2].
Many women experience pain that is triggered by specific activities. These can include sexual intercourse, inserting a tampon, having a pelvic examination, wearing tight clothing, prolonged sitting, bicycle riding, or even sometimes during bowel movements[1][8]. The pain may continue after these activities end[2].
The pain can affect just one area of the vulva, or it may be felt across the entire vulvar region[1]. Sometimes the discomfort extends to other nearby areas, such as the inside of the thighs, around the anus (bottom), or the urethra[8].
Types of Vulvovaginal Pain
Vulvovaginal pain is classified into different types based on where the pain is located and what triggers it[2][4].
Localized vulvodynia means the pain is limited to one specific spot. Most often, pain is felt in the vulvar vestibule, which is the skin between the inner labia (vaginal lips) and the openings of the urethra and vagina[2]. This type is sometimes called localized vulvar pain syndrome or vestibulodynia[2][4]. Less commonly, the pain may be centered in the clitoris, a condition called clitorodynia[4].
Generalized vulvodynia means the pain is not confined to one spot. Instead, women may feel pain in different parts of the vulva and vagina at different times, or the pain may be felt throughout the entire vulvar area[2].
Vulvodynia can also be classified by what triggers the pain. Provoked vulvodynia means the pain occurs with touch or activity, such as during sex or when inserting a tampon[2]. Unprovoked vulvodynia means the pain happens without any obvious trigger[2]. Some women experience a mix of both types.
Who Is Affected
Vulvovaginal pain can affect women of all ages, from young women to those in their 80s[1][5]. However, most women who are diagnosed with this condition are between 20 and 60 years old[2][4]. It is most common in young women who experience pain during sex and may be unable to have penetrative intercourse at all[5].
Vulvodynia is the most common cause of painful intercourse and chronic pelvic pain among women in their reproductive years[2]. Studies suggest that up to 16% of women worldwide are affected by this condition[4]. Research has found rates ranging from 1.7% to 15% depending on the setting studied[4]. This means that in the United States alone, more than 2.4 million women may experience vulvovaginal pain[4].
Despite being relatively common, many women with vulvodynia do not seek treatment or receive an accurate diagnosis[2][4]. Only about 50% of affected women ever receive a correct diagnosis[4]. In one study, 60% of women seeking treatment visited three or more doctors before getting a diagnosis[10].
Women with vulvodynia typically are in stable, long-term relationships and have often had the pain for several years before receiving a diagnosis[4]. The condition is not associated with sexually transmitted infections or risk factors for them[4]. Past research incorrectly suggested that psychological issues or abuse caused vulvodynia, but recent studies show that women with this condition are psychologically similar to women without it and are no more likely to have been abused[4].
Possible Causes
The exact cause of vulvovaginal pain is not known[1][8]. Vulvodynia is defined as vulvar pain without an identifiable cause, although several potential contributing factors may be present[4].
Researchers believe that vulvodynia likely results from multiple factors working together rather than a single cause[6]. These potential contributing factors include damage, irritation, or over-sensitivity of the nerves in the vulva[8][6]. Some research suggests that women with vulvodynia may have been born with more nerve endings in the vulvar area, and if these nerves become damaged, the area can become hypersensitive[5].
Other possible factors include inflammation of the vulva, hormonal imbalances or changes in hormone levels such as estrogen or testosterone, genetic susceptibility, and pelvic floor muscle dysfunction[4][6][8]. Weak or dysfunctional pelvic floor muscles, including muscle spasms, decreased strength, and poor coordination, are often associated with vulvar pain[4].
Previous vaginal infections, particularly chronic thrush (yeast infections), may trigger the condition[5][8]. Sexual trauma, such as sexual abuse or sex without adequate lubrication, and childbirth have also been suggested as possible triggers[5]. Some women using combined hormonal contraceptives may experience increased incidence of vulvar pain, suggesting that relative estrogen or testosterone deficiency could play a role[4].
Women who experience pelvic pain over long periods may develop pelvic floor muscle spasms and nerve sensitivities[10]. Many women diagnosed with endometriosis also experience vulvodynia[10].
It is important to understand that vulvodynia is not caused by active infections like yeast infections, is not a sexually transmitted disease, is not due to poor hygiene, and is not a psychological problem[7][10]. The pain is real and located in the vulva, not imagined[7].
Diagnosis
There is no specific test for vulvodynia. Instead, the diagnosis is made after ruling out other conditions that could cause vulvar pain[5][4]. This makes vulvodynia a diagnosis of exclusion.
When you see a doctor about vulvar pain, they will ask detailed questions about your symptoms, including how long you have had the pain, your medical and surgical history, sexual history, any allergies, and treatments you have already tried[1][4][6]. They may also ask about skin conditions, infections in the vagina, and whether sex is painful[8].
A physical examination is an important part of the diagnosis. Your doctor will examine your vulva and vagina carefully, looking for signs of infection or other causes of your symptoms[1][8]. In most cases, the vulva looks completely normal despite the pain[1][5]. Sometimes the tissue might look slightly inflamed or swollen[1].
A common diagnostic technique is the cotton swab test. During this test, a doctor uses a moistened cotton swab to gently touch different areas of the vulva to identify where the pain is located and how severe it is[1][4][8]. You will be asked to describe what the pain feels like and rate its intensity. This test helps determine whether the pain is localized to one spot or generalized across the vulva[4].
Your doctor may take a sample of vaginal discharge or cells to test for infections caused by yeast or bacteria[1][8]. Tests might include a wet mount examination, vaginal pH testing, fungal culture, or other methods to rule out infections[4].
If the skin of your vulva looks different than usual, your doctor might perform a biopsy, which involves removing a small sample of tissue to examine under a microscope[1]. Blood tests may also be done to check hormone levels, such as estrogen, progesterone, and testosterone[1].
If your doctor cannot find the cause of your vulvar pain, you may be referred to a specialist, such as a gynecologist who has experience with vulvar conditions[5][8]. Not all doctors are familiar with vulvodynia, and sometimes doctors may incorrectly conclude that the pain is caused by a psychological problem[5]. If you cannot get relief or want a second opinion, it may help to see a women’s health specialist[5].
Treatment Options
The main goal of treatment for vulvovaginal pain is to manage and reduce the pain[8]. There is no single treatment that works for everyone[1][5][8]. Finding the best treatment or combination of treatments often requires trial and error, and it can take time—sometimes several months—before relief is noticed[1][5][7].
Treatment for vulvodynia typically involves a multidisciplinary approach, meaning that care is provided by several different specialists working together[4][8]. These specialists may include a gynecologist, a physiotherapist, a psychologist, and a pain specialist[8]. Evidence and international guidelines support psychological intervention and pelvic floor physical therapy as first-line treatments for most chronic vulvar pain[4].
Oral medications are commonly used to help reduce nerve hypersensitivity and manage chronic pain. These include tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and anticonvulsants[1][4]. Even though these medications were developed to treat depression or seizures, they have also been found effective in treating chronic pain conditions[4]. The dosage used for pain is usually much lower than the dosage used for depression or other conditions[4]. It can take three to four weeks for oral medications to start working[4].
Topical medications applied directly to the vulva may provide relief. These include anesthetic creams containing lidocaine to numb the pain, hormonal creams with estrogen or testosterone, and compounded formulations designed specifically for vulvar pain[1][4][10]. Some topical antidepressants are also available as creams[1]. Lidocaine gel may sting for the first few minutes after application[4].
Pelvic floor physical therapy is an important treatment option. This therapy helps you regain control of the pelvic floor muscles through stretching, dilation, massage, and myofascial trigger point release to facilitate muscle relaxation, improve circulation, and increase mobility[4][8]. Research shows that nearly 76% of women report improvement in pain during intercourse and gynecological exams, as well as increased sexual satisfaction, after pelvic floor physical therapy[4]. This treatment also helps address pelvic floor muscle dysfunction, including spasms, which is a primary cause of vulvar pain[4].
Psychological therapies such as cognitive behavioral therapy (CBT) or psychosexual therapy can be very helpful[8]. CBT aims to reduce pain and associated distress, improve sexual function and satisfaction, and strengthen intimate relationships by targeting unhelpful thoughts, emotions, and behaviors associated with pain[4]. Research shows improvements in sexual pain with CBT, particularly when mindfulness training is included[4]. These therapies are not offered because the pain is “in your head,” but because chronic pain can be exhausting and demoralizing, and support is important[7].
Botox injections into the pelvic floor muscles may help prevent or manage pain caused by overly sensitive nerves and prevent pelvic floor muscle spasms[10]. Research shows that botulinum toxin injections can induce localized muscle relaxation and pain relief, with various studies reporting significantly improved vulvar pain after treatment[4].
Vaginal trainers, which are tampon-shaped objects, can be used to gently widen the vagina[8]. This treatment helps women gradually become more comfortable with vaginal penetration.
Surgery is rarely recommended and is reserved only for women with severe localized vulvodynia who have not responded to other treatments[5][8]. The surgical procedure, called vestibulectomy, involves removing the painful part of the vulva[4][8]. This surgery is nearly 90% effective in reducing chronic vulvar pain for women with localized provoked vulvodynia[4].
Other treatments under investigation include muscle relaxants (such as transvaginal diazepam), anti-inflammatory medications, and hormonal treatments[4]. More research is needed to determine the effectiveness of these approaches.
It is important to discuss treatment options thoroughly with your healthcare provider, including realistic goals for treatment[4]. Keeping a pain diary can help you track your symptoms and evaluate how well different treatments are working[4][6]. Treatment setbacks may occur, and they are not necessarily your fault or your provider’s fault[7]. Improvement can take weeks to months[7].
Self-Help Strategies
While seeking effective treatment, there are several self-help strategies you can use to relieve symptoms and prevent further irritation[4][6]. Even when symptoms are under control, these guidelines are recommended as a preventive strategy[4].
Clothing and hygiene choices can make a significant difference. Wear 100% cotton underwear and avoid wearing underwear while sleeping[4][6]. Choose loose-fitting pants or skirts instead of tight clothing[6][8]. Do not wear pantyhose; instead, wear thigh-high or knee-high stockings[4]. Remove wet bathing suits and exercise clothing promptly[4].
Use soft, white, unscented toilet paper and avoid using scented products such as soaps, deodorants, bubble baths, or feminine hygiene products in or around your vagina[4][6][8]. Do not clean inside your vagina (douching)[8]. Wash the vulva with water only, or use cool to lukewarm water[4][8]. Avoid getting shampoo on the vulvar area[4]. Rinse the vulva with water after urination[4].
For laundry, use dermatologically approved detergent and double-rinse underwear and any other clothing that comes into contact with the vulva[4]. Do not use fabric softener on undergarments[4].
Managing activities and sitting can help reduce pain. Avoid sitting in the same position for long periods[8]. If you must sit all day at work, try to intersperse periods of standing[4]. Consider using a donut cushion for long periods of sitting[4]. Avoid exercises that put direct pressure on the vulva, such as bicycle riding and horseback riding[4]. Limit intense exercises that create a lot of friction in the vulvar area; instead, try lower-intensity exercises such as walking[4].
Bathing and cooling measures can provide relief. Do not have hot baths; make sure the water is cool or lukewarm[8]. Use lukewarm or cool sitz baths to relieve burning and irritation[4]. Avoid using hot tubs and do not swim in highly chlorinated pools[4]. Use a frozen gel pack wrapped in a clean thin towel or a layer of a hand towel and apply it to the vulva for 15 minutes to relieve burning after intercourse or exercise[4].
For sexual intercourse, use a water-based lubricant[4][8]. Avoid lubricants with flavor or cooling/warming sensations[6]. Try different positions when having sex[8]. Ask your physician for a prescription for a topical anesthetic like lidocaine gel, which can be applied before sex, though it may sting for the first few minutes[4]. Urinate before the bladder is full and after sexual intercourse to prevent infection, then rinse the vulva with cool water[4]. Do not use contraceptive creams or spermicides[4].
Menstrual care should involve using 100% cotton menstrual pads and tampons[4]. During your period, try using pads instead of tampons if tampons cause pain[8].
Stress management and relaxation are important. Try to avoid stress, as stress can worsen symptoms[8]. Techniques such as yoga and mindfulness can help you relax[8]. Enroll in an exercise class to learn stretching and relaxation exercises[4]. Learn some relaxation techniques to use during the day[4].
Other helpful measures include preventing constipation by adding fiber to your diet and drinking at least eight glasses of water daily[4]. You may also want to ask a GP or pharmacist for advice about using an emollient (a moisturizing product) in place of scented products[8].
Impact on Daily Life
Vulvovaginal pain can have a profound effect on many aspects of life[2][4]. The condition can be so stressful and draining that it is life-altering for many women[2].
Pain from sitting for too long can make it challenging to do your job[2]. Simple tasks like sitting at a desk for extended periods may become unbearable, forcing women to find creative solutions or limiting their career options[4].
The difficulty or impossibility of sexual intercourse can damage intimate relationships[2][4]. Many women with vulvodynia experience pain during sex and may be unable to have penetrative intercourse at all[5]. This can affect both partners in a relationship, and couples counseling may be beneficial[7]. Special issues exist for single women who must navigate explaining their condition to new partners[4].
Sleep can be affected, as many women have a harder time falling and staying asleep[2]. The constant or recurring pain can disrupt sleep patterns and contribute to fatigue.
Even clothing options can be limited, as tight clothes may trigger or worsen pain[2]. Women often need to carefully choose what they wear to avoid exacerbating symptoms.
The condition can affect mental health as well. Research has linked vulvodynia to depression and anxiety[2]. Chronic pain is exhausting and can be demoralizing[7]. It is common for patients to become depressed, and there are treatment options available for this[7]. Healthcare providers may suggest antidepressants during treatment, not because they think the pain is imagined, but because chronic pain can be devastating to cope with[7].
Support from friends, family, and healthcare providers is essential[7]. Many women benefit from connecting with support groups where they can share experiences with others who understand what they are going through[4]. The more you learn about this condition, the more control you have over managing it[7].
Despite these significant challenges, most women experience substantial improvement when one or more treatments are used[4]. Vulvodynia will often go away by itself over time[5]. With appropriate care and a multidisciplinary approach, there is hope for relief and improved quality of life.