Vulvodynia

What vulvodynia is

The vulva includes the labia, clitoris and the vestibule, the area around the vaginal opening. Vulvodynia is diagnosed when pain persists for at least 3 months and is not explained by another condition. Pain caused by a specific disorder, such as infection, lichen sclerosus, skin conditions, nerve injury or menopause-related vaginal atrophy, is called vulvar pain due to a specific disorder and is treated differently.

Classification

Provoked vestibulodynia, pain at the vaginal opening on touch, is the most common type and the main cause of painful sex in premenopausal women.

Possible contributing factors

The exact cause is often unclear, and several factors may combine:

• increased density and sensitivity of nerve endings in the vestibule
• pelvic floor muscle overactivity and tension
• hormonal factors, such as some combined oral contraceptives in some women
• inflammation
• central sensitization, overlapping with conditions such as IBS, interstitial cystitis, fibromyalgia and TMJ disorders
• genetic factors
• previous recurrent yeast infections or irritant treatments
• psychological factors such as anxiety and fear of pain, which can amplify pain

Vulvodynia is not caused by a sexually transmitted infection and is not contagious.

Symptoms

• burning, stinging, rawness, aching, throbbing or itching
• pain at the vaginal opening with sex (dyspareunia), tampon insertion or speculum exams
• pain with prolonged sitting, cycling or tight clothing
• constant pain without a trigger in generalized vulvodynia
• the skin usually looks normal or slightly red

Many women also have pelvic floor muscle tension, involuntary tightening at the vaginal opening (vaginismus), anxiety about sex, and relationship strain.

Diagnosis

• detailed history: onset, triggers, sexual history, previous treatments, bladder and bowel symptoms
• examination of the vulva and vagina to look for skin disease or other causes
• cotton swab test: gently touching points around the vestibule to map areas of pain
• pelvic floor muscle assessment
• swabs for yeast and other infections, and biopsy of any abnormal skin

Treatment

Most women need a combination of approaches, and improvement can take months.

Vulvar care

• use gentle, fragrance-free cleansers or plain water
• wear cotton underwear and avoid tight clothing
• avoid douches, scented pads and irritating products
• use a lubricant for sex; apply cool gel packs after intercourse
• avoid repeated over-the-counter yeast treatments without testing

Pelvic floor physical therapy

A specialized pelvic floor therapist uses manual therapy, biofeedback, relaxation and graded dilators. This is one of the most effective treatments, especially for provoked vestibulodynia with muscle tension. See pelvic floor dysfunction.

Medicines

• topical lidocaine before sex or at night
• topical compounded creams (such as amitriptyline-baclofen or estrogen-testosterone in some cases)
• oral nerve-pain medicines: amitriptyline, nortriptyline, gabapentin or duloxetine for generalized or constant pain
• changing hormonal contraception when suspected to contribute
• botulinum toxin injections into pelvic floor muscles in selected cases

Psychological therapy

Cognitive behavioral therapy, sex therapy and couples counseling reduce pain, distress and fear-avoidance, and improve sexual function.

Surgery

Vestibulectomy, removal of the painful vestibular tissue, has high success rates for localized provoked vestibulodynia when other treatments have not helped.

Frequently asked questions

What does vulvodynia feel like?

Vulvodynia is usually described as burning, stinging, rawness or aching in the vulva. Some women feel pain only when the area is touched, such as during sex or tampon use. Others have constant pain, even when sitting or wearing clothes.

What causes vulvodynia?

The cause is often unclear. Contributing factors may include extra-sensitive nerve endings, tight pelvic floor muscles, hormonal changes, inflammation and heightened pain processing. It is not caused by an infection, poor hygiene or anything you did.

Can vulvodynia be cured?

Many women improve significantly or become pain-free with treatment, which often combines pelvic floor physical therapy, medicines and psychological support. For localized pain at the vaginal opening that does not respond, surgery can be very effective.

How is vulvodynia different from a yeast infection?

Yeast infections cause itching, redness and a thick discharge, and respond to antifungal treatment. Vulvodynia causes burning or pain without infection, and tests are negative. Many women with vulvodynia are first treated repeatedly for yeast, so testing is important.