Vulvar Pain: Why the Vulva Hurts and What Helps

How vulvar pain feels

People describe vulvar pain as burning, stinging, rawness, soreness, throbbing, or feeling cut or irritated. It may be:

• provoked: brought on by touch, sex, inserting a tampon, tight clothes, cycling or sitting
• unprovoked: present without any touch
• localized: in one spot, most often the vestibule (the area around the vaginal opening)
• generalized: across the whole vulva

Sudden or short-term causes

Infections

• Vaginal yeast infection: itching, burning and soreness, with thick white discharge and red, swollen skin. Urine can sting on raw skin.
• Genital herpes: tingling, then painful blisters that break into shallow sores. The first outbreak can cause fever, swollen groin glands and severe pain on urinating.
• Trichomoniasis: frothy, yellow-green discharge with soreness.
• Bacterial infections: folliculitis, boils and cellulitis.
• Bartholin's cyst or abscess: a swelling at the lower side of the vaginal opening that becomes very painful if infected.

Irritation and injury

• Contact dermatitis: from soaps, bubble baths, scented pads and wipes, spermicides, lubricants, condoms, laundry detergents and some creams, including over-the-counter anti-itch and anesthetic creams.
• Shaving, waxing and friction from tight clothes, cycling or prolonged sitting.
• Injury from childbirth, falls or sex.

Urinary causes

A UTI can cause burning and pain felt at the vulva, especially when urinating.

Long-term causes

Skin conditions

• Lichen sclerosus: white, thin, crinkly or shiny skin, intense itching, splitting and pain. It can scar and narrow the vaginal opening and slightly raises the risk of vulvar cancer, so it needs treatment with strong steroid ointment and regular follow-up.
• Lichen planus: raw, red, eroded areas, sometimes inside the vagina and mouth.
• Eczema and lichen simplex chronicus: itchy, thickened skin from scratching.
• Psoriasis, often appearing as smooth red patches in skin folds.

Hormonal changes

Low estrogen after menopause, while breastfeeding, or with some medicines causes thin, dry, fragile tissue (genitourinary syndrome of menopause or atrophic vaginitis), with burning, dryness and pain during sex. Some hormonal contraceptives are linked to vestibular pain in a small number of people.

Vulvodynia

Vulvodynia is vulvar pain lasting at least 3 months, without a clear identifiable cause, according to international consensus definitions. It is common, affecting perhaps 1 in 10 women at some point. The most frequent form is provoked vestibulodynia, pain at the vaginal opening with touch or penetration (previously called vulvar vestibulitis).

Contributing factors include increased nerve sensitivity, tight or overactive pelvic floor muscles, hormonal factors, past recurrent infections and the body's pain processing. It is not caused by anything a person did, and it is not "in the head", although stress and anxiety can amplify any pain.

Nerve and muscle causes

• Pudendal neuralgia: burning pain in the vulva and perineum, worse sitting, better lying down or standing.
• Pelvic floor muscle dysfunction: tight muscles causing pain with sex and an aching vulva.
• Postherpetic neuralgia after shingles.

Cancer and precancer

Vulvar intraepithelial neoplasia (VIN) and vulvar cancer are uncommon. They are more likely after age 60 or with HPV or lichen sclerosus. Warning signs are a lump, ulcer, wart-like growth, color change or thickened area, often with itching or pain. See vulvar cancer.

How vulvar pain is diagnosed

A clinician will ask when the pain started, what triggers it, its location and pattern, products used, sexual history, menstrual and menopause status, and previous treatments. Examination includes careful inspection of the vulvar skin and often a gentle speculum exam.

Tests may include:

• vaginal swabs for yeast, bacterial vaginosis and trichomoniasis, and herpes swabs of any sores
• urine test
• the cotton swab test: gentle touches at points around the vestibule to map tender areas, used to diagnose vestibulodynia
• biopsy of any abnormal-looking skin
• pelvic floor assessment by a physical therapist

Vulvodynia is diagnosed only after infections, skin conditions and other causes are excluded. Repeated antifungal treatment without a positive swab is a common pitfall.

Treatment and relief

Gentle vulvar care (helps every cause)

• wash with plain water only, or a soap-free emollient, once a day
• pat dry, or use a cool hairdryer
• wear cotton underwear, avoid tight pants, and sleep without underwear
• use unscented, 100% cotton pads, and avoid wipes, sprays and douches
• use a plain water-based or silicone lubricant for sex
• apply a plain emollient such as petroleum jelly as a barrier
• cool gel packs wrapped in a cloth can soothe burning

Treating specific causes

• antifungals for yeast and antivirals for herpes
• strong steroid ointment for lichen sclerosus and lichen planus
• vaginal estrogen for menopausal changes
• drainage or a Word catheter (a small balloon drain) for a Bartholin's abscess

Vulvodynia treatments

• Pelvic floor physical therapy: to relax and retrain tight muscles.
• Topical lidocaine before sex or at night.
• Oral nerve pain medicines: low-dose amitriptyline or nortriptyline, gabapentin or duloxetine.
• Cognitive behavioral therapy and sex therapy, which reduce pain and improve sexual function.
• Vestibulectomy: surgical removal of the painful vestibular tissue, for provoked vestibulodynia that does not respond to other treatment.

Most people improve with a combination of approaches. A vulvar specialist or a gynecologist with an interest in vulvar disorders can help when initial treatment fails.

Frequently asked questions

What causes vulvar pain?

Sudden vulvar pain is usually caused by a yeast infection, genital herpes, irritation from soaps or shaving, a Bartholin's abscess or a UTI. Long-term pain may come from vulvodynia, lichen sclerosus or lichen planus, eczema, low estrogen after menopause, or nerve and pelvic floor problems.

What is vulvodynia?

Vulvodynia is vulvar pain lasting at least 3 months without an identifiable cause such as infection or skin disease. It often feels like burning or rawness, is commonly triggered by touch or sex, and is treated with pelvic floor therapy, nerve pain medicines, local anesthetics and psychological support.

Why does my vulva burn?

Burning is most often due to a yeast infection, irritation from products, herpes, a UTI, or thin, dry tissue after menopause. If burning persists after these are treated or excluded, vulvodynia or a skin condition such as lichen sclerosus may be the cause.

Can vulvar pain be a sign of cancer?

Rarely. Vulvar cancer is uncommon and usually causes a lump, ulcer, or thickened or discolored patch, often with itching. It is more likely after 60 or with lichen sclerosus or HPV. Any non-healing sore or skin change should be examined and possibly biopsied.

Why does my vulva hurt during sex?

Pain during sex can come from vaginal dryness, low estrogen, infections, skin conditions, tight pelvic floor muscles or provoked vestibulodynia. Using enough lubricant helps, but persistent pain should be assessed, because most causes are treatable.