Introduction

Pain around the vulva is a common problem and can affect anyone who has a vulva.¹ It can affect people from any background, ethnic group, age or social class and can have a large effect on a person’s quality of life.² Fortunately, there is support and treatment available for people who suffer from pain around the vulva.

Definition of vestibulodynia

Vestibulodynia is pain around the area where the vulva (the outside of the female reproductive tract) meets the vagina (the inside)³. Vestibulodynia is diagnosed when the pain has been present for three months or more and where no cause can be found.¹  

People may also have tightness in their pelvic floor muscles and erythema (skin redness) at the tender areas.¹ 

The pain may affect small parts of the vulva, or spread as far as the urethra (the hole where urine exits your body) and your anus (where poo leaves you). It may cause constant pain or the discomfort could be intermittent (come and go)..¹

Who is affected by vestibulodynia? 

Vestibulodynia is thought to affect 15% of people with a vulva.⁷ 

Vestibulodynia occurs in adolescents⁵ as often as it occurs in adults.² (Adolescence is considered to be the period of someone’s life when they are between 10- 19 years old).⁴ The risk of developing vestibulodynia is highest during the teens and early twenties.⁶

This is what current figures tell us, but vestibulodynia may affect more people than we know. Many vestibulodynia sufferers either do not seek treatment or are misdiagnosed with a different health problem, which means that the numbers in the data may be well below the actual number of people who have to cope with this problem.³

Understanding vestibulodynia

The structure of the vestibule

The vulva is the portion of the genitals of people assigned female at birth (AFAB) that is outside the body. This includes the labia majora and minora (otherwise known as the “lips”), the urethra (the hole where urine exits the body), the clitoris, and Bartholin’s glands.⁸ 

The vagina is the internal part of the genitals of AFAB people. Made of muscle, it forms a tube from the cervix to the vaginal opening.⁹ 

The vestibule is the area of skin where these two structures meet.

Types of vestibulodynia

Provoked vestibulodynia

Provoked Vestibulodynia is pain around the vaginal opening that is triggered by touch.⁷ This could be from tight underwear, tampon insertion, routine cleaning of the vulva, sexual intercourse or tampon insertion.

Unprovoked vestibulodynia

Unprovoked, or spontaneous, vestibulodynia is when pain appears without touch to trigger it.^{7, 10}

Causes and risk factors

Genetic predisposition

Some studies have found that it is more likely for vestibulodynia to develop if there is a history of the problem in the family.¹¹ More research is needed to fully understand the link between genetics and vestibulodynia.

Hormonal factors

Some sources suggest that a reduction in oestrogen may cause vestibulodynia.^{12, 1} This reduction usually happens either after childbirth, during breastfeeding or around menopause.¹²

Infections and inflammation

Severe thrush has been linked to the development of vestibulodynia.³ In these situations, the thrush can be treated but the pain may continue as vestibulodynia.

People with allergies are more likely to have vestibulodynia, possibly due to the higher inflammatory response to environmental factors.¹³

There is evidence to show that people with autoimmune disease linked to higher cytokine (proteins that help manage the inflammation response in your body) production are more likely to have vestibulodynia.¹⁴

Psychological and social factors

Some other factors increase the risk of vestibulodynia. These include: 

• Anxiety
• Depression
• Catastrophising (thinking the worst will happen in every situation)
• Fear of pain
• Hypervigilance (constantly being on guard against bad things happening)
• Childhood sexual assault.¹⁵

Clinical presentation

Common symptoms of vestibulodynia

Pain 

People usually describe the pain as:

• Soreness
• Burning pain
• Throbbing pain
• A stabbing feeling

As mentioned above, the pain can be brought on by touch (provoked) or happen at random times (spontaneous).

Triggers 

The most common trigger is touch.¹

Due to this, it’s generally recommended to:

• Wear loose cotton underwear 
• When having sex, use lots of lubricant. Trying different positions can help to find the most comfortable one for you
• Use pads rather than tampons when menstruating
• Avoid stress as this can make vestibulodynia worse. See later in the article for more information regarding this¹ 

Impact on daily activities and quality of life

Vestibulodynia has significant effects on quality of life.¹⁶

It can affect many everyday things, such as:¹ 

• Avoiding scented soaps
• Avoiding baths, especially hot baths
• Avoiding swimming can affect a person’s sex life due to the discomfort caused
• It affects what menstrual products can be used
• It can affect what clothes people can wear

Psychological and emotional effects

People with vestibulodynia are more likely to suffer from depression and anxiety.¹⁵

It can also affect romantic relationships, as the pain can negatively impact the enjoyment of sexual contact,¹⁷ which can cause a relationship to suffer - especially if the symptoms last a long period.³

How is vestibulodynia diagnosed?

If you have symptoms that you think maybe vestibulodynia - or any other symptoms that cause pain around your vulva and vagina - you should seek help from your general practitioner. 

When you see your doctor, they will do some tests to try to find the cause of the problem and decide the course of treatment. These include:

Clinical history

Detailed pain history

Your doctor will ask:

• When the pain began
• Where the pain is (eg. at a specific part of your vulva or all over)
• How often do you get the pain
• How long the pain lasts
• If something brings it on (eg. touch) or if it happens by itself
• The severity of the pain

It is a good idea to write down when you get your symptoms, what caused them, and any other information that you think might be helpful for your doctor to know. It is sometimes difficult to remember these things off the top of your head, so having them in written form can help you remember.

Medical and sexual history

Your doctor will ask questions to try to narrow down what the cause could be.

Usually, your GP will ask if you have any other skin issues, for example, eczema, that could be causing the symptoms.

They will also ask about your sexual history to rule out sexually transmitted infections as a potential cause.

Physical examination

Your doctor will likely ask you to perform a pelvic exam, which involves looking at your vulva and vagina to check that they are healthy. You can request a female doctor and/or have someone you trust in the room with you during this procedure. If you are uncomfortable, you can request that the examination be stopped at any time.

Visual inspection

Your doctor will look at the vulva to try to see any signs of a rash, redness, infection, thrush, or other problem that might cause the symptoms you are having.¹

Cotton swab test

The GP will usually check to see which areas of the vulva are painful. They do this by gently touching a cotton bud to the skin to find which areas are sore.¹

They may also take a swab of the area to be assessed in a lab to rule out infection as a cause.¹

Pelvic examination

Your healthcare provider may perform a full pelvic exam.

This involves an inspection of the vulva, followed by a speculum (a smooth tool that’s inserted into the vagina to gently open it, giving the healthcare professional a view of your vagina and cervix) being used to examine you internally.¹⁸

The doctor or nurse will also insert gloved fingers into your vagina and, with their other hand, gently press down on your lower stomach. This lets them check the health of the uterus and other internal organs.¹⁸

Are there other diseases that may look like vestibulodynia?

Your doctor will want to rule out other problems that might be causing the problems.

Infections

Some infections, for example, thrush and certain sexually transmitted infections, can cause similar symptoms. Your doctor might take a swab of the area to be cultured and investigated to rule this out.¹

Lichen planus, chlamydia, and trichomoniasis can all be potential infectious causes of vaginal discomfort.²⁰

Skin conditions

Conditions like eczema or allergic response can cause discomfort around the vulva and vagina. Your GP will likely ask you about any history of skin problems you have had in the past to rule this out. 

Other pain syndromes

There are other syndromes which can cause pain that your doctor will need to rule out.

For example, vaginismus is a condition where the muscles in the vagina tense up when something is inserted into it which causes intense pain.¹⁹

Hormonal changes can cause pain when having sex. These changes can be triggered by breastfeeding, some contraception types, and childbirth.²⁰

Management strategies

There are many management options for vestibulodynia. Different techniques work for some people better than others, so it may take some experimentation to find the management strategy that works best for you.

Multidisciplinary approach

You may see several healthcare professionals who specialise in different medical fields so that you can get the benefit of expert advice and treatments from different areas. The people you may be referred to could include:

Gynaecologists

Gynaecologists are doctors who specialise in the reproductive organs of AFAB people. Your GP may refer you to a gynaecologist for further checks or to confirm the vestibulodynia diagnosis.³

Physical therapists

Physiotherapists are trained to help you recover physically from problems such as this.¹

Psychologists and counsellors

You may be referred for counselling, either psychosexual therapy (which is designed to help with sexual problems) or Cognitive Behavioural Therapy (CBT, more on this below).¹

Non-drug treatments

Pelvic floor physical therapy

You may be referred to a physiotherapist, who will talk you through exercises for the vaginal muscles (Pelvic floor). These will help you relax your muscles, which can help reduce pain.¹

Your physiotherapist may also provide you with vaginal trainers.³ These are tampon-shaped devices and are designed to gently widen and relax your vagina.¹

Cognitive-behavioral therapy (CBT)

CBT is a therapy which is designed to help you deal with problems by breaking them down into manageable parts, which allows you to break negative patterns.²¹

This can help with the depression and anxiety that can be caused by vestibulodynia, as well as helping with pain management.²¹

Drug P treatments

Topical agents

If your doctor suggests it, you can buy creams over the counter which numb the skin. These can be applied half an hour before intercourse to improve comfort during sexual situations.³ However, these creams cannot be utilised if a condom is being used as it can affect the protection given by the condom.⁷

Oral medications

Medications may be prescribed to help with vestibulodynia. The most common are: ⁷

• Pregabalin
• Gabapentin
• Nortriptyline
• Amitriptyline

Injectable treatments

For people whose vestibulodynia is caused by touch, injections of numbing medications or steroids at the site of the pain may be suggested.⁷

In rare cases, botox injections may be used to treat the pain.⁷

Surgery

If other types of treatment have been attempted but were unsuccessful, your doctor may suggest surgery to remove the painful part of your vulva.¹

Complementary and alternative therapies

Acupuncture

Some early studies suggest acupuncture may help when combined with other therapies like numbing creams.²² However, more data is needed on this before it is definitively proven.

Support groups and resources

Many support groups offer information and resources for people with vestibulodynia. Please follow the links below to find information on these groups.

• National Vulvodynia Association
• Vulval Pain Society
• International Society for the Study of Vulvovaginal Disease
• British Society for the Study of Vulval Disease

Challenges and future directions

Barriers to diagnosis and treatment

Some doctors may be unaware of vestibulodynia, which can lead to misdiagnosis. People who suffer from vestibulodynia report that they often have to attend multiple appointments before they are diagnosed, and that sometimes they have to do their own research or find a different doctor before they are diagnosed.²³

Cultural and sexual stigma can also play a part in a delay in diagnosis.²³ However, the same study shows that the time taken to get diagnosed is decreasing, so things do seem to be improving.

Conclusion

Vestibulodynia is a little-known problem that can affect anyone with a vulva. However, it can be treated and does not have to cause problems in everyday life.