Vulvovaginal Pain

What are some of the causes of vulvovaginal pain?

There are many problems that cause or contribute to vulvovaginal pain. These can be divided into 2 categories – 1) skin conditions and 2) nerve and muscle conditions.

Skin conditions that may cause vulvovaginal pain: (*see Information sheets):
Lichen sclerosus*
Erosive and hypertrophic lichen planus*
Psoriasis*
Acute and chronic dermatitis*
Plasma cell vulvitis / desquamative inflammatory vaginitis*
Rashes due to medication reactions
Vulvovaginal candidiasis (thrush)*
Herpes simplex virus
Shingles = varicella zoster
Problems relating to human papillomavirus (HPV)*


Nerve and muscle conditions affecting the vulva and pelvic floor muscles:

Bowel problems like chronic constipation or irritable bowel syndrome
Bladder problems like painful bladder syndrome or recurrent urinary tract infections
Chronic back pain or sciatica
Problems with the spine, hips, knees, or feet
Overactive pain nerves in the vulval or vaginal skin
Repetitive strain injuries to nerves or muscles
Previous sexual trauma or injury
Having sex if not aroused or if already in pain*
Previous pelvic or vaginal surgery or injuries
Childbirth and pregnancy
Previously treated skin problems

 

What is vulvodynia and how does it relate to vulvovaginal pain?

The word ‘vulvodynia’ means vulval pain or discomfort – ‘odynia’ is Greek for pain. Vulvodynia usually refers to vulval pain lasting more than 3 months that is NOT due to a skin condition or some other specific diagnosis. For example, if the pain is due to a medication reaction and gets better once the medication is stopped, that is NOT vulvodynia. Health care professionals often use the word ‘vulvodynia’ to refer to dysfunctional overactivity of pain nerves with these excessive pain signals making their way through the spinal cord to the brain. The pain experience of vulvodynia is different for different people. The pain may come and go or may be constant. In some people it occurs only with touch or pressure, while others feel it all the time. It might occur only during or after sex. Some people’s pain starts in childhood, while others develop pain later in life. Over a lifetime, at least 1 in 5 or 20% of people with a vulva will experience pain there. Some people with vulvodynia also have abdominal and pelvic pain. Causes of chronic abdominal pain are often different to causes of vulvovaginal pain, but sometimes there is overlap. Treatment options depend on the reasons for the pain, but most people can find treatments that work for them and improve their quality of life.

 

What will happen if I bring this up with my doctor or nurse?

It is important to discuss vulvovaginal and sexual pain with your doctor or nurse. If you bring it up while seeing them for another issue, they may book a longer appointment with you in future. They need to ask a lot of questions about your experience of the pain, products you have used on the vulva, issues with your bowels and bladder, skin problems, your medical problems and previous surgeries, past accidents and injuries, your job and hobbies, and your sexual life.

The examination for vulvovaginal pain can involve lots of different steps and depends on your symptoms. The doctor or nurse might look at your posture and how you walk and sit. They might ask you to bend forward to look for curves in your spine. They may press on your hips, back, or abdomen to see if there is pain to light or deep pressure. They look carefully at the vulval skin. Skin tests may include a swab, scrapings, or biopsy (see Biopsy). They might use a cotton bud to gently press at the base of the hymen and ask you to score the discomfort (see Vulval anatomy). A speculum examination allows them to see if the vaginal skin and discharge looks normal. Depending on the location and severity of your pain, you and your doctor may choose not to do this. An internal examination allows them to check if skin and muscles are tender or overactive. They may also press on the lower abdomen while examining internally check the pelvic organs.

 

What are some of the treatments for vulvovaginal pain?

Good vulval care practices are an important part of treating vulvovaginal pain (see Vulval care advice). This includes regular use of a soothing ointment or oil on the vulval skin. People should avoid sexual practices that cause pain, and instead work on being intimate in ways that are comfortable (see Painful sex).
Constipation and irritable bowel syndrome are extremely common in people with vulvovaginal pain. Both can be improved with a combination of strategies: drinking at least 2L of water throughout the day, eating fibre-rich foods, doing some physical activity every day, and going to the toilet when you have the urge. A daily fibre supplement is helpful for many people. Certain foods, drinks, and substances can be irritating to the bladder and bowel. Common irritants include tobacco smoke, alcohol, coffee, tea, chocolate, citrus fruit, spicy food, artificial colours and sweeteners, and processed meats.

 

Treatments for skin problems

Many skin problems are treated with corticosteroid ointments. Your doctor or nurse should tell you where and how often to place these. They will see you again to make sure the skin has improved and discuss if you need to use them long-term. Sometimes, a person who has never examined your vulva and has no medical training in this area will make a comment about your use of steroid ointment on the vulva. Their opinion is not helpful and might be harmful. Instead, talk with your vulval specialist about how you are going with your treatment.

Some skin problems do not need steroid ointments, and instead can be treated with antifungals, antibacterial tablets or creams, or antiviral tablets. Sometimes it is necessary to take a biopsy or remove an area of concern. Some people with skin conditions also have nerve and muscle problems, so both issues need treatment in order to feel better.

 

Treatments for nerve and muscle problems

Sometimes the nerve and muscle problem is mostly due to a single issue like a hip injury or the legs being different lengths. Fixing that problem can make all the other pain better. This might mean going to a health care provider specialised in that area, like a podiatrist, an orthopaedic surgeon, a neurosurgeon, or a rheumatologist. Some people have pain that affects most of their body, like fibromyalgia. Any improvement in generalised pain tends to help people with their vulvovaginal pain. This usually requires working with your GP and members of a pain team like anaesthetists, psychologists, exercise physiologists, and physiotherapists.

Nerve and muscle pain often responds to a nerve-modulating medication. These include tablets like amitriptyline, gabapentin, pregabalin, and/or duloxetine. Some people do well with low doses, but others need higher doses or combinations of medication. For some these medications are temporary, but others find they need them long-term – that is OK. It is NOT a good idea to use opioid medications (codeine, oxycodone) for chronic nerve and muscle pain. These narcotic medications have many serious side effects, do not improve function or quality-of-life, require bigger and bigger doses to get an effect, and pose a risk of addiction.

Pelvic floor physiotherapy is one of the most helpful strategies for people with vulvovaginal muscle and nerve pain. A pelvic floor physiotherapist has extra training and experience in this area – they are a ‘personal trainer’ for your vagina and pelvic floor. They figure out which muscles and nerves are causing your problems, and then teach you how to stretch and relax those areas. They also can help you learn to use vaginal dilators/trainers to gain comfort and confidence in vaginal function. There are on-line resources about pelvic floor relaxation exercises for women with pelvic pain. Be aware that basic ‘pelvic floor exercises’ or ‘Kegel exercises’ are NOT the same as pelvic floor physiotherapy. ‘Kegel exercises’ are used to strengthen and tighten the pelvic floor – this can make the pain worse.

 

Should I see a psychologist or a sexual counsellor?

Vulvovaginal pain is usually due to a skin issue or a nerve/muscle issue, but it also has a big impact on your mental health, your relationships, and your sexual life. Chronic pain can make people feel depressed, anxious, and angry. Psychologists and sexual counsellors help patients work through these issues to speed recovery. They can talk with you on how to have sex in ways that are comfortable and fulfilling. For some people, pain makes them feel like they are not ‘normal’, not a ‘real woman’, or might never have a happy sexual life. Psychologists and sexual counsellors are experienced in issues of self-confidence, self-acceptance, healthy sexuality, gender identity, and recovery from previous trauma.

 

Should I get a laparoscopy?

Laparoscopy is a surgical procedure done under general anaesthetic and involves placement of sharp instruments (trocars) into the abdomen. A camera is used to look around the abdomen and pelvis to see if there is anything to explain the symptoms. When gynaecologists do this, they primarily are looking for endometriosis. If the surgeon sees areas that look like endometriosis, they take biopsies, remove, or burn them. Endometriosis was traditionally defined as glands from the lining of the womb being located outside of the womb. However, it is better thought of as a complex condition that involves a combination of inflammatory, genetic, hormonal, and other pathways that behaves differently in each individual.
It is important to realise that many people with endometriosis do NOT have pain. Many people with pain do NOT have endometriosis. Some people with pain have endometriosis AND other reasons for pain. So, finding out if endometriosis is or isn’t there may not provide the answers people want. For example, if pain is due to a skin, nerve, or muscle condition, laparoscopy cannot see this.

Many people with sexual pain or chronic pelvic pain have been told to have a laparoscopy. It is important that your doctor checks the vulval skin and does a pelvic examination BEFORE they advise a surgery like laparoscopy (see Vulval anatomy and Pelvic anatomy). They should also discuss various strategies and treatment options to help with your pain. If you have not had a thorough examination and discussion of treatment options, you could seek out a second opinion from an expert in vulval conditions or chronic pain. They might find reasons for the pain that can be treated with medications or physiotherapy. If these treatments improve symptoms, then the risks of surgery and general anaesthetic might be avoided.

 

What if I started treatment but am not getting better?

Vulvovaginal pain is complicated and often due to more than one cause. Keep doing your treatment even if it doesn’t seem to work straightaway, because it might just be a matter of time. Keep making efforts to improve your general health and do any exercises provided by your physiotherapist. See your doctor again for a review. It is common to feel frustrated when improvements seem slow or plans change over time, but this happens a lot when treating vulvovaginal pain.

Some people benefit from getting an opinion from another doctor, like a pain specialist. Resources like the Pain Toolkit (www.paintoolkit.org) and Explain Pain (www.explainpain.org) help us to understand pain and how to overcome it. Even though it can be hard, nearly everyone with chronic vulvovaginal pain can identify the main causes, find helpful treatments, and improve their function and quality of life.