The term vulvodynia literally means “painful vulva” (vulvo- meaning vulva, and -dynia meaning pain). It is a diagnosis of exclusion, meaning it is made only after all other possible causes of the pain, such as infections, skin conditions like lichen sclerosus, or neurological diseases, have been ruled out.

At its core, vulvodynia is now understood to be a neuropathic pain condition. This means the problem does not lie with the tissue itself, which usually appears perfectly normal, but with the nerves that supply sensation to that tissue. The nerve endings in the vulvar skin have become hypersensitive and are sending inappropriate or exaggerated pain signals to the brain.

A helpful analogy is to think of the nerves in your skin as a highly sensitive car alarm system.

• In a normal car, the alarm only goes off when there is a real threat, like someone trying to break in.
• In vulvodynia, the alarm system’s wiring has become faulty and hypersensitive. Now, even a gentle breeze, the light touch of clothing, or sometimes nothing at all can set off the full, blaring alarm, the pain signal. The pain is real and intense, but the “threat” is not proportional to the body’s response.

In recent years, the official medical terminology has evolved. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) now combines vaginismus and dyspareunia (painful intercourse) into a single diagnosis called Genito-Pelvic Pain/Penetration Disorder (GPPPD). This change acknowledges the complex interplay of pain, muscle guarding, and fear that often characterizes these conditions (American College of Obstetricians and Gynecologists [ACOG], 2022).

Vulvodynia is generally classified into two main types based on the location and nature of the pain:

• Generalized Vulvodynia: The pain is felt in different areas of the vulva at different times. It can be constant or intermittent, and it may occur spontaneously without any touch or pressure.
• Localized Vulvodynia (Vestibulodynia): The pain is confined to a specific area of the vulva. The most common form is vestibulodynia, where the pain is in the vestibule, the area of skin surrounding the opening of the vagina. This pain is typically provoked, meaning it occurs only with touch or pressure, such as from sexual intercourse, tampon insertion, a gynecological exam, or even prolonged sitting or wearing tight pants.

In my practice, vulvodynia is one of the most frustrating conditions for patients. Everything looks normal on the exam, but the pain is real and deeply life-altering.

The exact cause of vulvodynia is not fully understood. Rather, it is believed to be a complex puzzle resulting from an interplay of several different factors that lead to the development of nerve hypersensitivity and chronic pain.

Some of the leading theories and contributing factors include:

• Nerve Injury or Irritation: Damage or irritation to the nerves that supply the vulva can cause them to become overactive and fire spontaneous pain signals. This can result from childbirth, pelvic surgery, or even minor, unnoticed injuries.
• Pelvic Floor Muscle Dysfunction: The muscles of the pelvic floor, which support the bladder, bowel, and uterus, are often found to be overly tight (hypertonic) or in a state of spasm in women with vulvodynia. This chronic muscle tension can contribute to nerve irritation and pain.
• Genetic Predisposition: Some women may have a genetic makeup that makes them more prone to chronic inflammation or makes their nerves more susceptible to developing a chronic pain response after an injury or infection.
• A History of Recurrent Infections: While vulvodynia is not an active infection, a history of severe or recurrent vaginal yeast infections or other vaginal infections may “prime” the area. The chronic inflammation from the past infections may cause lasting changes in the nerve endings, leaving them hypersensitive even after the infection has cleared.
• Hormonal Factors: Some research has pointed to a potential link between hormonal changes or the use of low-dose combined oral contraceptives and the development of vestibulodynia in some women.

I’ve seen women blame themselves or think it’s “just in their head”, but vulvodynia is a genuine neurological condition, and your body is trying to protect you, even when it misfires.

It is important to dispel myths and misconceptions surrounding this condition. You do not “get” vulvodynia like an infection.

• It is not a sexually transmitted infection (STI) and is not contagious.
• It is not caused by poor hygiene. In fact, overly aggressive washing with harsh soaps can sometimes irritate the skin and worsen the symptoms.
• It is not a sign of cancer.
• It is not a purely psychological problem, although the chronic pain it causes can understandably lead to significant anxiety, depression, and emotional distress.

For most women, the condition appears to develop spontaneously without a single clear initiating event. It is a complex pain disorder arising from a malfunction in the body’s nerve signaling and pain processing systems.

Clinically, I often hear “It just started one day, and never went away.” That uncertainty can be incredibly frustrating, but it’s not uncommon with vulvodynia.

The primary symptom of vulvodynia is vulvar pain. However, the character, timing, and location of the pain can vary widely.

The pain is often described with a range of words, including:

• Burning
• Stinging
• Rawness
• Itching
• Aching or throbbing
• Sharp or knife-like pain

The pattern of the pain is what helps to define the type of vulvodynia:

• For Generalized Vulvodynia: The pain may be constant or may come and go. It can affect the entire vulva or move around to different spots, such as the labia, clitoris, or perineum.
• For Localized/Provoked Vestibulodynia: The pain is specifically at the vaginal opening and occurs only upon contact. Triggers include:
  • Painful Intercourse (Dyspareunia): Pain during or after attempted sexual penetration.
  • Tampon Insertion.
  • A Gynecological Exam.
  • Pressure from tight clothing or a bicycle seat.
  • Prolonged sitting.

What stands out is how deeply this pain affects a woman’s life, from intimacy to confidence. Many patients have seen multiple doctors before finally getting a name.

One of the greatest challenges for women with vulvodynia is accurate diagnosis.  Due to a lack of provider awareness, many women suffer for years and see multiple doctors before their condition is correctly identified.

The diagnosis of vulvodynia is a diagnosis of exclusion. This means a doctor must first rule out all other possible causes of vulvar pain. The diagnostic process, performed by a knowledgeable gynecologist or vulvar pain specialist, involves:

1. A Detailed Medical History: This is the most important part of the evaluation. A doctor will ask very specific questions about the nature of the pain, its location, what triggers it, and how it impacts your life and relationships.
2. A Thorough Pelvic Examination: The doctor will carefully inspect the vulvar skin to look for any visible signs of infection, skin diseases, or anatomical abnormalities. In classic vulvodynia, the vulvar tissue looks perfectly normal.
3. The Q-tip Test: This is a key test for diagnosing vestibulodynia. The doctor uses a moist cotton swab to gently touch different points around the vestibule, asking the patient to rate the pain at each point on a scale of 0 to 10. This can map the precise areas of nerve hypersensitivity.
4. Vaginal Swabs: Samples of vaginal discharge may be taken to be examined under a microscope or sent for culture to definitively rule out a yeast or bacterial infection.

I always emphasize that “normal results” are still useful. They confirm this is vulvodynia and help us move toward treatment instead of more tests.

There is no single “magic bullet” that cures vulvodynia., but most women find significant relief with multimodal therapy.

1. Vulvar Self-Care and Trigger Avoidance (The Foundation)

This is the first and most important step. It involves removing all potential irritants from vulva contact.

• Use only gentle, hypoallergenic, fragrance-free soaps or, preferably, just warm water to cleanse the area.
• Avoid all bubble baths, scented lotions, feminine hygiene sprays, and perfumed detergents.
• Wear loose-fitting, 100% cotton underwear.
• Use generous amounts of a high-quality, water-based lubricant for any sexual activity.
• Apply cool gel packs to the vulva to soothe burning pain.

2. Pelvic Floor Physical Therapy

This is a cornerstone of treatment. A physiotherapist specializing in pelvic health can be instrumental in recovery. They can:

• Teach you how to relax and release chronically tight pelvic floor muscles.
• Use biofeedback to help you gain conscious control over these muscles.
• Perform gentle manual therapy to release trigger points.

3. Medications

Medications can help soothe hypersensitive nerves.

• Topical Medications: A doctor can prescribe a compounded cream containing medications like amitriptyline or gabapentin that can be applied directly to the vestibule to block pain signals locally. Topical lidocaine ointment can be used to numb the area before sexual activity.
• Oral Medications: Low doses of medications typically used for nerve pain are often prescribed. These include tricyclic antidepressants (like amitriptyline), SNRIs (like duloxetine), and anti-seizure medications (like gabapentin or pregabalin).

4. Counseling and Sex Therapy

The psychological impact of vulvodynia is immense. Counseling or sex therapy is crucial for:

• Addressing the fear, anxiety, and depression associated with chronic pain.
• Developing coping strategies.
• Help couples navigate intimacy challenges and improve communication.

5. Other Interventions

For severe, localized, provoked vestibulodynia that has not responded to other treatments, procedures like nerve blocks or a surgical procedure called a vestibulectomy may be considered as a last resort.

I’ve seen the best results when treatment is personalized, sometimes physical therapy is the game-changer, other times it’s topical meds and counseling combined.

Vulvodynia is a real and often debilitating chronic pain condition that can profoundly affect a woman’s physical comfort, emotional well-being, and intimate relationships. It is essential to cast aside the outdated and harmful notion that this pain is psychological or “in your head.” Vulvodynia is a complex neuro-inflammatory disorder, and you are not alone in your struggle. While the path to diagnosis and treatment can be long, it is a journey worth taking. A correct diagnosis from a compassionate provider is the first step toward validation. What I always tell women is this: your pain is real, and you’re not alone. With the right care, I’ve seen patients go from avoiding intimacy and daily activities to living fully again, pain-free and empowered.

American College of Obstetricians and Gynecologists (ACOG). (2022). When Sex Is Painful. Retrieved from https://www.acog.org/womens-health/faqs/when-sex-is-painful

National Vulvodynia Association. (n.d.). What is Vulvodynia? Retrieved from https://www.nva.org/what-is-vulvodynia/

International Society for the Study of Women’s Sexual Health (ISSWSH). (n.d.). Genito-Pelvic Pain/Penetration Disorder (GPPPD). Retrieved from https://www.isswsh.org/resources/public-education/gpppd