Pain With Sex? It Could Be Vestibular Vulvodynia

Pelvic pain, especially pain with sex, can be one of the most frustrating and emotional experiences. If you are grappling with unexplained pelvic pain - especially pain in the vulvar region at the opening of the vagina, you should know about vestibulodynia. Vestibulodynia is a form of vulvodynia, which is chronic pain affecting the vulva, or pain in the vulvar area that lasts for at least three months. In vestibular vulvodynia, the pain is focused at the opening of the vagina, which can make sex, pelvic exams, and even inserting a tampon extremely painful. Keep reading to learn more about vestibulodynia, how to know if you may have it, and what treatment options are available to help you become pain-free or manage the pain. 

What is vestibulodynia? 

Vestibulodynia is a type of vulvodynia, also known as vestibular vulvodynia or localized provoked vestibulodynia (LPV). It is a type of vulvodynia that specifically affects the vestibule region or the opening of the vagina.  There are three types of vestibulodynia - provoked,  unprovoked, and spontaneous. With provoked vulvodynia, the pain is brought on by contact to the area, or with insertion or attempted insertion of something in the vagina, such as a tampon, a pelvic exam, or during penetrative sex. With unprovoked, pain is present without contact or attempted penetration. Spontaneous vulvodynia is when pain occurs in situations without contact or insertion.

What causes vestibulodynia?

One of the most frustrating and confusing aspects of vulvodynia is that there is usually no one identifiable cause of the pain. "Vulvodynia by definition is vulvar pain lasting at least three months without an identifiable cause; however, we have identified associated factors that are likely causes, but require more research," says Dr. Jill Krapf, MD, Director of the Center for Vulvovaginal Disorders in Tampa, Florida.

"There is often more than one cause present, which makes it so complex to determine the diagnosis," says Dr. Krapf. But the good news is that there are specialists out there who are trained to help identify the causes of vestibular pain, she adds. 

Because there are so many factors that can contribute to vestibular vulvovaginal pain it’s important to rule out common conditions that could be causing symptoms, such as:

• Hormonal conditions: when hormones are disrupted (specifically estrogen and testosterone) it can affect vulvar tissue.  This could be due to certain conditions, birth control use early in life or for prolonged periods of time, breastfeeding or the perimenopause/menopause hormone shift.
• Dermatological conditions:   Different disorders of the tissue of the vestibule like Lichen Sclerosis, Lichen Simplex Chronicus, Lichen Planus or Vulvar Dermatitis should be ruled out.
• Infections:  Some of the infections most known to cause vestibular pain include Herpes, HPV, yeast infections, bacterial vaginosis or cytolytic vaginosis. You may find companies like Evvy useful in helping you and your doctor rule these conditions out. 

The main causes of vestibular vulvovaginal pain, according to the National Vulvodynia Association are: 

1. Pelvic floor muscle dysfunction: overactive pelvic floor muscles or pelvic floor hypertonicity means the muscles surrounding the vaginal vestibule can become tight and tender, contributing to the pain through a combination of weakness, spasms and instability.
2. Nerve-related: one nerve-related cause is known as Neuronal proliferation (NP), which is a condition that affects the density of the nerve endings in the vestibular tissue. Another nerve-related cause may involve injury to or irritation of pelvic nerves.
3. Abnormal vulvar cell response: This can happen to different types of vulvar cells when faced with environmental factors such as infection or trauma
4. Inflammation: increased levels of inflammatory substances in the vulva
5. Genetic susceptibility:  Some people have an increased susceptibility to chronic vestibular inflammation, pain or an inability to combat infection

How do I know if I have vestibulodynia? 

Although not all cases of painful sex are related to vestibulodynia, pain with penetrative sex, especially when the pain is concentrated at the opening of the vagina, is one symptom. 

Other signs and symptoms of vestibular vulvodynia can include:

• Severe pain with vaginal penetration or attempted penetration 
• Tenderness and redness at the vaginal opening (not present in all cases)
• Pain at the opening of the vagina that feels like stinging, burning, rawness, soreness, or even a sharp, stabbing pain 

Pain from vestibular vulvodynia can present several different ways; you can have pain that only happens when the vestibule is touched, that happens immediately, or comes on later, or happens and fades, or happens and stays.

Getting a diagnosis

"With vulvodynia, and specifically vestibulodynia, a thorough medical examination with an experienced clinician more consistently determines these causes," says Dr. Krapf.  "Unfortunately, there are not enough doctors that specialize in this condition and access is often a barrier to care," she adds. With this in mind, finding a specialist can be difficult, but it's not impossible. (You can refer to the resources section below for help finding someone who specializes in these conditions). 

"We are gathering clinical experience, doing much needed research, and sharing important information on diagnosis and treatment of these conditions through teaching to increase knowledge among clinicians, which will hopefully increase access. In time, the specific causes of chronic vulvar pain will be recognized, and more clinicians will be able to accurately diagnose these conditions. This will lead to better treatment," says Dr. Krapf.

How can I treat vestibulodynia?

Although it can be difficult to find an accurate diagnosis with vestibulodynia, the good news is that once you are diagnosed, a specialist can help you identify the cause of the pain and help you with a treatment plan. 

Treatment for vestibulodynia depends on the cause. But there are several different ways to treat it, and the chronic pain can become much more manageable. Treatment options range from oral medication, topical medications, surgery, and physical therapy (specifically pelvic floor physical therapy). "I often recommend pelvic floor physical therapy for my patients as a component of their treatment," says Dr. Krapf. 

Origin's physical therapists are experts in pelvic physical therapy, and can help you find a treatment plan that works for you. 

Dr. Krapf says that pelvic floor therapy is specifically helpful for those with overactive pelvic floor muscles, or tight, hypertonic pelvic floor. "Tight pelvic floor muscles lead to decreased blood flow to the muscles themselves as well as the overlying tissue of the vulva. This can lead to pain with vaginal insertion, redness of the tissue, tearing at the vaginal opening, burning during and/or after intercourse, as well as urinary and bowel problems," says Dr. Krapt.

Other treatments, like medications, depend on the causes identified by your doctor. "For example, if the pain is hormone-related due to perimenopause or use of an anti-androgen medication, a topical hormone cream or gel applied to the vestibule is a treatment option," says Dr. Krapf.

In addition to medical treatments, your doctor or physical therapist may also recommend exercises you can do at home, such as stretches that help relax the pelvic floor, or dilator therapy. Dilatators are devices that can be inserted into the vagina to help stretch and train the muscles to relax. A physical therapist can recommend dilators for you to use, and teach you how to use them at home. 

Don’t wait to get help

Don't forget, if you are suffering from vestibular vulvodynia or other forms of chronic pain, you're not alone. Origin's team of physical therapists are here to support you in every step of your journey to a life with less pain - book a visit today to get started with your treatment plan.

Additional Resources:

Here are some helpful resources to learn more about vulvodynia and vestibulodynia:

“When Sex Hurts: Understanding and Healing Pelvic Pain” written by four experts and researchers, Andrew Goldstein MD, Caroline Pukall PhD, Irwin Goldstein MD and Jill Krapf MD. 

Directories for finding care providers: Tight Lipped, National Vulvodynia Association (NVA) and the International Society for the Study of Women’s Sexual Health (ISSWSH)

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Sources Cited:

Paavonen, Jorma, and David A. Eschenbach. “Localized Provoked Vulvodynia—An Ignored Vulvar Pain Syndrome.” Frontiers in Cellular and Infection Microbiology, vol. 11, 17 June 2021, article 678961, https://doi.org/10.3389/fcimb.2021.678961.

Centers for Vulvovaginal Disorders. “Vulvar Vestibulitis.” Vulvodynia.com, Centers for Vulvovaginal Disorders, https://vulvodynia.com/conditions/vulvar-vestibulitis.

Cleveland Clinic. “Vestibulodynia: Causes, Symptoms & Treatment.” Cleveland Clinic Health Library, last reviewed 21 July 2022, https://my.clevelandclinic.org/health/diseases/23514-vestibulodynia.