By Nicole Guappone

Getting it on feels good, but only once you “get it in.” Does this sound familiar? Maybe you get a burning/tearing feeling that dissipates after you get going. Maybe it doesn't get better as you continue. Maybe it's painless at first, but starts to hurt over time.

There is a pervading myth that this is normal—that it always just hurts at first. This pain (which can feel burning, stabbing, or tearing) is incredibly common but shouldn’t be expected or tolerated.

Pain experienced upon penetration—felt at the entrance of the vagina or just inside—is called superficial dyspareunia. 

There are a number of reasons why you might experience this pain and we spoke to Dr. Jill Krapf, director of the Center for Vulvovaginal Disorders in Florida, about what might be causing it and what might help. 

What is vestibulodynia?

In its plainest sense, vestibulodynia means entry pain! Pain in and around the vestibule (opening) of the vagina. But when it comes to medical diagnoses, vestibulodynia has a slightly different meaning. Long considered idiopathic or “without discernible cause,” vestibulodynia is a type of vulvodynia (vulvar pain). 

According to Pelvic Pain Explained by Stephanie A. Prendergast and Elizabeth H. Akincilar, vestibulodynia is a “diagnosis of exclusion.” This means that any other causes—such as infection—are first ruled out, but if symptoms persist, the patient is given a “descriptor diagnosis,” which simply describes the diagnosis. In this case, pain in the vestibule. 

It can be really frustrating to receive a diagnosis like this because it just confirms what you already know—you have vestibular pain. And it doesn’t have specific, one-size-fits-all treatment protocols. Treatment for pelvic pain varies greatly because it can have many different causes: neurological, musculoskeletal, or hormonal. And these causes may overlap—meaning there are multiple treatment paths involved. It often takes a team of professionals to help treat pelvic pain but don’t be discouraged—identifying your pain is the first step. 

Causes of vestibulodynia 

Hormones 

You didn’t think we’d discuss a potential reason for a difficult diagnosis without talking about hormones, did you? Everyone’s hormones cycle and shift and this is especially true for those with a menstrual cycle. Not only do our hormones shift throughout the menstrual cycle, but as we move into perimenopause and menopause, even more shifts happen. In the absence of musculoskeletal issues (discussed below), it may be a “lack of estrogen and testosterone to the glands in the vestibule that produce natural lubrication and keep the area healthy” that is leading to entry pain, says Dr. Krapf. 

Decreased levels of estrogen and androgens lead to tissue thinning and irritation of the vestibule. These more dramatic changes in hormones can occur with menopause, perimenopause, postpartum, breast/chestfeeding, irregular periods, or with medications that cause similar side effects, such as birth control pills and spironolactone, which is used for acne. And remember when Dr. Bahlani taught us that antihistamines can lead to vaginal dryness and discomfort? Medications, life stages, and other conditions absolutely affect our bodies, so if you have entry pain and take meds or are menopausal/perimenopausal, this could be a contributing factor. 

Gender affirming care

Folks who are on hormone replacement therapy for gender affirming reasons may also experience pain with penetration. Similarly, some folks who have gender affirming surgery like a vaginoplasty may have pain with penetration due to the nature of the neovagina that doesn’t self-lubricate and will require vaginal dilation to maintain the size and health of the vagina post surgery.

Superficial muscle tension

Superficial muscles are those just under the surface of the skin and Dr. Krapf says tightness at the bottom of the vaginal opening is very common. The entire pelvic floor, including this spot (the transverse perineal muscle and the bottom portion of bulbocavernosus), is prone to tension due to stress, poor posture, certain exercises—even just from sitting on a hard surface for too long because these muscles are so superficial. 

Tender, tight, or restricted muscles in the superficial pelvic floor can hurt to touch—plus, there may be increased nerve sensitivity caused by dysfunction in the deeper pelvic floor muscles (like the levator ani muscle group), resulting in perceived pain in the vestibule. But we'll talk more about that in the next section!

If you have tension here (most of us do, even if we don’t realize it!), Kiwi could be a helpful addition to your toolkit. Massaging the muscles and fascia (connective tissue) in the superficial pelvic floor and surrounding structures may help reduce tenderness. Plus! Vibration has been shown to encourage blood flow and relaxation of muscles, but it can also be used to desensitize the area to ease pain.

Dr. Krapf said the most common reason for vestibulodynia is a combination of hormonal issues and superficial muscle tension, but they aren’t the only reasons you may develop vestibulodynia. 

Neuro-proliferation 

Some are born with it—some develop it over time! 

Inflammation from infection, allergies, or a dermatological cause can cause pain—but long term inflammation can actually lead the nerves to become more “active” or sensitized. We’ll discuss nervous system sensitization more below. 

Research is ongoing, but studies suggest that some people are simply born with an increased vestibular nerve density. 

According to Dr. Krapf, a special examination is needed to detect these conditions. “That involves…

• A neurosensory examination (cotton swab test)
• Vulvoscopy (examination of the vulva using a microscope)
• Evaluation of the pelvic floor muscles and nerves
• Looking at vaginal cell samples to rule out an inflammatory vaginitis (which is inflammation without evidence of the usual causes)

Pudendal Neuralgia

The pudendal nerve provides sensation to (innervates) the external genitalia, skin of the perineum (the area between the genitals and anus), and around the anus. Pudendal neuralgia is a chronic pelvic and perineal pain that can be caused by a number of things, including: injury, giving birth, and periods of prolonged pressure from activities such as horseback riding or cycling. Sometimes it isn’t known what causes this, but it can lead to pain with penetration. 

Peripheral + Central Sensitization

Neuromuscular impairments like pudendal neuralgia and chronic pain conditions in general “actually have the potential to modify the way our brain and spinal cord work. . . this phenomenon is called ‘central sensitization.’ A sensitized nervous system not only makes people more sensitive to things that should hurt, but also things that should not, like ordinary touch and pressure, for example” (Prendergast et al). 

Some good news? There is research being done on using vibration to desensitize a sensitized nervous system. 

Vulvar dermatoses 

Vulvar skin conditions like lichen sclerosus and lichen planus can cause pain with penetration. These are autoimmune skin conditions that affect 1-3 percent of people with vulvas, according to The Vagina Bible by Dr. Jen Gunter. Lichen sclerosus only affects the vulva, so it will stop at the vestibule (exactly where that pain we’re talking about is located!), but lichen planus can involve mucosa more broadly, so it can affect both the vulva and vagina. While lichen planus is less common than lichen sclerosus, it’s also possible to have both at the same time. 

Get to know the skin around your vulva! If you know what you look like down there on an average day, you will be more likely to recognize if something looks off. Lichen sclerosus can cause the skin to become white and thin, for example, or even shiny. Lichen planus does not have this same cosmetic effect, but if you are experiencing pain and don’t see any changes to your vulva, it’s still important to have this pain examined by a doctor.

Vestibulitis and vaginitis

A yeast infection or BV (bacterial vaginosis) that keeps popping up or doesn't seem to go away can cause inflammation in the vaginal opening. This is called vestibulitis. Seeking out care from a doctor to get these infections treated is a great next step. Sometimes it can be difficult to effectively treat recurrent/persistent infections via traditional, front-line methods. That's why it's always a good idea to go to a specialist like Dr. Krapf for vulvovaginal pain. If seeking out a specialist is out of reach, using a vaginal microbiome testing company (like Evvy) may give you a better idea of whether chronic infections are the culprit behind your vestibular pain.

Desquamative inflammatory vaginitis is also a potential cause of vestibular pain. These big scary words just mean inflammation of the vaginal area that isn’t caused by infection. Experts aren’t sure of the exact cause of DIV and, while it is rare, it seems to be more common in women and AFAB folks who are nearing menopause or who have had their ovaries removed. If you’re a trans or nonbinary individual who has undergone surgical and/or hormonal transition, this is also a possibility. DIV is treated topically with antibiotics or steroids. Since we still don’t know much about DIV, clinicians will try one or a combination of different topical treatments. 

If I have vestibulodynia, what do I do now? 

First line of action should always be to see a professional. One of the reasons treating vestibulodynia is difficult is because diagnosis is often delayed, according to Dr. Krapf. “Everything looks ‘normal’ to the naked eye and identification of these conditions requires a more specialized examination or testing.”

Furthermore, “not all doctors, even doctors trained to diagnose and treat the vulva and vagina, are well-trained in vulvar pain and skin conditions.”

The good news is, there are practitioners like Dr. Krapf who specialize in vulvar pain and skin conditions. She says, “they may be labeled as vulvar pain specialists or sexual medicine practitioners.” These specialists may include gynecologists, urologists, dermatologists, women’s health nurse practitioners, and certified midwives. If you need help finding an appropriate clinician near you, you can find a list of different types of providers here. Feel free to fill out the Pelvic Pain Assessment while you’re there so you’ll be prepared for your visit!  

First-line considerations for vulvar pain include evaluating what is coming into contact with your vulva to limit irritants and allergens. “However,” Dr. Krapf says, “it is also important to question why the vulvar skin and vaginal microbiome is not protecting itself, which may be related to hormonal, muscular, and skin barrier reasons.” 

Potential therapies for entry pain

• Devices like vaginal dilators, wands, and Kiwi are designed to help release tension and increase blood flow into the pelvic floor muscles. These help the muscles become more functional, as well as help the overlying tissue become more healthy. 
• Entry pain related to tight pelvic floor muscles is often addressed with pelvic floor physical therapy.
• For vulvovaginal dryness, the first-line approach is using a vaginal or vulvar moisturizer day-to-day and using a lubricant with insertion.
• If there are concerns about pelvic floor muscles, gentle yoga-based stretching exercises can be helpful.

“Beyond this,” Dr. Krapf says, “it is best to see a clinician with experience in chronic vulvar pain conditions to figure out what is going on and set up a good treatment plan. There are causes of vestibulodynia and there are treatments that work.” 

You are not alone—vestibulodynia and entry pain are common, but should not be tolerated or normalized. Don’t grit your teeth and hope it goes away. It may take some effort but we’re here to support you along the way.