Pain 'down there': the different causes and when to seek help

Many of us aren’t used to talking about our vulvas and vaginas. In fact, many women don’t know the difference between the vulva and the vagina. So if you’re experiencing pain in either of these areas, it’s important to start with the basics and learn which body part is which.

The vagina is the internal tube that connects the uterus (womb) to the outside of the body, while the vulva is the general name given to the outside parts of the female genitals.

The vulva includes the inner and outer lips (labia), the clitoris, the urethral opening (where your urine/wee comes out) and the vaginal opening.

Jean Hailes gynaecologist and medical director Dr Elizabeth Farrell says pain can be experienced in either the vulva or the vagina, or both.

If your pain is located outside the vagina and/or vulva, but still within the pelvic region (the area below your belly button and above your legs), you might find this article on pelvic pain helpful.

For now, let’s look at some of the common causes of vaginal and vulval pain, how to tell them apart, what you can do about them and when you need to seek further advice.

Vulval irritation
The symptoms of vulval irritation include itching, discomfort and/or burning pain. The skin of the vulva is very sensitive, so irritation of this part of the body is very common. Common causes of irritation include sweating, wearing tight clothing, eczema/dermatitis, personal hygiene issues, product allergies, infections and skin conditions such as lichen sclerosus (more on these conditions below).

Read more: Older Aussies at increasing risk of STIs

Dr Farrell says that when the vulval skin is irritated, it can look reddened, swollen or split, and there can also be associated vaginal discharge or inflammation.

“But even though vulval irritation is common, it is important to see your GP,” says Dr Farrell. “She or he needs to examine you and check your vulva to make the diagnosis.”

Often, vulval irritation can be managed by making simple changes and practising good vulval care, but the treatment depends on the diagnosis.

Infection
A range of infections can affect the vulva and/or vagina, causing pain and sometimes a feeling of heat.

Candida, also known as ‘thrush’, causes inflammation and swelling of the vulva, itchiness and often a white cottage cheese-like discharge. And while candida is a common infection for women, Dr Farrell wants all women to know that not all itch is thrush, so see your GP for a proper diagnosis, rather than managing it on your own or with over-the-counter medications.

Bacterial vaginosis (BV) is another common infection. It causes a watery, white or green/grey vaginal discharge, a strong fishy odour and sometimes vulval or vaginal pain.

STIs that cause pain
Sexually transmissible infections (STIs) such as gonorrhoea, chlamydia, trichomoniasis and herpes can cause vulval and/or vaginal pain.

However, some STIs are not only painless (at first), but can have no symptoms at all, says Dr Farrell.

Read more: It’s time to talk about herpes

“It’s very important to know that some STIs such as chlamydia can be silent with no symptoms,” she says. “If left untreated, the infection can develop into a condition called pelvic inflammatory disease, which can cause vaginal and low pelvic pain and lead to permanent damage of the reproductive system and infertility.”

Remember, many STIs are easily treated with medication, so get sexual health check-ups regularly, or when you have a change in partners and remember to practise safe sex.

Vaginismus
Vaginismus is when the pelvic floor muscles tighten excessively and narrow the lower vagina. It is linked to painful sex, and sometimes an inability to have any sexual penetration, says Dr Farrell.

“Women with vaginismus can also experience pain with using tampons or menstrual cups, or they may not be able to use them all,” she says. “Additionally, vaginal examinations by a doctor for cervical screening tests are extremely painful or unable to be performed.”

This condition can be complex, often needing treatment by a team of specialists (called a multidisciplinary team), including an empathetic GP, a pelvic floor physiotherapist (to teach a woman how to ‘release’ her overactive pelvic floor muscles) and a psychologist.

Vulval/vaginal dryness
Dryness can occur at any stage of life, but is especially common after menopause due to a drop in levels of the hormone oestrogen. Vaginal and vulval tissues can become thinner, drier and more susceptible to damage and irritation.

“After the menopause, lubrication may not occur naturally and sex may feel like ‘sandpaper’,” says Dr Farrell. “A decrease in lubrication can also be due to other hormonal changes such as breastfeeding.”

She suggests using a good-quality personal lubricant that can be bought at supermarkets and pharmacies (not petroleum jelly, which can damage condoms and dams), but to see your GP if the pain continues or gets worse.

Vulvodynia
The pain of vulvodynia is often described as a burning pain or discomfort in the vulva. It can be located in one area or across the whole vulva.

In vulvodynia, the pain cannot be linked to a specific cause. It may or may not be triggered by touch. ‘Provoked vulvodynia’ means the pain occurs with touch, such as inserting a tampon or attempting sex, whereas ‘unprovoked vulvodynia’ means the pain is there all the time.

Dr Farrell says it’s important to know that women with vulvodynia have a normal-looking vulva – that is, there is no sign of irritation, inflammation or disease.

Vulvodynia is a chronic pain condition that can last for months or years, but can often be treated with a multidisciplinary team of health professionals.

Lichen sclerosus
Lichen sclerosus most often affects the skin around the vulva and also the anus. It can occur at any age, but most commonly affects postmenopausal women.

Patches of skin in affected areas can look white, thickened and crinkly, and can feel itchy and painful.

The condition can cause permanent changes to the vulva, such as the shrinking and disappearance of the labia minora (the inner lips), which is known as adhesion.

Exactly what causes lichen sclerosus is unknown, but researchers think it is probably an autoimmune disease (where the immune system mistakenly attacks your own body).

Women with lichen sclerosus have a small increased risk of vulvar cancer, so this condition needs lifelong monitoring.

Key advice for women with vaginal or vulval pain
You don’t have to suffer in silence. If you are having pain in this part of your body, or in any part of your body, there is nothing to be embarrassed or ashamed about. Pain can be a bit like a messenger – gaining our attention to tell us there might be something wrong – so it’s important to listen and work out what your body is trying to tell you.

Get an expert opinion. Vaginal and vulval pain can range from mild to severe, can be temporary or longer lasting, and can be caused by wide range of conditions – from the not-so serious to the serious. The important thing is to visit your GP. They will need to examine your vulva and vagina to correctly diagnose your condition. This will ensure you get the correct treatment.

Read more: The big ‘O’ and ageing

If you don’t feel heard by your current GP, or you don’t feel comfortable with him/her, you might benefit from finding a women’s health clinic (such as Jean Hailes), a gynaecologist or sexual health clinic with specialist knowledge in this area.

Know what’s normal for you. Being familiar with your own body makes it easier to tell if something isn’t right and you need to seek extra help. Remember that everyone’s body parts are different – there is no ‘normal’. From our faces to our hands, to our sexual organs – we’re all unique, so get to know what’s normal for you!

Be wary of home remedies. It can be tempting to look online for solutions to help deal with our intimate body parts, but it’s important to try to get health advice and information that is based on evidence and comes from a reliable source. Avoid douching or steaming. Be well informed before applying non-medical treatments to the vulva or vagina. Your doctor may suggest some specific over-the-counter products from the chemist to use.

Know that help, support and treatment are available. Vulval or vaginal pain can be complex. It can impact many areas of life; from our self-esteem, our ability to move freely and use tampons or menstrual cups, to our sex life and relationships. Getting specialist care from a health professional where appropriate (e.g., skin specialist, pelvic floor physiotherapist, psychologist or sex therapist) can make a real difference.

Do you have a good GP you are comfortable seeing for such issues?

This article was first published by Jean Hailes and is reproduced with their permission.

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Written by Jean Hailes



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