Vulvodynia is chronic discomfort in the external female genitalia. Hormonal birth control is a common medication used for pregnancy prevention and other health concerns. While hormonal contraception does not cause vulvodynia in the majority of users, a recognized association exists for a subset of individuals experiencing new onset pain. This link is theorized to be related to the hormonal changes induced by certain birth control formulations, which can impact vulvar tissues and the body’s pain response.
Defining Vulvodynia and Its Symptoms
Vulvodynia is defined as chronic vulvar pain lasting three months or longer that has no identifiable infectious, inflammatory, or neurologic cause. It is considered a diagnosis of exclusion, meaning a healthcare provider must rule out other potential sources of pain, such as yeast infections or skin disorders. The pain can manifest in different ways, which helps clinicians categorize the condition.
The most common symptoms include a burning sensation, stinging, rawness, or throbbing in the vulvar area. The pain may be constant, or it may occur only during certain activities. Vulvodynia is broadly classified into two main types based on where the pain is felt and how it is triggered.
Localized vulvodynia, also known as vestibulodynia, is pain restricted to one specific area, most commonly the vestibule (the tissue surrounding the vaginal opening). This type is often described as provoked, meaning the pain is triggered by touch, such as during sexual intercourse, tampon insertion, or tight clothing. Generalized vulvodynia involves pain felt across multiple areas of the vulva and can be spontaneous, meaning it occurs without external pressure or touch.
The Hormonal Mechanism Linking Contraception and Pain
The specific type of birth control most strongly linked to the onset of vulvodynia symptoms is the combined oral contraceptive (COC), which contains both synthetic estrogen and progestin. These synthetic hormones interfere with the body’s natural endocrine function to prevent ovulation. The primary mechanism of concern is the suppression of naturally occurring sex hormones, particularly androgens like testosterone, which are necessary for maintaining vulvar tissue health.
The synthetic estrogen in COCs causes the liver to significantly increase its production of Sex Hormone-Binding Globulin (SHBG). SHBG binds to circulating sex hormones, including testosterone, with a high affinity. This process effectively lowers the level of free testosterone, which is the biologically active form that tissues can utilize. The resulting deficiency in free androgens can negatively impact the hormone-dependent tissues of the vulva.
Androgen deficiency can lead to changes in the vulvar tissue, specifically in the vestibule. This hormonal effect may cause thinning or atrophy of the tissue and a decrease in the function of vestibular glands responsible for natural lubrication. Furthermore, low androgen levels are suspected of causing an increase in the density of pain-sensing nerve fibers in the vulvar vestibule, making the area hypersensitive to pressure and touch. This combination of tissue fragility, decreased lubrication, and heightened nerve sensitivity is the theorized pathway through which COCs may contribute to the development of provoked vestibulodynia.
Diagnosis and Initial Management Strategies
Diagnosis of vulvodynia is a process of elimination, requiring a thorough medical history and physical examination to rule out other causes of vulvar pain. The healthcare provider will check for signs of infection or skin conditions, often taking a sample of cells for testing. The most definitive diagnostic tool is the cotton swab test, where a moistened cotton swab is used to apply gentle pressure to different areas of the vulva to identify the location and severity of the pain.
If the onset of pain is strongly associated with the initiation of a hormonal contraceptive, the first-line management strategy is generally to discontinue the suspected medication. This step aims to remove the hormonal trigger and allow the body’s natural sex hormone levels, including free testosterone and SHBG, to normalize. However, the resolution of symptoms after stopping the birth control is often gradual and may take several months.
Because the chronic pain state can involve nerve sensitization and muscle tension, additional treatments are often necessary even after hormone levels recover. Topical hormone therapy, such as estrogen or testosterone creams applied directly to the vulvar tissue, can be prescribed to locally restore tissue health and reverse atrophy. Other supportive treatments may include nerve pain medications, such as low-dose tricyclic antidepressants or anticonvulsants, to calm overactive pain signals. Pelvic floor physical therapy is also commonly recommended to address associated muscle tension that contributes to the pain.
Contraceptive Options That Do Not Affect Vulvar Health
For individuals who have experienced vulvodynia symptoms while using combined oral contraceptives, switching to an alternative birth control method is a practical next step. Non-hormonal options eliminate the risk of systemic hormonal suppression associated with vulvar pain. Barrier methods, such as condoms and diaphragms, are a safe choice for vulvar health.
The copper intrauterine device (IUD) is another highly effective, non-hormonal option that is generally considered safe for those with vulvodynia. Since it contains no hormones, it does not alter the body’s androgen levels or SHBG production. Hormonal IUDs, which release progestin locally into the uterus, are also often well-tolerated because systemic absorption of the hormone is significantly lower than with oral pills.
Progestin-only pills, sometimes called the mini-pill, are also an option to consider as they lack the estrogen component that drives the increase in SHBG. Even progestin-only methods can occasionally be problematic for some individuals, so any new contraceptive choice should be carefully discussed with a healthcare provider specializing in vulvar conditions. The goal is to find an equally effective method that minimizes the risk of hormonal side effects on sensitive vulvar tissues.