Endometriosis and Vulvodynia: When Sexual Pain Occurs in More Than One Place

Sexual pain can be part of living with endometriosis. When we talk about it, we often focus on pain felt internally, deep within the pelvis. But vulvar pain and pain at the vaginal entrance can also coexist with endometriosis and may need their own assessment [1].

Understanding where pain occurs helps explain why one diagnosis may not account for every symptom. Here is a closer look at a less discussed topic: vulvodynia.

What is dyspareunia?

Dyspareunia is the medical term for pain during or after sexual intercourse. Describing its location helps distinguish different experiences:

• Deep dyspareunia is pain felt deeper within the pelvis, usually with deeper penetration. Endometriosis is one possible cause [1].
• Superficial or entry dyspareunia is pain around the vulva or vaginal opening when penetration begins. Provoked vestibulodynia is one possible cause [1] [2].

These patterns can overlap. Someone may experience both deep pelvic pain and tenderness at the entrance, so asking about each location matters [1].

What is vulvodynia?

Vulvodynia means vulvar pain lasting at least three months without a clear identifiable cause. The vulva is the external genital area, including the labia and the tissue surrounding the vaginal opening [2] [3].

The pain may feel like burning, stinging, soreness, or rawness. It can affect a specific area or be more widespread, and may occur spontaneously, with contact, or both [2].

Provoked vestibulodynia, often shortened to PVD, is a localized form affecting the vestibule: the area between the inner labia containing the urethral opening and vaginal entrance [2] [3].

With PVD, touch, pressure, or penetration can trigger pain at the entrance. This may happen during sexual activity, tampon insertion, or an examination [2].

PVD and deep dyspareunia therefore describe different pain locations. Neither description alone establishes the underlying cause, and both can occur in the same person [1] [3].

How is it assessed?

Assessment starts with a conversation about the pain: where it occurs, how long it has been present, and whether touch or penetration triggers it. A clinician also considers other possible explanations for vulvar pain [2] [3].

One assessment tool is the cotton-swab test, sometimes called the Q-tip test. With your consent, a clinician gently touches different points around the vestibule with a cotton-tipped applicator. You describe whether each touch hurts, helping identify where the tissue is tender [3]. The test supports assessment, but a painful response alone does not confirm PVD [2] [3].

What do we know about the overlap?

A study of 129 patients attending a specialist pelvic-pain service compared 42 participants with PVD against 87 without it. Those with PVD had approximately 12 times the odds of severe superficial sexual pain, four times the odds of severe deep sexual pain, and 4.4 times the odds of poorer sexual quality of life. However, these results cannot establish how common PVD is among patients with endometriosis [3].

Could nerves and immune cells help explain the connection?

One idea researchers are exploring is the neuroproliferative framework. In simple terms, this means increased local nerve growth. Studies found increased nerve fibers around endometriosis tissue and in vestibular tissue affected by PVD compared with control tissue. This may contribute to sensitivity and pain with contact.

Mast cells may also be involved. These immune cells release signals that influence inflammation. Researchers are investigating how mast cells, other immune cells, and surrounding tissue may interact with nerve growth factor, a protein that supports nerve growth and can also contribute to pain sensitivity. This proposed framework nevertheless needs further confirmation [1].

The takeaway

Deep pain and entry pain can coexist. If you have endometriosis, experiencing burning or tenderness around the vaginal opening deserves attention too. Tell your healthcare professional where it hurts — those details can help you get care that considers the full picture.

If pelvic pain is affecting your life, our Pelvic Floor PT Directory can help you find a pelvic health physical therapist, and our Mentorship program offers peer support from people who understand. Mentorship is peer support only — not medical advice, diagnosis, or treatment.