Vulvodynia is a blanket term for “pain of the vulva” and not a real diagnosis that actually specifies the root cause of pain. It can have many different causes, including pelvic floor dysfunction, infections, lichen sclerosus, hormonal imbalances, pudendal neuralgia and others. It is a complex and debilitating condition, characterized by vulvar pain lasting at least 3 months that manifests as intense burning, stinging, stabbing, rawness, soreness, itching, and/or other painful sensations. It is often described as “having acid poured on my skin” and “a constant knife-like pain”, and varies between constant pain or pain only with pressure / contact (e.g., sexual intercourse) (1). As many as 16% of women in the U.S. suffer from vulvodynia at some point in their lives (2) and its healthcare costs are estimated to be $102 to $117 billion dollars annually in the U.S. (3). It is strongly linked to increased rates of depression, anxiety, and suicidal ideation in women who suffer from it (4, 5). Sexual intercourse is often painful or impossible, many women cannot wear pants due to the pain, and the pain can interfere with nearly every aspect of daily life. A subtype of vulvodynia is vestibulodynia, which manifests as pain in the vestibule (area around the vaginal entrance) that is often triggered by vaginal penetration. Vestibulodynia is the most common subtype of vulvodynia (6). Very often, tests for vulvovaginal infections will be negative, skin disorders will be ruled out, and the tissue will appear red or completely normal. Treatments are focused on reducing the pain via antidepressants (e.g., Amitriptyine), anticonvulsants like Gabapentin, pelvic floor physical therapy, and even surgery to remove the painful vestibule tissue.

Over two-thirds (~70%) of women with vulvodynia report that it started with a yeast infection (6, 7). Of course, there is a large group of women with vulvodynia who do not have a history of yeast, and this page is not meant to invalidate their diagnoses or treatments (e.g., hormonally associated vestibulodynia). This page focuses on vulvar pain that is caused by candida.

Typically, the initial yeast culture will be positive for candida when symptoms start. In this acute infectious stage, a woman may experience excessive vaginal discharge, itching, burning, painful sex and other yeast infection symptoms. A primary care doctor or urgent care center will prescribe the standard treatment of 2 fluconazole pills. However, even when treatment is completed, these women will continue to experience pain. The acute symptoms of discharge and itching may subside, but the burning and redness do not. Repeat cultures for yeast are likely to be negative for candida at this point. The woman is left with chronic vulvovaginal burning pain which can detrimentally affect mental health, work, family, social life, and intimate relationships. After seeing many doctors and undergoing more testing, she may get diagnosed with vulvodynia at some point in the journey.

So, why are women left with chronic inflammation and pain after a standard antifungal treatment for a yeast infection? Some experts strongly argue that vulvodynia is caused by the failure of short-term antifungal therapy in these cases, and the remaining low levels of yeast should be treated with daily antifungal therapy (8). Others argue that an initial yeast infection triggers chronic vulvar inflammation and nerve damage, but because yeast cultures are often negative, there is no reason to believe the yeast is still there (6, 9).

Standard antifungal treatments for yeast infections (e.g., 2 fluconazole pills) do not eradicate all the candida cells, and certain women are unable to tolerate even the lowest levels of candida. Standard antifungal treatments will also not eradicate the intracellular yeast infection inside vaginal tissues (8). This means that a hypersensitivity, or exaggerated immune response, will persist after an acute yeast infection because the residual candida from the acute infection continues to trigger inflammation. The prevailing cause of chronic vulvovaginal candidiasis (CVVC) is an excessive, dysregulated immune response to low levels of candida organisms. It is a loss of tolerance to the organism in otherwise healthy individuals, and is regulated by polymorphisms (gene variations) that control inflammation and immune response (10). To learn more about the genetic susceptibility of this disease, click here.

Because the subsequent vaginal swabs for candida can be negative and many of these women do not feel better after just 2 fluconazole pills, doctors have a hard time believing that these cases of vulvodynia are due to CVVC. Many of these women are given vulvodynia treatments that may make symptoms even worse (e.g., a prescription of estrogen cream which actually feeds candida because it stimulates glycogen storage). Unfortunately, they get trapped in a cycle of debilitating pain, treatments that don’t work, and doctors not understanding the root cause of the problem. If the candida is left untreated for too long, it can even cause neuroproliferation which means an overgrowth of painful nerve endings at the vestibule (6).

Many cases of vulvodynia with erythema (redness) of the labia minora are due to CVVC (8, 11). The skin can appear completely normal (pink) as well in cases of CVVC and vulvodynia (11, 12). A 2025 research paper authored by Dr. Jack Sobel and Dr. Tania Day finally acknowledged that CVVC and vulvodynia diagnoses may be concurrent, even when the culture is negative for candida (10). There is simply too much evidence supporting a hypersensitivity to candida in patients with vulvodynia, especially the studies conducted by the Falsetta Lab at University of Rochester Medical Center. In these studies, vestibular fibroblasts (connective tissue cells from the vestibule) were taken from women with vulvodynia and showed an inflammatory response to extremely low doses of candida albicans — as few as 100 colony forming units — while pain-free external vulvar cells failed to respond. Therefore, the vestibule tissue of these women with vulvodynia is inherently sensitive to yeast and unfortunately, today’s testing technology often cannot pick up such low levels (7).

Too many women with CVVC are being diagnosed with vulvodynia. They are given pain treatments that do not work, because the treatments do not address the underlying cause of pain.

So are these cases of vulvodynia treatable with long-term antifungals? A 2021 study at Penn State assessed the efficacy of itraconazole (an oral antifungal) in 106 vulvodynia patients who had a negative candida culture. The average pain reduction for the entire cohort was ~61%, and patients who continued itraconazole for 5-8 weeks demonstrated a ~70% average reduction in pain. Over 85% of patients in this study had at least some reduction in pain, even if partial. It concluded that itraconazole therapy is associated with a significant reduction in pain from vulvodynia despite negative cultures, and hypothesized that “itraconazole is possibly active against a small population of yeast that do not grow in culture; alternatively, itraconazole may reduce vulvodynia pain through an anti-inflammatory or other systemic effect yet undocumented since its synthesis” (3). A study with a 70% reduction in pain should not be ignored by vulvodynia specialists, as these results are too significant and the % reduction in pain is higher than the statistics associated with certain other vulvodynia treatments (e.g., topical nerve pain medications). This study did not specify whether its patients had a previous history of positive swabs for candida (i.e., if their vulvodynia started with a culture-positive yeast infection), as they were chosen based on a vulvodynia diagnosis, negative candida cultures, and insufficient reduction in vulvar pain when previously using fluconazole (3). If the study had focused on vulvodynia patients with a history of positive candida swabs, it is very likely the average % reduction in pain would be even greater than 70%. Of course, there are more complicated vulvodynia cases that are not simply due to candida and will require other treatment methods to relieve pain — and it is clear that some patients in this study fell into that group, otherwise the % reduction in pain would likely be closer to 100%.

In a 2014 Australian study where patients had a history of previous positive candida swabs (e.g., a positive swab when the pain started but negative swabs thereafter) and symptoms of CVVC (which are nearly the same as vulvodynia), a 3-month course of oral antifungal medication completely resolved pain in 100% of patients. 32% of these patients were still fully responsive to antifungal therapy despite having a negative candida swab at presentation (i.e., when recruited for the study). To validate the study’s accuracy, the diagnostic criteria was also applied to an additional 163 patients during the following year. 100% of these additional patients were fully responsive to oral antifungal therapy as well (13). This study received some backlash from vulvodynia experts, stating that a yeast infection can only exist with a positive culture or microscopy at presentation, and cannot just be diagnosed based on symptoms and history. They claimed that diagnosing CVVC without a positive candida culture at presentation can lead to misdiagnosis and inappropriate oral antifungal therapy, and that a complete response to antifungal therapy in 100% of patients was inadequate to confirm the diagnosis of CVVC. They disagreed with the assumption that the treatment was responsible for the cure (9). Do they think it was pure coincidence? Hopefully, these vulvodynia experts have come around by now. CVVC is an immunologic process rather than a simple infection, and the standard testing approach is often inadequate at detecting very small numbers of candida. Because CVVC is a maladaptive inflammatory response to a normally-tolerated (commensal) vaginal organism, we can’t always expect positive candida tests to confirm diagnosis of this disease (14).

The links between CVVC and vulvodynia should not be overlooked. Perhaps if more vulvodynia patients were assessed for the symptoms of CVVC (history of positive swab, soreness, cyclicity, discharge) and given long-term antifungal therapy, we would have a better cure for vulvodynia.