We totally get it. You’re dealing with frustrating symptoms, and every test seems to come back normal. You were hoping Evvy could pinpoint the issue, but when your results say your vaginal microbiome is fine, you’re left wondering — what now?

The good news? If an imbalanced microbiome isn’t the problem, you’ve ruled out one major category of potential causes. That means you’re one step closer to figuring out what’s actually going on. So, what else could be causing your symptoms? Let’s explore some other possible reasons your vagina or vulva might be acting up.

Contact dermatitis

Contact dermatitis is when your skin reacts badly to something it comes into contact with. Think itching, burning, redness, and even swelling. The vulva’s skin is extra sensitive, making it more prone to irritation from common products like soaps, wipes, lubricants, and even laundry detergent. Researchers aren’t sure how common contact dermatitis is, but it’s one of the most commonly diagnosed conditions in vulvar dermatology clinics.

There are two main types: allergic contact dermatitis (ACD) and irritative contact dermatitis (ICD).

  • ACD happens when your immune system overreacts to something, like certain metals (nickel, cobalt, or copper), fragrances, preservatives, or even corticosteroids. It is also important to note that a common cause of ACD is continuous exposure to urine, so if you have any urinary incontinence be sure to keep the vulva as dry as possible to avoid irritation. 
  • ICD occurs when a product irritates your skin without triggering an allergic reaction. If a lotion makes your face itchy, chances are it won’t be any kinder to your vulva.

Some surprising culprits? Flushable wipes, bleached toilet paper, condoms, and even underwear made from synthetic fabrics. A quick note about condoms, some people are allergic to latex itself, but other compounds like nonoxynol-9 (which is found in spermicides) have been identified to cause irritation for some women. 

There are a few things you can do to avoid contact dermatitis:

  • Stick to warm water and unscented soap to clean your vulva (and remember, your vagina cleans itself!).
  • Ditch scented products, including wipes, lotions, and bath gels.
  • Switch to fragrance-free detergent and avoid dryer sheets.
  • Keep the area dry. If you have urinary incontinence, change pads regularly and consider seeing a pelvic floor specialist.
  • Choose breathable cotton underwear and avoid overly tight clothing.

Resources

The best thing you can do is to stop using any products that might be causing irritation. Typically, the irritation will heal on its own with a little time. To help speed things up, you might want to try a soothing topical cream to reduce inflammation. We recommend Evvy’s Soothing Vulva Cream, which is made with prescription-grade hyaluronic acid, aloe, and vitamin E — ingredients that have been shown in clinical studies to help soothe, moisturize, and relieve itching.

Friction abrasions and clothing

As we stated above, to maintain the health of your vagina and vulva, it's commonly recommended to wear breathable cotton underwear. This type of fabric helps prevent moisture buildup, which can inhibit the growth of harmful organisms that disrupt the microbiome. Many Evvy users report avoiding synthetic underwear for this reason.

Unfortunately, there is limited research on this topic, a reflection of the gender health gap. While over 30 research articles (some as recent as 2020) examine how the tightness and material of men's underwear affect sperm quality, similar studies focused on the vulva and vagina are lacking. This gap extends to other types of clothing, such as wet bathing suits made from synthetic materials. In the meantime, it's best to choose what feels comfortable and effective for you, and we hope that science will provide more insights in the future.

When it comes to vulvar symptoms, wearing tight-fitting clothing can cause friction and abrasions on or around the vulva. This issue is particularly common with tight clothing or thongs during exercise, potentially leading to bumps, chafing, or even lesions.

Resources:

If you're looking for underwear made from natural fibers, you have plenty of great options to explore. Here are a couple of recommendations from Evvy users that might work well for you:

  • Boody: Bamboo underwear that is naturally absorbent and wicks away moisture faster than cotton.
  • ODDOBODY: 100% cotton underwear that emphasizes education. Each order comes with a specific theme to teach about the menstrual cycle, vulvar care, pelvic floor health, and more. 

Pelvic floor dysfunction

Your pelvic floor  is a group of muscles that help support your vagina, uterus, and urethra. Think of it like a supportive hammock that keeps everything in place.

Sometimes, your pelvic floor can experience some challenges, leading to issues that might feel similar to an infection: 

  • Urologic chronic pelvic pain syndrome (UCPPS): This can affect anyone, regardless of sex or gender. It often involves persistent pelvic pain and urinary issues that can mimic infections. For those born with vaginas, you might also hear it called interstitial cystitis (IC) or painful bladder syndrome (PBS).
  • Pelvic inflammatory disease (PID): PID can lead to increased sensitivity in your pelvic muscles and nerves. Even after the infection is gone, this extra sensitivity can linger and cause ongoing discomfort.
  • Pelvic organ prolapse: This happens when the pelvic floor weakens and can no longer support your pelvic organs properly, causing them to bulge into the vagina. Unfortunately, this can sometimes lead to pain during intercourse.
  • Urinary retention: When you pee, it helps flush out bacteria from the urethra, which is important for preventing infections. If your bladder isn’t completely emptying, bacteria can stick around. Urinary retention can occur for various reasons, often related to how the pelvic floor muscles coordinate bladder emptying. 

Resources

If you’re dealing with any of these issues, a pelvic floor physical therapist is a great resource. They specialize in treating these conditions. Finding one, though, can sometimes be a bit tricky, so here are a few helpful resources to get you started:

Menopause

Menopause is a natural part of life that every woman experiences, but it can come with some surprising symptoms. While people often talk about hot flashes, night sweats, and mood swings, there are some other less-discussed symptoms that many women face. Here are a few:

  • Vaginal itching: About one in three postmenopausal women experience vaginal itching.
  • Vaginal dryness: Often referred to as vaginal atrophy or atrophic vaginitis, this happens due to the thinning and inflammation of the vaginal lining. About half of women going through menopause deal with this.
  • Painful sex: The discomfort known as dyspareunia, which occurs before, during, or after intercourse, can be more prevalent during and after menopause. It’s something that can happen at any age, but many find it particularly challenging during this transition.
  • Higher incidence of UTIs: UTIs can become more frequent during menopause, and they might sometimes cause itching too.
  • Changes in vaginal odor: Some women notice that their vaginal smell changes during menopause. One study found that 24% of menopausal women reported a noticeable difference in this aspect.

Resources

  • Evvy’s Hyaluronic Acid Suppositories are designed to combat common menopause symptoms like vaginal dryness, itching, and discomfort — for hormone-free relief.
  • Midi is an online mid-life health (including peri and post-menopause) that offers virtual care and takes many forms of insurance. 
  • Alloy is an online healthcare platform that specializes in menopause care. 
  • Elektra is an online healthcare platform providing menopause care, education, community, and 1:1 support.
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Lichens planus or lichens sclerosus

Vulvar lichen planus is a long-lasting skin condition that can cause inflammation and rashes on the vulva and vagina. It’s seen more often in women going through perimenopause or menopause, though the reasons for this aren’t completely understood. Experts believe it may be an autoimmune condition. The main symptom to look out for is a dry, itchy rash on the labia, clitoris, or vaginal opening. Here are some other signs you might notice:

  • Dry, sore patches of skin on the vulva
  • Pain or burning around the vulva and/or vagina
  • Overall soreness, burning, and itching in that area
  • Discomfort during sex or when urinating
  • Bleeding after sex
  • Unusual vaginal discharge.

Similarly, lichen sclerosus is another long-term skin issue that creates white, wrinkled, and dry patches on the genital skin, including the vulva and anus. These patches can appear shiny or raised and, in some cases, may also show up on the upper body, like the arms or breasts.

Although it’s not very common and isn’t contagious, lichen sclerosus can really affect someone's quality of life, especially their sex life, and it may increase the risk of skin cancer. Everyone experiences it differently; some people may have no symptoms at all, while others might experience:

  • Dry, white patches on the vulvar skin
  • Itching and soreness, especially at night
  • Genital lesions or bruising
  • Pain and discomfort around the vulva and vagina
  • Difficulty or pain during sexual activity
  • Bleeding, blisters, or ulcers (in more serious cases).

If you're concerned about either condition, it's essential to see a doctor. They can help diagnose lichen sclerosus through a physical exam and may take a small skin biopsy if needed to confirm the diagnosis.

Resources

Finding a specialist in vulvar dermatology can be challenging. A great place to start is educating yourself and bringing resources to your doctor. We recommend checking out Dr Jill Krapf’s website. She runs the Center for Vulvovaginal Disorders has some amazing educational resources around lichen schlerosus and lichen planus that can help you get started.

Vulvodynia 

Vulvodynia is a term used to describe ongoing and unexplained pain in the vulva. This can include conditions like vestibulodynia, which is pain at the entrance of the vagina, and clitorodynia, which refers to chronic discomfort in the clitoral area.

Many people describe vulvodynia pain as a stinging or burning sensation that can be quite intense or even debilitating. The discomfort can affect just one area or multiple parts of the vulva.

At this time, doctors aren’t exactly sure what causes vulvodynia. It’s often diagnosed after other possible causes of vulvar pain have been ruled out, particularly if the pain has been present for more than three months. If you or someone you know is experiencing this type of pain, seeking advice from a healthcare professional can be an important step toward finding relief.

Resources

Again a great place to start is educating yourself and bringing resources to your doctor. We recommend checking out Dr Jill Krapf’s website. She runs the Center for Vulvovaginal Disorders and has some amazing educational resources about vulvodynia. 

This is also another great reason to see a pelvic floor specialist. 

Histamine intolerance (HIT)

Histamine intolerance (HIT) is a bit different from having an allergic reaction. While allergies involve the immune system reacting to something specific, HIT happens when your body has trouble breaking down histamine, leading to too much of it building up.

People often associate HIT with stomach issues and allergy-like symptoms, but new research suggests it might also cause some vaginal symptoms. Mast cells, which are immune cells in the body, release histamine. Some studies have found that higher levels of mast cells are connected to vulvodynia, and those who experience vulvodynia may also have more allergic reactions.

Diamine oxidase (DAO) is the enzyme that helps break down histamine, and its levels in your bloodstream can change during the menstrual cycle, being highest during the luteal phase. We know that estrogen can influence the vagina and the microbiome there. Some research shows that when ovarian cells encounter histamine, they may produce more estradiol (a type of estrogen). This could mean that histamine impacts hormone levels and then affects the vaginal microbiome. However, this is still just a theory, and there aren't any studies directly testing it yet. 

Resources

For more information on histamine intolerance check out these resources from the Cleveland Clinic and the Histamine Intolerance Awareness group.

Sexually transmitted infections 

Sexually transmitted infections (STIs) can sometimes be an uncomfortable topic, but knowing how they affect your vaginal health is key to staying informed and taking care of yourself.

Many STIs cause vaginal symptoms like pain, itching, a burning sensation when you pee, and abnormal vaginal discharge. Some STIs can also cause painful sores and discomfort during sex. The good news? Many STIs are treatable, and even those that aren’t curable can be managed with proper care.

Here are some of the most common STIs and the vaginal symptoms they can cause:

  • Chlamydia: Often has no symptoms, but when present, it can cause abnormal vaginal discharge, pain during sex, or a burning sensation when peeing.
  • Gonorrhea: Can lead to increased vaginal discharge, pelvic pain, and burning when you pee.
  • Trichomoniasis: Causes frothy, yellow-green vaginal discharge with a strong fishy or "rotten" odor, as well as itching and discomfort.
  • Genital herpes: Leads to painful sores or blisters around the vagina, itching, and flu-like symptoms.
  • Human papillomavirus (HPV): Some strains cause genital warts, while others may lead to cervical cell changes (usually detected through a Pap smear).
  • Syphilis: In its early stages, it can cause sores that are painless but highly contagious.

Resources

If you ever notice changes in your vaginal health, it’s always best to check in with a healthcare provider or take Evvy's at-home STI test.

  • Evvy’s Vaginal Health Test & Expanded PCR Panel detects four of the most common STIs (chlamydia, gonorrhea, trichomoniasis, and Mycoplasma genitalium). You’ll receive physician-reviewed results in just a few days, and if eligible, a provider will design a custom prescription treatment program.
  • Some types of STIs, like syphilis and HIV, can only be diagnosed with a blood test. Your primary care physician or gynecologist can conduct STI screenings during routine visits. Community health clinics like Planned Parenthood also provide confidential and often low-cost or free STI testing services. You can find local clinics that offer HIV, STI, and hepatitis testing services by entering your zip code on the CDC’s Get Tested page.

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