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Vulvar Health

March 6, 2011

The mysterious vulva has been referred to by more names than any other part of the female anatomy: private parts, down there, pookie, yoni, and many others. In a culture that has discouraged women from understanding or exploring their intimate body parts, women are missing out on an important opportunity to positively affect their health. From common concerns like vaginitis to more serious conditions like cancer, this is a part of the body women should become familiar with in order to receive the best health care possible. If you know what’s normal for you, than you will be more capable of detecting when something goes wrong.

Anatomy of the vulva

The vulva is a multipart organ consisting of many sensitive parts. As you move down from your belly button, you come to the mons veneris, or mons pubis, which is sometimes called the mound of Venus, which is the protective fatty tissue that lies on top of the opening to the vagina and is covered by skin and pubic hair.

Moving further south, the outside vaginal lips are called the labia majora. Shrinking or swelling in response to both temperature and touch, these “lips” are extremely sensitive. Inside the labia majora is a second set of “little lips” known as the labia minora, which serve to protect the interior of your vagina. The labia minora have no hair, but oil glands within them can be felt through the thin skin as tiny bumps. Even more sensitive than the labia majora, they also swell with blood during sexual excitement. Both sets of lips sweat and produce discharges which serve to waterproof the vulva and defend the vagina from disease organisms.

The clitoris is a tiny organ made of soft, spongy tissue and is covered by a hood of skin called the prepuce. The clitoris sits atop of the labia minora and, like a penis, it becomes engorged with blood when you are sexually stimulated. The clitoris has more than 8000 nerve endings, which is twice the number in the penis!

Located just below the clitoris is the urethra, which serves as the passageway for urine. It also has erectile tissue which responds when the vulva is stimulated. The perineum is the short piece of skin that stretches from the bottom of the vagina to the anal opening. Forming the entryway into the vagina is the vestibule. The Bartholin’s glands, located on either side of the vaginal opening, produce lubricating fluid to the vulva and vagina.

Women’s vulvas can look very different from each other in shape, size, and color. Therefore, it is important for women to learn what a “normal” vulva for them personally looks like, smells like, and feels like to the touch.

Vulva self-exam (VSE)

Experts now advise that doing a vulva self-exam (VSE) on a regular basis, just like you do monthly breast exams, is one of the best ways to catch changes and health problems early on. You should perform VSE in-between menstrual periods or choose a date each month that will help you remember to perform your VSE. You can view your vulva by getting in a comfortable position and holding a hand mirror. Here are the steps you should take:

  • Separate the outer lips with your fingers. A normal vulva is pink to medium red, with no white or reddened areas. Look for any new freckles or moles and feel for any cuts or sores, lumps, or cysts.
  • Now look a little deeper inside by separating your inner lips. Look for the same signs mentioned above. Also, check the entrance to your vagina.
  • Examine your clitoris, which is under a hood or fold of skin. It should resemble a small, fleshy mound and is soft to the touch and pink in color.
  • Check outside the lips: your urethra, perineum, and anus for any soreness, irritation, itching, or signs of bleeding.

Most changes in your vulva will NOT be cancerous, but you should discuss all changes with your doctor at the earliest opportunity.

Common problems of the vulva

  • Vaginitis is the single most common health problem affecting women and usually causes vulvar problems secondarily. It is the general term used to describe a variety of conditions caused by everything from bath products to complex infections. Vaginitis commonly means you have an infection known as bacterial vaginosis (BV). When treated early on with pills or creme, BV is usually cured with no complications. But left untreated, BV can increase your risk of pelvic inflammatory disease (PID), infertility, and other sexually transmitted diseases. The vaginal discharge with BV is usually thin, watery, milky-white or gray, sometime sticky, and may smell “fishy”. This discharge typically becomes worse after intercourse, but doesn’t always itch or become inflamed.
  • Another form of vaginitis which causes vulvar itching, burning, and even pain, is a vaginal yeast infection. When the balance of your good lactobacillus bacteria drops in the vaginal environment or when other things alter this environment, the candidiasis or yeast fungus multiplies. The vagina and vulvar environment can change due to many things including: antibiotics, douching, birth control pills, vaginal products, diabetes, hormonal patterns, HIV, or poor bathroom hygiene. The most obvious sign of infection is a white, clumpy, cottage cheese-like discharge. Both over-the-counter and prescription medications are available to treat yeast infections. However, experts advise that every first-time yeast infection should be diagnosed by a doctor, and not just over the phone. Your yeast infection should clear within seven days with medication. If it doesn’t, or if it recurs within ten days, see you doctor right away.
  • Lichen sclerosus is a chronic skin disorder of the vulva which causes itching and inflammation and occurs in an hour-glass pattern with ivory-colored patches. For most women, early treatment of lichen sclerosus with cortisone-like preparations or hormone preparations controls symptoms.
  • Lichen planus is a common skin inflammation that presents with tiny, itchy white bumps on the inside or outside of the vulva. It requires a biopsy for accurate diagnosis and to rule out the rare chance of having cancer of the vulva. Lichen planus can be treated with a variety of prescription creams.
  • A round, bulging growth on the vulva will probably be due to a cyst – a liquid or semisolid filled sac – commonly found in, or next to, the Bartholin’s glands. If you are over forty and experiencing recurring cysts, your doctor may need to perform a draining procedure, or in rare cases, remove the gland and biopsy it for cancer. Another very common cyst is one which develops when a hair follicle grows inward. These are often tender to the touch and hot, moist compresses can help relieve the inflammation and drain the cyst. Some women develop sebaceous, or oil-filled cysts on the vulva, but all cysts should be diagnosed by a doctor.

Serious diseases of the vulva

  • Human papilloma virus, known as HPV, can cause genital warts which may be transmitted sexually. While warts can be painful, they pose no serious danger to your health. If you feel a wart or any irregularity, it should be checked out by a specialist. However, some strains of HPV have been linked to cancerous growths, and they present no obvious signs, like warts. Some women are now choosing to be tested for HPV when they receive their annual pap test.
  • One of the most alarming of vulvar infections to discover is genital herpes. Herpes simplex type 1 is common in fever blisters on your lips. With fever blisters, it is important to avoid infected lips contacting the vulva or penis. Similarly, herpes simplex type 2, a close cousin to type 1, almost always spreads by sexual contact. When active lesions of the vulva or penis are present, sexual contact must be avoided. These small blisters can develop anywhere on the vulva and are usually itchy and burn.
  • Other sexually transmitted viruses and infections which women should become familiar with the symptoms of, include: hepatitis B (HBV), HIV, chlamydia, gonorrhea, syphilis, and trichomoniasis.
  • Finding raised brown, pink, or white lesions on the inside of your vulva should be checked by a doctor for vulvar intraepithelial noeoplasm, or VIN. This is a precancerous condition that occurs when changes in the cells of the vulva cause abnormal growth. Cancer of the vulva is relatively rare (4,000 cases annually in the US) and is almost always curable when the growth is less than two centimeters (about 3/4 of an inch) in size. This kind of cancer most often occurs in women over 60 and almost all cases are associated with a chronic itching.

Vulva self-care tips

  • Wash the vulvar skin with water and one’s hand only – soaps and washcloths can dry out or irritate the vulva.
  • Wash your undergarments with detergent made for babies or those with sensitive skin and even run them through a second rinse with water only.
  • Go without underwear when possible, such as at night. Make sure underwear is 100 percent cotton in all places and avoid panty hose. Change out of wet bathing suits as soon as possible.
  • Avoid fragranced products, such as perfumed shower gels, scented toilet paper, douches and genital sprays, on the vulvar skin and vagina.
  • After bowel movements, wipe from front to back.
  • Dry your vulva thoroughly before dressing or use a hair dryer set on cool to the outside of the vulva only.
  • Cotton menstrual products may be preferable over synthetic versions.
  • Baking soda or oatmeal sits baths or soaking in a bath of chamomile tea bags may help reduce itching.
  • Use non-irritating lubricants for sexual intercourse.
  • Learning about gluten free, dairy free or yeast free diets may help chronic vulvar problems.

For more information on the vulva and treatment options take out one of the following books from the WHRC free lending library: The V-Book: A Doctor’s Guide to Complete Vulvovainal Health by Dr. Elizabeth Stewart, The V Zone: A Women’s Guide to Intimate Health Care by Colette Bouchez, or The Vulvodynia Survival Guide: How to Overcome Painful Vaginal Symptoms and Enjoy an Active Lifestyle by Dr. Howard Glazer and Dr. Gae Rodke. Our staff can also provide you with information about DHMC’s multidisciplinary vulvar clinic.

Learn more about possible causes of feminine itching, and the therapies and procedures that can help.
Gynecology: Infections & Pelvic Pain
Annual Exams & Pap Smears
DHMC’s Vulvar Clinic
Copyright © 2011 Dartmouth-Hitchcock Women’s Health Resource Center – All rights reserved. Re-printed with permission.
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