Vulvar Health and Related Conditions

What is the vulvar?

The vulva is the external part of the female genitalia, and its primary functions are related to reproduction and sexual pleasure, as well as the protection of internal reproductive organs. The vulva comprises various components, including:

• Mons pubis: this is a fat pad that is located in front of the pubic symphysis (the joint between your left and right pubic bones). 
• Labia majora: these are the larger outer folds of skin that surround the opening of the vagina. They are typically covered with hair and protect the internal genital structures.
• Labia minora: these are the smaller and hairless inner folds of skin located within the labia majora; they extend around the vaginal opening and fuse anteriorly to form the clitoris. 
• Clitoris: the clitoris is a highly sensitive organ located at the top of the vulva, beneath the mons pubis. It contains many nerve endings and is a key structure for sexual arousal and pleasure.
• Bartholin’s glands: these are small glands located on either side of the vaginal opening. They secrete fluids that help with lubrication during sexual arousal. They also help maintain moisture in the vaginal area, contributing to overall comfort and preventing dryness.
• Vaginal opening: this is the entrance to the vagina, the muscular tube that connects the external genitalia to the uterus. 

The vagina serves various functions, including:

• Reproductive function: this is where sperm are deposited during sexual intercourse and start their journey of fertilising the egg by first entering the uterus; it is also the birth canal where a baby passes during vaginal delivery.  
• Menstruation: the endometrial lining, aka uterine (womb) lining, sheds regularly in women of reproductive age and exits a woman’s body through the vagina during a process known as menstruation. 
• Sexual function: the vagina plays a crucial role in sexual intercourse by accommodating the penis, allowing for the deposition of sperm. Additionally, the vagina contains many nerve endings that contribute to sexual pleasure.
• Lubrication: the walls of the vagina have the ability to produce lubrication, especially during sexual arousal, which helps reduce friction during sexual activity, making penetration more comfortable.
• Immune defence: the vagina has a slightly acidic pH, which helps create an environment that discourages the growth of harmful bacteria that may otherwise ascend upwards to affect the reproductive organs. The presence of beneficial bacteria in the vaginal, such as Lactobacillus, contributes to maintaining a healthy balance in the vaginal ecosystem and helps protect against infections.

The vulva is an integral part of the female reproductive system. Maintaining vulvar health is crucial for overall well-being, and issues such as infections, hormonal changes, or other medical conditions can affect its function and comfort. Regular gynaecological check-ups and proper hygiene practices are essential for promoting vulvar health.

What are the common vulvar conditions? 

Some common problems that can affect vulvar health include: 

• Infections: vulvar infections, such as yeast infections or bacterial vaginosis, can cause itching, redness, and discomfort. Maintaining good hygiene practices and wearing breathable underwear can help prevent these issues.
• Vulvodynia: this condition affects the vulva and is characterised by chronic pain or discomfort in the vulva. The pain associated with vulvodynia is often described as a burning, stinging, irritation, or rawness; this can significantly impact a woman’s quality of life and may affect her sexual function. 
• Lichen sclerosus: lichen sclerosus is a chronic, inflammatory condition that can affect the genital area, including the vulva, particularly in postmenopausal women. Common symptoms include itching, pain, and discomfort. The vulva skin characteristically appears thin and white and can sometimes scar/fuse in severe cases. It can lead to an increased risk of vulvar cancer. 
• Vulvar cancer: vulvar cancer more commonly affects older women but is relatively rare compared to other gynaecological cancers (such as uterine or ovarian cancer). Risk factors include advanced age, infection with certain strains of human papillomavirus (HPV), smoking, longstanding lichen sclerosis, and a suppressed immune system. 
• Genital warts: these are caused by certain strains of the human papillomavirus (HPV); genital warts can develop on the vulva. They may appear as small, raised, or flat growths. HPV vaccination with Gardasil-9 can help offer some protection against genital warts. 
• Genital ulcers: these are commonly caused by the herpes simplex virus and can be extremely painful.
• Bartholin’s cysts and abscesses: Bartholin’s glands, located on either side of the external vaginal opening, can develop cysts or abscesses, causing the vulva to appear swollen on one or both sides resulting in pain, swelling, and discomfort.
• Contact dermatitis: irritation or allergic reactions to substances such as soaps, detergents, or pantyliner/pads can lead to contact dermatitis, characterised by redness, itching, and inflammation of the vulvar skin.
• Atrophy: menopause and hormonal fluctuations can impact vulvar health, manifesting in dryness, itching, burning sensation, discomfort or pain during sexual intercourse.  

What causes vulvar disorders?

Vulvar disorders are mainly caused by the following factors: 

• Infections: although most infections occur in the vagina, these usually result in excessive, foul-smelling vaginal discharge that eventually makes its way out to the vulval skin and can then result in vulval irritation and infection. Common causative organisms include Gardnerella (bacterial vaginosis) or Candida (yeast/fungal), which are not sexually transmitted, and chlamydia, gonorrhoea, and trichomonas, which are sexually transmitted. Recurrent infections can sometimes result in chronic pain like vulvodynia. 
• Hormonal changes: during pregnancy and childbirth, the vulval and vaginal opening is stretched to accommodate the passage of the baby and can result in vulvar tears. In some cases, your obstetrician may need to perform an episiotomy (surgical cut) of the vagina and vulva to facilitate vaginal delivery. It is also common for women to experience oedema (swelling) of the vulva following childbirth, especially if the labour was prolonged; this typically resolves with time. As women age, their ovaries produce less oestrogen leading to changes in the vaginal and vulval tissues. Vulval skin can become thinner, drier and less elastic due to a drop in oestrogen levels after menopause. Other causes, such as pelvic radiation therapy, can also precipitate this. 
• Autoimmune conditions: autoimmune conditions involve the immune system mistakenly attacking the body’s tissues. Non-gynaecological autoimmune conditions include Behcet’s disease, psoriasis, Sjogren syndrome, and systemic lupus erythematosus (SLE). 

What does a vulvar infection look like?

Vulvar infections are typically characterised by changes in the vulval skin colour (e.g. redness, erythema), texture (either thickened or thinned out), or abnormal discharge.  

How are vulvar conditions diagnosed?

Vulvar conditions can be diagnosed with one or a combination of the following methods: 

• Medical history: presenting symptoms, duration, lifestyle factors including use of soaps, pantyliners etc, medical history
• Physical examination: visual inspection of the vulva, looking for signs of infection, inflammation, or other abnormalities. A pelvic exam is usually also required to assess for other co-existing issues. 
• Cultures: in cases accompanied by abnormal vaginal discharge, collection of vaginal samples for laboratory analysis, i.e. swabs or cultures, may be necessary to identify the cause. 
• Vulvoscopy and biopsy: use of a magnifying instrument (colposcope) to examine the vulvar tissue more closely to perform targetted removal of a small tissue sample for microscopic examination to diagnose conditions like lichen sclerosus or lichen planus or even to rule out cancer.
• Blood tests: testing for sexually transmitted infections (STIs) or autoimmune conditions if necessary.

What precautions should I take to ensure vulvar health? 

Keeping your vulva clean is vital to ensuring good vulvar health, a critical component of overall well-being for females. Understanding the anatomy, recognising common conditions, and adopting healthy practices can contribute to good vulvar health. 

• Hygiene: practice gentle hygiene by using mild, fragrance-free soaps and avoiding harsh chemicals. Feminine washes may not be suitable for all. Wipe from front to back after using the toilet to prevent the spread of bacteria.
• Clothing choices: wear breathable cotton underwear and avoid tight-fitting clothing to allow air circulation and minimise moisture buildup, particularly in humid weather. 
• Safe sex practices: use barrier methods, such as condoms, to reduce the risk of sexually transmitted infections (STIs).
• Vaccination: consider taking Gardasil-9 (HPV vaccination) to protect against genital wart-causing HPV types 6 and 11 
• Regular check-ups: schedule routine gynaecological exams to monitor vulvar health and detect any abnormalities early on, particularly if you feel any itch/discomfort. 
• Lubrication: use water-based lubricants to enhance comfort during sexual activity, especially in cases of vaginal dryness.
• Non-hormonal vaginal moisturisers: these can help mitigate vulval dryness/itch, particularly for women who cannot or choose not to use hormonal therapy. 
• Topical vaginal oestrogen: this usually comes in the form of creams and is helpful for peri- or postmenopausal women; it needs to be prescribed and used under the direction and guidance of a gynaecologist.

If you are suffering from vulvar conditions or need guidance on maintaining vulvar health, it is essential to seek advice from a skilled gynaecologist. Regular consultations and diligent monitoring will help ensure your overall reproductive health and comfort.