The “vulva” refers to the genital structures external to the vaginal canal in the female. The vulva has many anatomical components, including the labia majora (large lips), labia minora (small lips), clitoris, vestibule, vestibular glands, and the urethral opening (see figure). The health of the vulva is dependent on natural hormones, and therefore, it can change with aging.
Common Vulvovaginal Disorders
Contact dermatitis refers to irritation due to an external agent which causes inflammation of the vaginal and/or vulva. Women with contact dermatitis can present with burning, itching, and pain with intercourse. Proper vulvar skin care and removal of the irritating agent can cure contact dermatitis.
When estrogen levels are lowered in the female (due to menopause, or occasionally from oral contraceptive pills), the thickness of the layers of the vaginal and vulvar wall decreases. Atrophy can cause dryness and bleeding. Additionally, the lack of estrogen causes the vagina to become alkaline, which can predispose a woman to urinary tract infections.
Lichen sclerosus and lichen planus are benign disorders of the vulvar epithelium that can affect women of any age group. Symptoms include chronic itching, burning, They cause thinning of the vulvar tissue with edema and fibrosis. If untreated, the labia may fuse together, the clitoris may shrink, and the introitus may become stenotic. With lichen planus, the skin has a white, thin, shiny, “parchment paper” appearance. Fissures may be present. Bilateral symmetry is common. Some patients are asymptomatic, while others report pruritus, painful intercourse, and anorgasmia from clitoral shrinkage. There is a familial tendency. The diagnosis is by biopsy, which must be done before treatment, as treatment (topical high-dose steroids) can misguide the pathologist making the diagnosis.
Vulvar Intraepithelial Neoplasia (VIN)
Vulvar intraepithelial neoplasia is a potentially precancerous condition that can be either white, dark, or red. Excess keratin production leads to a white appearance, whereas excess melanin production leads to dark lesions. VIN may be focal or affect multiple sites on the vulva. Colposcopy with acetic acid (vinegar) may help delineate areas of VIN and make biopsy easier.
The vulvar vestibule is the area inside of the labia minora (small lips), extending to the hymen (opening) of the vaginal canal. The vulvar vestibule is embryologically distinct from the rest of the vulva and vagina. The vestibular nerve endings are extremely close to the surface, and some women may develop extreme sensitivity or even pain at this area (vestibulodynia). Women with vestibular pain typically complain of severe pain, burning, rawness, or stinging. Women with Primary Vestibulodynia often have pain since their teenage years when they inserted their first tampon. Those with Secondary Vestibulodynia may be affected later in life due to the hormonal changes after menopause.
Diagnosis of Vulvovaginal Disease
Your doctor will take a detailed history in order to determine the exact etiology of the problem. A detailed physical exam, often in conjunction with colposcopy (figure) can help in making a diagnosis of vulvar and vaginal problems.
The colposcope is a microscope that is used to visualize the vulvar skin at high magnification. Your physician may apply acetic acid (vinegar) solution which provides better visualization of pre-cancerous lesions. This procedure may also be done in conjunction with a vaginal biopsy, should any abnormal lesions be seen.
Often times, a small vaginal biopsy may be necessary to diagnose certain dermatologic diseases such as lichen sclerosis, or premaliganant conditions. A vaginal biopsy is done in the office by anesthetizing the skin with a small amount of anesthetic, and then removing a few millimeters of superficial skin. A vaginal biopsy typically takes a few minutes, and usually minimal to no bleeding is encountered.
Treatment of Vulvovaginal Disease
Your physician will thoroughly discuss all treatment options after making a diagnosis. Often times, simple therapies can cure vulvovaginal disease. Other diseases require extensive medical therapy, and more rarely, surgical therapy may be necessary.