What are Vulvar Diseases?

Vulvar diseases are quite common—approximately 15% of patients seen by a gynaecologist have one.

The Vulva

The vulva refers to the visible parts of the external female genitalia, including the clitoris, the vaginal lips and entrance to the vagina. There are many different diseases that can involve the vulva, such as infections, skin conditions, cancer, and chronic pain.

Many of these diseases have symptoms that are easy for health professionals to diagnose and treat. A handful of them may not have visible symptoms, making them difficult for even a seasoned doctor to identify. The vulvar pain condition called vulvodynia has been in medical literature since the 1980s, though its existence may still be unheard of by many doctors. That is why a woman who suffers from a chronic, long-term discomfort in the vulvar region may have to scout out a health professional who is familiar with these diseases to ensure she receives a proper diagnosis.

What type of infections can affect the vulva?

Most women have experienced a yeast infection. The symptoms typically are a red, swollen and itchy vulva. This can be associated with a heavy discharge that resembles cottage-cheese. However, it is unusual to have more than three yeast infections a year.

If you are suffering from constant vulvar itch you should see a physician for an examination. It is much more likely that you have a skin condition. Other common infections involving the vulvar are herpes infections and jock itch, a type of yeast.

What type of skin conditions can affect the vulva?

Any skin condition that affects skin in other parts of the body can also appear on the vulva. These include eczema, psoriasis, irritant dermatitis, lichen sclerosus, lichen planus, and lichen simplex chronicus.  It is often difficult to diagnose specific skin conditions, as many share symptoms. Often a skin biopsy may be required to make a proper diagnosis

The Three Lichens – Lichen simplex chronicus, Lichen sclerosus and Lichen planus

Lichen is a word used to describe the patchy appearance of a skin condition. Lichen simplex chronicus, Lichen sclerosus and Lichen planus are all different skin conditions, not infections. They can involve the vulva or other areas of the body like the arms, legs, and mouth, and these skin conditions commonly appear in more than one place at the same time. These lichens all change the way skin looks and feels, causing an intense itch that most women need to scratch for temporary relief.

Lichen simplex chronicus
Lichen simplex chronicus causes an intensely itchy patch of skin on the vulva. The itch is often worse with at night, with heat, dryness and stress. Scratching the skin is like scratching a bug bite—it only makes the itch worse.

Lichen sclerosus
Lichen sclerosus thins and whitens the skin around the vulva and sometimes around the anus. The vulvar skin will be itchy, and it often cracks and bleeds because it is so thin. Women may notice that the skin tears when they have sexual intercourse.

Lichen planus
Lichen planus affects the skin at the entrance to the vagina as well as inside the vagina. Women may often mistake this for a yeast infection because of the burning and itching. They may also notice a yellow-green discharge from the vagina and or bleeding after intercourse. The skin in the vagina is fragile and breaks down when touched.  If left untreated, the skin in the vagina may begin to stick together.

Irritant dermatitis

One of the most common skin conditions is an irritant dermatitis. This results from exposure to some type of “irritant” that causes skin inflammation—a red, swollen and itchy vulva. Common irritants include soap, synthetic panty liners, and fabric softeners. Good skin care practices can help the skin to heal.

• Avoid soap. Any soap can dry the skin. Consider rinsing just with water and or using a skin cleanser instead.
• Do not wear synthetic pantyliners on a daily basis. If your symptoms are always worse after a period consider switching to tampons and or a menstrual cup.
• There are 100% unbleached cotton pads and pantyliners available.
• Do not use harsh chemicals such as antibiotic soaps, vinegar, and Lysol to cleanse the skin. You can not wash away your symptoms.
• Moisturize the skin after a bath and or a shower with any non-perfumed over the counter dermatology approved moisturizer.

Vulvodynia

What is vulvodynia?

Vulvodynia is any type of unpleasant sensation in the vulva area that is distressing for more than six months. Women describe feeling intense burning, rawness, sharp stabbing pains, and soreness involving any part of the vulva. The discomfort may interfere with their ability to sit, wear clothing, walk and be sexually active. In fact, sexual intercourse can cause agonizing pain.

There are few symptoms to be seen during a physical examination, sometimes none. After seeing many different doctors in a desperate attempt to find out what is wrong, some women may be left thinking it is all in their heads?“this is not so. For centuries, undiagnosed pain in the vulva area was regarded by doctors as a psycho-sexual issue, and women were often sent to sexual therapists. Modern research tells us the pain is real. It is important to find an understanding doctor who is aware of vulva conditions.

What causes vulvodynia?

The exact cause of vulvodynia is unknown. Research has found that any one of the following could cause or contribute to vulvodynia:

• chronic yeast infections
• spasm of the pelvic floor muscles
• irritation of the skin nerves
• genetic predisposition

Types of vulvodynia

There are several different types of pain conditions that affect the vulva. Two of the most common are burning vulvar syndrome (dysesthetic vulvodynia) and vulvar vestibulodynia:

Burning vulvar syndrome or Dysesthetic Vulvodynia
Burning vulvar syndrome is more common among perimenopausal or postmenopausal women. Women suffer from constant discomfort, usually a burning sensation, which is felt throughout a wider area of the vulva rather than specific spots. Dysesthetic vulvodynia can be accompanied by urethral or rectal pain.

Vulvar Vestibulodynia (Previously known as vulvar vestibulitis syndrome)
Vulvar vestibulodynia causes a pain of the vestibule, the opening of the vagina that is only seen when the labia are separated. This pain is usually associated with a pressure that makes it uncomfortable to wear tight clothing, sit down or ride a bike. It may be painful or impossible to engage in intercourse, and even inserting tampons can cause severe pain. Women may also experience a burning, stinging, redness or a frequent or sudden urge to urinate, which can irritate the vulva even further.

How do you diagnose vulvodynia?

Diagnosing vulvodynia involves eliminating all other possible causes of pain. Unfortunately not all doctors are familiar with this condition and you may need to see more than one doctor before getting a diagnosis.

The doctor will take a medical history and focus on your pain complaint. They will ask you to describe the pain, where it is located, and if it radiates. They will ask if anything makes the pain better and or worse. It can be helpful to keep a pain diary in the days leading up to your appointment so that you can answer these questions accurately.

A pelvic examination will take place during which your doctor will examine the vulva and vagina. The doctor will check for visible signs of infection or skin condition. Then the doctor will touch different areas of the vulva with a cotton swab to try and determine what areas are painful.

If there are obvious changes to the appearance of the vulvar skin, the doctor may recommend a taking a tissue sample for a skin biopsy. If the skin looks normal there is no reason for a skin biopsy. If you undergo a biopsy you’ll be given a topical freezing pain or anesthetic to numb your skin. The doctor will snip a tiny piece of affected skin (4-5mm) and may have to use a stitch afterwards. You should be all healed up in about two weeks. The entire process should only be mildly uncomfortable.

How is vulvodynia treated?

There is no single cure for vulvodynia, but there are several treatment options for women depending on their symptoms. You may need to undergo several types of treatment before finding one that works for you. If side-effects occur, talk to your doctor before quitting the treatment. It may take patience and several tries to find the treatment, or combination of treatments, that works for you.

Treatments for vulvodynia:

• Topical medications like xylocaine or estrogen cream can be rubbed on the area that is causing pain.
• Oral medications like antidepressants or anticonvulsants are pain adjuvants that are useful in reducing chronic pain.
• Pelvic floor physiotherapy and biofeedback involve exercises that can help you manage and relieve the pain.
• Physical therapy reduces the increased tension in the pelvic floor muscles, and relieves any associated muscle spasms.
• Surgery can by helpful for women with vestibulodynia. The surgery removes the skin at the entrance of the vagina.

Counseling should accompany any form of treatment. Dealing with chronic pain can be difficult. The pain associated with sexual activity naturally affects how a woman feels sexually. Women often feel embarrassed, frustrated and depressed. The depression can make the pain feel worse. Women often lose interest in sex and have difficulty becoming sexually aroused. Naturally, some will avoid the pain by having little or no sex. In relationships, this can result in a loss of sexual intimacy between the woman and her partner. It’s important for women to be open and honest with their partners about the pain that they are experiencing. Sex should be a pleasurable activity, not painful one.

Education & Support Groups will not alleviate physical pain, but knowing you are not the only one going through this can put your mind at ease.

Vulvar Self-Examinations

Check yourself out. Some women have never gotten a real look at their own genitals.  The best way to maintain your vulvar health is to perform self-examinations.  Doctors recommend women who are 18 and older, or women who are sexually active, perform vulva self-examinations regularly.  This is the best way to catch any type of infection or disorder, and the earlier it’s caught the better the chance of curing it.

Vulvar self-examinations are best performed between periods, every month.  You’re looking for anything else that wasn’t there before, such as changes in colour (dark, white, red), bumps, blisters, lesions, ulcers, warts, and sores.  Feel for swelling, soreness, irritation or itching.

How it’s done

• With a mirror in one hand, sit with your legs spread using your free hand to separate the labia majora, the outer lips of the vagina, exposing the vagina’s opening.
• Check for visible changes to the mons pubis, the area above vagina where pubic hair is located. 
• Examine the labia minora, by spreading the small folds of skin surrounding the opening of your vagina, like you did for the labia majora.
• Check the perineum, the skin right between the vagina and anus.
• Lastly, look at the area surrounding the anal opening.

If you’re concerned about anything you see, make an appointment with your doctor immediately. 

Talking to your Doctor or Partner

If you think you might have an infection or disorder, see a health professional. Diagnosing yourself and attempting to self-medicate with over-the-counter products may make things worse.  Leave diagnosis to a professional.

Vaginal health is something that can be awkward to discuss, understandably, but remember that your doctor is trained to discuss these issues, no matter how embarrassing.  Some women may feel more comfortable seeing a gynaecologist as opposed to a family physician. It’s important to feel comfortable and safe with your doctor, so don’t feel guilty about asking for a referral to see someone else if you feel it’s necessary.

Tips for talking to your doctor

Before your appointment, read online about other women who have similar symptoms.  Their testimonials may help you describe yourself.   Be very specific about where it hurts and what exactly makes you hurt, for instance, pressure or menstruation. Bring a pain diary if you are suffering from chronic pain. Bring all of the medications that you have tried in a bag for your doctor to review. If your physical exam looks normal and the doctor is unsure as to what is going on, ask if it could be vulvodynia.  Be open and honest with your doctor and provide all the details you can remember.

Tips for talking to your sexual partner

For some, discussing the problem with a sexual partner is very difficult.  Try sharing resources about your disease with your partner.  There are many excellent websites, books and medical journals you can use to educate yourself as well as your significant other. 

Try having your partner accompany you to doctors appointments.  That way he or she can learn about your condition first-hand and ask questions directly to the doctor.  Couples may also benefit from remaining sexual in ways that do not provoke your pain.  Explore other ways of expressing yourself sexually that don’t hurt you.