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Vulval Conditions






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    Vulval Conditions Vulval Conditions Document Transcript

    • GYNAECOLOGICAL HEALTH 2.08 Vulval Conditions ‘Vulva’ is the general name given to the external parts Some general tips are: of the female genitals. It includes: the mons pubis • Switch to hypoallergenic versions of products (the pad of fatty tissue covered with pubic hair); the like toilet paper and laundry detergent as these clitoris; labia majora (the outer lips); labia minora (the products have no or limited perfume and smaller, inner lips); the vestibule (area immediately colourings known to cause irritation. surrounding the vaginal opening); the urinary • Avoid soap or use a soap substitute. opening; vaginal opening; and the perineum (area of • Take showers instead of baths and do not use skin between the anus and vagina). douches, feminine hygiene products and talc in the genital area. The skin of the vulva is extremely delicate, making it • Wear cotton underwear and avoid tight-fitting susceptible to a wide range of conditions. Women can trousers, pantyhose and G-strings. experience difficulty in obtaining a correct diagnosis • When showering, avoid getting shampoo or and may be told their symptoms are psychosomatic. conditioner residue on the vulval area. Alternatively, While vulval conditions are not “all in the mind”, wash hair in the basin. their sometimes chronic nature can lead to mental • Use cotton tampons rather than sanitary pads, and emotional health issues. By providing a brief where possible. If pads are preferred, consider overview of some of the more common conditions, using washable cloth sanitary pads (available from this factsheet aims to assist women in obtaining an some health food stores). Avoid the use of panty appropriate diagnosis and treatment. liners between periods. • Avoid the repeated use of over the counter anti- Conditions of the vulva are loosely grouped into: fungal preparations for thrush. If symptoms of dermatological; sexually transmitted infections and thrush continue after an initial treatment women thrush; vulvodynia (vulval pain); and pre-cancerous should consult their doctor as these preparations and cancerous conditions. are a common cause of irritation. It can take some time for symptoms to resolve as the Dermatological skin of the vulva generally takes longer to heal than in other areas of the body. If a woman’s symptoms There are a number of different dermatological persist she should return to her doctor as women with conditions associated with the vulva. vulval dermatitis may develop secondary infections such as thrush. Dermatitis Dermatitis is the most common cause of chronic Lichen sclerosus vulval symptoms. In some cases, vulval dermatitis can The exact cause of this condition is unknown, be caused by a genetic predisposition to allergies and although an overactive immune system or genetic hypersensitivity. These women will have conditions predisposition may play a role. The main symptom like asthma, hay fever or dermatitis in other areas of lichen sclerosus is severe itching. Scratching can of the body. Vulval dermatitis can also be caused result in broken skin, burning or stinging, pain during by contact with an irritant or allergen. Irritants or sex and/or urination. On inspection, the skin is dry, allergens can include laundry detergents, toilet shiny, finely wrinkled and may have white patches. paper, deodorants, dusting powders, lubricants and If left untreated, lichen sclerosus can cause severe spermicides, sanitary pads and panty liners, bath scarring of the vulva (including the shrinking of the products, soap and shower gels, depilatory products, labia and narrowing of the vaginal entrance). It is also underwear (lace, G-strings), latex (condoms, associated with a small increased risk of vulval cancer. diaphragm), over-the-counter medication (thrush Treatment involves the use of a topical steroid and treatments) or bodily fluids. is often life-long. Once a woman is diagnosed with lichen sclerosus she should undergo regular reviews, The main initial symptom of dermatitis is itching. even if asymptomatic, to ensure the condition is under Scratching the area can result in broken skin, control and no cancerous changes have occurred. burning or stinging and pain during sex. Treatment for dermatitis usually involves the use of a weak, Lichen planus topical corticosteroid cream. Cool compresses and This skin condition affects a number of areas of antihistamines may be used to bring relief from the body including the vagina and vulva. As with symptoms. If the dermatitis is thought to be due to lichen sclerosus, the exact cause is unknown, but an an allergy or irritant, it is important that attempts are made to identify the source.
    • overactive immune system or genetic predisposition Genital warts may play a role. Symptoms can include small Genital warts are caused by particular types of the lesions, a red-purplish colour to the skin, soreness human papillomavirus (genital HPV). Genital HPV is and burning, bleeding and/or painful sex. Vaginal transmitted through vaginal, anal or oral sex. Warts discharge may be heavier, sticky and/or yellow. If left can be found on the vulva, clitoris, cervix, inside the untreated, lichen planus can cause scarring of the vagina or urethra and in or around the anus. They vagina and vulva. Treatment involves topical or oral can be flesh coloured or pink and come in a variety steroids. Lichen planus may be associated with a small of sizes and shapes, occurring singularly or in clusters. increased risk of vulval cancer. The warts do not usually cause pain. Warts can be treated with chemical applications, ablation (freezing, Psoriasis burning or use of laser to remove warts) or a cream Women with psoriasis of the vulva often have the skin that enhances the body’s immune response to the condition elsewhere on their body. Symptoms include viral infection. For more information on genital warts scaly, red plaques (although on the vulva these are see our Genital HPV factsheet. generally less well defined than on other areas of the body). Other signs which may point to psoriasis Vulvodynia include nail pitting, scalp scaling and a family history The term vulvodynia, literally means pain of the vulva. of the condition. Treatment includes the use of topical The International Society for the Study of Vulvovaginal steroids and a low dose coal tar cream. Disease (ISSVD) provides a more precise definition: vulval discomfort, most often described as burning Ingrown hairs/sebaceous cysts pain in the absence of visible or neurological findings. Ingrown hairs can develop in the vulva, particularly Numerous factors have been suggested as causing following waxing or shaving. The trend towards vulvodynia, however, no single factor has been Brazilian waxing (where all hair in the vulval region proven to be the cause. is removed) has made this problem more common. An ingrown hair can result in the development of a The pain experienced by women with vulvodynia pimple or cyst on the skin’s surface. Gentle exfoliation varies in intensity from mild to severe and may of the skin can help with ingrown hairs. Sebaceous be constant or intermittent. Certain activities can cysts are caused by a blocked sebaceous gland (oil exacerbate pain with the most common being gland in the skin). They occur quite commonly in penetrative sex. Wearing tight clothing, riding the vulva and appear as a small, hard lump which a bicycle, inserting a tampon, having a pelvic is generally painless. Sebaceous cysts require no examination or sitting for long periods of time can treatment unless they cause discomfort. also cause pain. Often, women experience the pain for a number of Thrush and sexually years and consult a number of practitioners before transmitted infections being diagnosed. The chronic pain of vulvodynia, coupled with difficulty in obtaining an accurate Candidiasis (thrush) diagnosis can lead women to suffer mental and Thrush is caused by an overgrowth of yeast-like fungi emotional health problems such as depression. called Candida. It is not considered to be a sexually Women may also experience sexual and relationship transmitted infection. Symptoms include: itchiness difficulties. or redness of the vagina and vulva; a thick white, creamy vaginal discharge; and discomfort and/or Treatment for vulvodynia is focused on relieving the pain during sex. A simple thrush infection is treated discomfort experienced. Symptoms may be reduced with an anti-fungal cream. Sometimes if the thrush by following the general vulval care tips listed under has been longstanding (months to years) it can be the dermatitis section. Women should also avoid associated with chronic vulval pain, and longer term constipation or a full bladder and activities like bike thrush suppression treatment may be required. It is riding or sitting for long periods of time as these all important to note that other vulval conditions (eg. place pressure on the vulva. dermatitis) are often initially mistaken for thrush. Therefore, if symptoms persist following treatment Biofeedback and physical therapy appear to be for thrush, women should see their doctor. For more effective conservative treatments for vulvodynia. They information on thrush see our Thrush and other can assist women in strengthening and relaxing the vaginal infections factsheet. pelvic floor muscles (pelvic floor muscles that are not relaxed can cause spasms and pain). Biofeedback Genital herpes involves the use of sensors which provide feedback to the woman so she can learn to control and relax Genital herpes is a sexually transmitted infection the pelvic floor muscles. Physical therapy involves a caused by the herpes simplex virus. It is transmitted number of techniques including therapeutic exercises, through vaginal, anal or oral sex. Symptoms include pelvic floor rehabilitation, trigger-point pressure/ flu-like symptoms and painful blisters in the genital massage, electrical stimulation, ultrasound and area, within 2-14 days of exposure. For some people manipulation. this will be their only outbreak, while others may have several more. A minority of those infected experience Women may also benefit from cognitive behaviour frequent recurrences. therapy (CBT) to help manage chronic pain. CBT helps patients understand that their thoughts and There is no cure for genital herpes but antiviral behaviours may affect the way they experience pain. medications can help reduce the duration and severity It also involves a variety of coping strategies including: of an outbreak and prevent frequent recurrences. progressive relaxation; pleasant activity scheduling; Keeping the area clean and dry and bathing with a and distraction techniques to assist people to identify saline solution will help relieve discomfort and assist and challenge overly negative pain-related thoughts. healing. It is important to remember that genital herpes can be transmitted to a partner even when there are no blisters present.
    • Another conservative measure is a low oxalate diet A vaccine for some types of HPV (which are linked combined with calcium citrate supplementation. It is to VIN and, therefore, vulval cancer) will hopefully thought that a high concentration of oxalate crystals reduce the incidence of vulval cancer in the future. in the urine may irritate the vulva. Calcium citrate, taken before meals, binds to the oxalates preventing their absorption. Foods high in oxalates include tea, Other vulval conditions coffee, spinach, celery, sweet potatoes, most berries, purple grapes, tangerines, nuts and chocolate. Vulval varices There is, however, limited evidence to support the While varicose veins are usually thought of as effectiveness of this approach. occurring in the legs, they can also affect the vulva. Vulval varicose veins or vulval varices, as they are Some women find a mild local anaesthetic ointment often known, most commonly arise during pregnancy applied to the area provides relief. Medications like but can also affect non-pregnant women. Symptoms antidepressants and anticonvulsant medications are may include itching, pain in the vulva and the also used. It is important that women understand that sensation of prolapse (feeling as though something antidepressants are prescribed in the treatment of has fallen down). Vulval varices during pregnancy vulvodynia for their pain-relieving properties. usually improve once the baby is born, but if they are still symptomatic three months after childbirth, If other treatment options have been unsuccessful and treatment should be considered. For symptom relief a woman’s symptoms are very severe and localised women can use ice packs on the area, ensure periods to the vestibule, surgery may be considered. Surgery of rest lying down and avoid constipation. involves removing the area which causes the pain. The use of surgery for vulvodynia is still controversial. Treatment for vulval varices consists of sclerotherapy, It is important that a woman consults a surgeon who which involves injecting the vein with a saline is experienced in the area. solution. The saline solution irritates the lining of the vein causing it to collapse and be reabsorbed. A compression garment needs to be worn following Pre-cancerous and cancerous sclerotherapy. If sclerotherapy is unsuccessful surgery may be required. conditions Vulval intraepithelial neoplasia (VIN) Bartholin’s glands cyst Like a woman’s cervix, the tissue of the vulva can The Bartholin’s glands are tiny glands located on undergo abnormal cell changes. These changes are each labia minora, near the vaginal opening. These referred to as vulval intraepithelial neoplasia (VIN). glands are responsible for producing a small amount Some cases of VIN are associated with the human of fluid to lubricate the entrance to the vagina. papilloma virus (HPV), while other are thought to be The glands can become blocked, causing a cyst to due to irritation. If VIN persists for many years cancer develop. The cyst can become tender and, if large, of the vulva can develop. can cause discomfort when walking/sitting. If the cyst is small and is asymptomatic it can just be monitored. Symptoms of VIN may include: itching and burning Sometimes the cyst can become infected and an in a specific area of the vulva; raised brown, red, pink abscess develops. In these cases, the cyst or abscess or white lesions; warty lesions or persistent erosions or can be drained by a doctor. ulcers. Treatment for VIN depends on the stage of the condition but may involve monitoring the area as VIN can disappear on its own. In some cases removing the Diagnosis of vulval abnormal tissue by surgery or laser may be required. Other treatments are being trialled and a vaccine conditions against some types of HPV will hopefully decrease the Women experiencing a vulval condition should visit incidence of HPV-related VIN in the future. their doctor. As some vulval conditions are not widely understood, women can experience delays in being Vulval cancer correctly diagnosed and treated. It is, therefore, important that a woman’s initial consultation is Vulval cancer is relatively uncommon, with just over thorough. A detailed history taking and examination 200 cases diagnosed in Australia each year. The at this stage will assist in achieving a more accurate majority of these cancers occur in women 50 and diagnosis. over. There are two main types of vulval cancer, those associated with lichen sclerosus (see lichen sclerosus section) and those related to VIN (see VIN section). History Symptoms of vulval cancer include: itching, burning It may be helpful for women to take along a list of the or pain in the vulva; vulval skin that looks white, following information to their doctor’s appointment feels rough or has a lump; bleeding or discharge not to assist in their diagnosis. related to menstruation. About symptoms: Treatment for vulval cancer depends on how • Type of symptoms (burning, itching) advanced the cancer is when diagnosed, the person’s • Severity age and their overall medical condition. Early • How long the symptoms have been present detection of vulval cancer is important as it improves • When the symptoms occur (ie. do they change the chances of successful treatment. according to different phases of the menstrual cycle) Surgery is the most common treatment for vulval • Factors that exacerbate symptoms (eg. sex, cancer. Radiation therapy and/or chemotherapy may tampon use) also be used. • If the symptoms began around a particular time (ie. following treatment for a vaginal infection or STI, surgery, new sexual partner, pregnancy)
    • • Impact of symptoms on sexual activity • Treatments tried to alleviate the symptoms. Further help and information About other conditions: from Women’s Health • Personal or family history of skin conditions, The Health Information Line: asthma or hay fever • Oral lesions (these can indicate lichen planus) Our statewide line is staffed by women’s health • Allergies (including to previous medications) nurses and midwives. They provide women with up • Urinary or faecal incontinence (these can cause skin to date information, support and referral to health irritation) practitioners and services. Women can contact the • History of thrush or sexually transmitted infections Health Information Line by phone or email via the like genital HPV, genital herpes and the treatment ‘Ask a Health Question’ page on the website. All received phone calls and emails are confidential. • Family history of genital cancers • Medications taken The library: • History of gynaecological surgery Our lending library is available free of charge to all • Medical conditions like diabetes or women across Queensland. The library offers a select immunosuppressive illnesses (these can cause a range of books on major women’s health topics. susceptibility to infection). Topic-based booklists are available for browsing Other on the website, or can be posted out. Books can • Recent use of new products like detergent, soap or be requested by phone or email and are posted to sanitary products. borrowers. For Queensland women who want to read more widely about their health, a guide to other Examination library services is also available. It is important that the doctor performs a close The website: inspection of the entire vulval area. If appropriate, they will arrange for tests to exclude sexually All our factsheets and booklets are on our website. The transmitted infections and fungal infections like website also features articles on women’s health from thrush. In the case of vulvodynia, the doctor will try our newsletter, student factsheets, upcoming events, and ascertain the areas which are painful. The doctor library services and ‘Ask a Health Question’ page. A list may also provide a referral to a specialist. of reputable links is also available where women can search for further information on health topics. If there are any unusual looking changes a biopsy will be carried out. A biopsy involves removing a small A full list of references is available from the piece of skin from the affected area on the vulva, after Centre or on the website. having a local anaesthetic. It is hoped that improved awareness of the conditions which can affect the vulva will encourage women to consult a doctor about vulval symptoms. In addition, better knowledge and understanding of vulval conditions amongst medical professionals will assist women in getting a correct diagnosis and receiving appropriate treatment. Having trouble understanding this 165 Gregory Terrace Spring Hill Q 4000 PO Box 665 Spring Hill Q 4004 factsheet? Health Information Line .............. (07) 3839 9988 Please ring our Health Information Line Toll free outside Brisbane ............... 1800 017 676 (see numbers opposite) Administration and library .......... (07) 3839 9962 to speak to a women’s health nurse. TTY ............................................. (07) 3831 5508 Email .......................admin@womhealth.org.au © Copyright Women’s Health Queensland Wide Inc Web................http://www.womhealth.org.au This factsheet was originally published by Women’s Health Queensland Wide (Women’s Health) in June 2002. It was Facsimile ..................................... (07) 3831 7214 revised by Kirsten Braun at Women’s Health in July 2006. Disclaimer The content of this publication (“the information”) is provided for information purposes only. The information is provided solely on the basis that recipients should verify all the information provided. The information is not intended to be used to diagnose, treat, cure or prevent any disease or condition, nor should it be used for therapeutic or clinical care purposes. The information is not a substitute for your own health professional’s advice and treatment in relation to any specific patient issue. Women’s Health Queensland Wide Inc. does not accept any liability for any injury, loss or damage incurred by the use of or reliance on the information. While we have made every effort to ensure the information is accurate, complete and current, Women’s Health Queensland Wide Inc. does not guarantee and assumes no legal liability or responsibility for the accuracy, currency or completeness of the information. External resources referred to in this publication should not be taken to be an endorsement or a recommendation of any third party products or services offered and the views or recommendations provided by these external resources do not necessarily reflect those of Women’s Health Queensland Wide Inc.