GYNAECOLOGICAL HEALTH 2.08
‘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
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 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
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.
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
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
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.
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
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)