Vulvovaginal Health

The external female genital area is called the vulva. The outer folds of skin are called the labia majora, and the inner folds are called the labia minora. Inside the labia minora is the vestibule, where the vagina and urethra are located.

The clitoris is located at the top of the labia minora. It actually extends deep inside the body. The visible part is called the glans, which is partially covered by a fold of tissue called the clitoral hood.

There are many other parts of the vulva, including:

• On either side of the opening of the urethra are the openings to tiny glands called Skene glands.

• Two additional glands, called Bartholin glands, are located on either side of the vaginal opening.

• The perineum is the area between the anus and the vagina.

There is a wide range of normal genitalia and the appearance varies from person to person. All of these differences are normal:

• The labia majora can range in width from one fourth of an inch to 2 inches.

• The labia minora are often longer than the labia majora, but it is also normal if they are not.

• The labia may be uneven in size.

Rarely, uneven or enlarged labia minora can cause discomfort with wearing clothing, exercising, having sex, or inserting tampons. If you have this type of problem, talk with your obstetrician–gynecologist (ob-gyn) or other health care professional.

Most women have the same general pattern of pubic hair—an upside-down triangle. But there can be differences in the amount and texture of pubic hair.

Just like fashions and hairstyles, there are also trends in pubic hair grooming. You may choose to remove some or all of your pubic hair, but there is no medical or hygienic reason to do so. Some ways for removing pubic hair can increase the risk of infection, or you can be injured during shaving or waxing.

If you choose to groom your pubic hair, make sure that you do it safely, either by yourself or by visiting a professional.

Changes in vulvar skin color can be a sign of a problem, including genital warts, infections, or skin disorders. Rarely, it can be a sign of vulvar cancer. Cancer is the growth of abnormal cells. Vulvar cancer can be caused by infection with human papillomavirus (HPV).

It is a good idea to become familiar with what is usual for your own vulva. If you see changes in the skin color (redness, dark- or light-colored spots), including moles, or if you have any new bumps or painful swelling, itching, or burning that do not go away, talk with your ob-gyn or other health care professional.

The vagina is the tube-like structure that leads from the uterus to the outside of the body.

At puberty, the vagina begins to produce discharge. This discharge is normal. It is mostly water, and contains beneficial microorganisms. The discharge naturally keeps the genital area clean and healthy by removing dead cells from the lining of the vagina. The amount and makeup of normal discharge change throughout the menstrual cycle.

Normal vaginal discharge is clear to white and does not have a noticeable odor. Signs of abnormal discharge include a change in the color, odor, amount, or consistency from what is usual for you.

A certain amount of vaginal odor is normal. If the odor is strong and noticeable, an infection or other problem may be the cause. If you feel that you need to cover up the odor, you may have a medical condition that needs treatment. Sprays, deodorants, and douches are not recommended and may make things worse.

Throughout your life, estrogen plays an important role in maintaining a healthy vagina. It helps keep the vaginal lining thick and supple. Estrogen encourages the growth of lactobacilli. These bacteria make a substance that keeps the vagina slightly acidic. The acidity protects the vagina from harmful, disease-causing microorganisms.

Yeast may also be present in the healthy vagina. The natural acidity of the vagina helps keep yeast and other microorganisms from growing out of control.

Vaginal infections can occur if anything disrupts the natural balance of the bacteria that normally are present in your vagina. Two common infections are yeast infection and bacterial vaginosis (BV).

A yeast infection is caused by an overgrowth of yeast in the vagina. This can be caused by

• lubricants

• spermicides

• taking antibiotics (which destroy the “good” bacteria in the vagina)

• pregnancy

The most common symptoms are itching and burning of the vulva. Yeast infections can be treated either by placing anti-yeast medication into the vagina or by taking a pill.

Bacterial vaginosis is caused by an overgrowth of the bacteria that normally live in the vagina. It is not a true infection. Anyone can get it, no matter their age or whether they’ve had vaginal sex.

The main symptom is increased discharge with a strong odor often described as “fishy.” BV is treated with antibiotics, either taken by mouth or inserted into the vagina. If you’re having sex, your sex partners should consider getting treatment to reduce the risk that BV will recur. Female partners have the same treatment as you. Male partners are treated with antibiotic pills and an antibiotic cream on the penis.

You may be able to prevent some of these problems by practicing careful hygiene.

General Hygiene

• Always wipe from front to back after using the bathroom.

• Use only unscented and uncolored toilet paper.

• Do not use baby wipes, feminine sprays, “full body deodorants,” or talcum powders.

For the Vagina

• Avoid douching, which washes away the protective bacteria of the vagina.

• Use menstrual pads or tampons that are deodorant-free and do not have a plastic coating.

• Avoid vaginal hygiene products, including perfumes and deodorants.

For the Vulva

• Wash your vulva with plain, fragrance-free soap. Rinse with cool or lukewarm water.

• After rinsing, gently pat dry.

• Avoid using lotions and perfumed products on the inner vulva.

• If you are having mild vulvar irritation or discomfort, first stop using soap on the inner parts of your vulva. Clear water is perfectly adequate for washing.

Allow for Air to Circulate

• Wear pants and underwear that are not tight-fitting.

• Only wear underwear with a cotton panel.

• Wear leggings or tights that have a cotton crotch.

Puberty starts when the ovaries begin to make a hormone called estrogen. The vulva changes during puberty in response to the increase in estrogen and other hormones.

• The labia minora grow and widen.

• Pubic hair begins to grow. Pubic hair increases in amount over time and becomes thicker and curlier.

• The vulva may also change in color. In adults, the color can range from light pink to dark brown-red or black. Color can also vary with different ethnicities.

The hymen is a thin membrane that partially covers the entrance to the vagina. The hymen sometimes can be torn or stretched during your first experience with sex (usually through sexual intercourse [vaginal sex]), but it’s just as common for it to be torn because of tampon use, sports activities, or medical procedures.

The presence or absence of a hymen does not indicate “virginity.”

During pregnancy, the levels of the hormones estrogen and progesterone increase. As more estrogen and more blood flows to the vaginal area, your vulva may become swollen. The color of the vulvar skin and the opening of the vagina may darken. These changes are normal. They often go away, but not always.

Other changes can include:

• You may have more vaginal discharge than normal.

• Hormonal changes may also cause changes in the balance of yeast and bacteria in the vagina.

• Vaginal infections are more common during pregnancy.

Sometimes varicose veins may develop in the vagina, vulva, and anus (these are usually called hemorrhoids) during pregnancy. They are caused by the weight of the uterus pressing down on a major blood vessel, which slows down blood flow from the lower body. They may be uncomfortable, but usually go away after pregnancy.

These tips may help relieve discomfort:

• Avoid constipation by eating a high-fiber diet and drinking plenty of liquids.

• Sitting for a long time puts pressure on the veins in your pelvic area. Get up and move around to shift the weight of your uterus off these veins.

• If you do get hemorrhoids, apply an ice pack, over-the-counter witch-hazel pads, or over-the-counter ointments to the area to relieve pain and reduce swelling.

• Try soaking in a warm (not hot) tub a few times a day.

Changes in the vulva can also develop after pregnancy. During childbirth, the skin of the perineum stretches to accommodate the baby’s head. Sometimes, the skin and tissues of the perineum tear. Minor tears may heal on their own without stitches, but some tears need surgical repair.

If you have perineal pain, try cold packs or cool witch hazel compresses. Sitz baths (sitting in warm water that is just deep enough to cover your buttocks and hips) can be helpful. Numbing sprays or creams can also be used to numb the area while you heal.

Another problem after childbirth is vaginal dryness, especially if you are breastfeeding. Vaginal dryness can be caused by changes in hormone levels. Lubricants and local estrogen therapy can be used to help with this problem.

Menopause is when the ovaries stop making estrogen and menstruation ends. Menopause also marks the end of the reproductive years. The average age of menopause in the United States is 51 years.

The years leading up to menopause are called perimenopause. Perimenopause generally begins in the mid-40s. During this time, the amount of estrogen produced by the ovaries gradually decreases.

Common signs of perimenopause include changes in the menstrual cycle, hot flashes, and sleep problems. Decreasing estrogen levels can also affect the vagina and urinary tract. Over time:

• The vaginal lining can get thinner, dryer, and less elastic

• The clitoris, labia, and opening of the vagina may get smaller

• The vagina may narrow and become shorter

• The amount of vaginal discharge may decrease

• The decrease in estrogen may also thin the lining of the urinary tract

As a result of these changes, you may have symptoms that are known as genitourinary syndrome of menopause (GSM). Signs and symptoms of GSM include:

• Vaginal burning and itching

• Decreased lubrication during sex, leading to pain

• Bleeding after sex

• More frequent vaginal and urinary tract infections

• Frequent urination

All of these changes can affect your enjoyment of sex and the way you feel about yourself. It is estimated that between 1 in 10 and 1 in 4 menopausal women have at least one of these signs and symptoms.

Many treatment options are available to address the signs and symptoms of GSM. Some are available over the counter without a prescription. Others need to be prescribed by your gynecologist or other health care professional. Treatment options include the following:

• Vaginal moisturizers and lubricants—Moisturizers and lubricants can help relieve vaginal dryness and painful sex. You can buy moisturizers and lubricants at many stores and online. Because they do not contain hormones, these products have no effect on the vagina’s thickness or elasticity.

• Local estrogen therapy—With low-dose vaginal estrogen therapy (vaginal creams, vaginal rings, and vaginal tablets), a small dose of estrogen is released directly into the vaginal tissue. The estrogen helps restore the natural thickness and elasticity to the vaginal lining and relieves dryness and irritation.

• Systemic estrogen therapy—With this type of estrogen therapy (pills, skin patches, or gels or sprays applied to the skin), estrogen is released into the bloodstream and travels to the organs and tissues where it is needed. If you still have a uterus, you also need to take progestin. Estrogen alone can increase the risk of cancer of the lining of the uterus, and adding progestin helps reduce that risk.

• Selective estrogen receptor modulators (SERMs)—These medications have estrogen-like effects on some types of tissue in the body while having no effect on other types of tissue. This can be useful if you don’t want systemic estrogen therapy, which can affect your whole body. For example, one SERM has been approved to treat painful sex in postmenopausal women.

Antibiotics: Medications that treat or decrease the risk of certain infections caused by bacteria.

Bacteria: One-celled organisms that can cause infections in the human body.

Bacterial Vaginosis [va-juh-NOH-suhs] (BV): A condition caused by an overgrowth of certain bacteria in the vagina. Symptoms may include vaginal discharge, fishy odor, pain, itching, and burning.

Bartholin Glands [bahr-TOH-lin]: Two glands located on either side of the vaginal opening that make a fluid during sexual activity.

Clitoris: A female sex organ found at the top of the vulva. 

Estrogen: A sex hormone made in the ovaries.

Genitourinary Syndrome of Menopause [jen-uh-toh-YUR-uh-nair-ee] (GSM): A collection of signs and symptoms caused by a decrease in estrogen and other sex hormones. Signs and symptoms can include vaginal dryness, pain with sex, bladder symptoms, frequent urinary tract infections (UTIs), burning, itching, and irritation.

Hemorrhoids: Swollen blood vessels located in or around the anus.

Hormone: A substance made in the body that controls the function of cells or organs.

Human Papillomavirus [pap-uh-LOH-muh-vy-ruhs] (HPV): The name for a group of related viruses, some of which cause genital warts and some of which are linked to cancer of the cervix, vulva, vagina, penis, anus, mouth, and throat.

Hymen [HIE-muhn]: A membrane at the entrance of the vaginal opening.

Labia Majora [LAY-bee-uh muh-JOR-uh]: The outer, larger folds of tissue of the female genital area.

Labia Minora [LAY-bee-uh muh-NOR-uh]: The inner, smaller folds of tissue of the female genital area.

Lactobacilli [lak-toh-buh-SILL-eye]: A type of bacteria normally found in large numbers in the vagina. These bacteria help keep the vagina acidic and prevent overgrowth of unhealthy bacteria.

Menopause: The last menstrual period, often happening around age 51. Menopause can only be confirmed after 1 year of no periods.

Menstrual Cycle: The monthly changes that prepare the body for a possible pregnancy. A menstrual cycle is defined as the first day of menstrual bleeding of one cycle to the first day of menstrual bleeding of the next cycle.

Microorganisms: Life forms that are invisible to the naked eye and can only be seen with a microscope. Bacteria are an example.

Obstetrician–Gynecologist (Ob-Gyn): A doctor with medical and surgical training and education in the female reproductive system.

Ovaries: Organs that contain the eggs necessary to get pregnant. Ovaries also make important hormones, such as estrogen, progesterone, and testosterone.

Perimenopause: The time period leading up to menopause.

Perineum [pair-uh-NEE-uhm]: The area between the vagina and the anus.

Progesterone [proh-JES-tuh-rohn]: A sex hormone that is made in the ovaries and prepares the lining of the uterus for pregnancy.

Progestin [proh-JES-tuhn]: A synthetic form of progesterone that is similar to the hormone made naturally by the body.

Puberty: The stage of life that leads to sexual maturity. It includes change in the external genitals, the appearance of pubic hair, and growth spurts.

Selective Estrogen Receptor Modulators (SERMs): Medications that stimulate certain tissues that respond to estrogen while not stimulating other tissues that respond to estrogen.

Sexual Intercourse: The act of the penis entering the vagina. Also called vaginal sex.

Skene Glands [SKEEN]: Glands located on either side of the urethra and urethral opening.

Spermicides: Chemicals (creams, gels, foams) that stop sperm from traveling to an egg.

Urethra [yu-REE-thruh]: A tube-like structure. Urine flows through this tube when it leaves the body.

Uterus: A muscular organ in the female pelvis. During pregnancy, this organ holds and nourishes the fetus. Also called the womb.

Vagina: A tube-like structure surrounded by muscles. The vagina leads from the uterus to the outside of the body.

Varicose Veins: Swollen, twisted veins often caused by poor blood flow.

Vestibule: The tissue surrounding the opening of the vagina.

Vulva: The external female genital area.

Yeast Infection: An infection caused by an overgrowth of a fungus. Symptoms may include itching, burning, and irritation of the vulva or vagina and a thick, white discharge.