Vaginal Health
Women frequently perceive themselves as isolated when experiencing vulval symptoms, often hesitating to discuss these issues with family or friends. However, it is crucial from women to recognise that vulval disorders are widespread, and obtaining a diagnosis is the initial stride towards effectively managing any conditions.
This guidance pertains to individuals experiencing vulval symptoms, including itching, soreness, or burning pain. Proper care of the vulva is crucial for managing various vulval conditions.
- Key principles to follow include:
- Avoiding contact with potential irritants.
- Limiting cleaning to once daily.
- Refraining from scratching.
- Keeping the skin well moisturised.
- Applying topical treatments as prescribed by your healthcare provider.
- Using appropriate vaginal lubricants during intercourse as recommended.
To avoid irritation:
- Refrain from using perfumed or soapy products.
- Avoid feminine wipes or toilet wipes.
- Opt for loose clothing over tight trousers or jeans.
- Choose cotton underwear.
Avoid wearing pyjamas and underwear to bed. - When necessary, opt for pantry liners or sanitary towels without chemicals.
- Seek treatment for urinary incontinence.
It’s important not to over-clean the area, as excessive washing can disrupt the skin’s natural bacterial balance, leading to increased irritation. Instead, a warm bath once daily is recommended.
Resist the urge to scratch, as it can exacerbate soreness and damage the skin. Keep fingernails short and avoid nail varnish. If nighttime scratching is an issue, consider wearing cotton gloves to bed. Alternatively, apply cool moisturizer or ice wrapped in a cloth to alleviate itching.
Regular moisturizing is essential to condition the skin. Apply a moisturizer at least once daily as per your healthcare provider’s recommendation.
Follow your healthcare provider’s instructions regarding the application of topical treatments. Less is often more, and medication will be reviewed at each visit.
For individuals experiencing difficulties with intercourse due to vulval conditions, using a natural water-based lubricant can help. Your healthcare provider can provide further guidance on this matter, particularly regarding arousal and pain management during sex.
Vulval and Vaginal Conditions
Depending on the clinic you attend we may recommend referral to a specialist for further management and examination. Whilst we cannot examine patients on our virtual consultations we can advise you on self examination and help navigate you to NHS or private specialists for further management.
Lichen Planus (LP) is an inflammatory condition that can affect women of any age but is more prevalent after menopause. Inflammation may impact the skin of the vulva, inside the vagina, in the mouth, or elsewhere on the skin. The exact cause of LP is not fully understood, but it may involve an autoimmune response, where the body’s immune system attacks its own tissues. LP is not contagious or infectious.
Common symptoms of LP include:
- Soreness of the vulval skin
- Skin appearing raw with breakdown
- Painful intercourse
- Persistent vaginal discharge (which may be bloody)
- Changes in the appearance of the vulva, such as loss of labia minora (vulval lips) and flattening of the clitoral hood
- Blockage within the vagina, making intercourse or smear tests difficult
- Vulval itching
Diagnosis:
LP is typically diagnosed based on medical history and a physical examination by a specialist. Occasionally, a biopsy (a small piece of skin) may be necessary to confirm the diagnosis.
Treatment:
There is no cure for LP, as it is a chronic condition. Treatment aims to alleviate symptoms and prevent further inflammation. The course of LP varies for each individual, with symptoms often fluctuating over time and occasionally resolving completely. The main treatment involves the use of steroid ointments on the skin and vaginal steroid preparations. It’s important to avoid vulval irritants, such as soapy or perfumed products, and daily moisturizing can help improve skin quality. In cases where symptoms are challenging to manage, oral steroid tablets or medications to suppress the immune system may be prescribed. For involvement of the vagina, vaginal dilators and specialized physiotherapy may be recommended. Surgical intervention is rarely necessary, but division of scar tissue within the vagina may be indicated in some cases.
Follow-up:
Regular appointments with a specialist are essential until symptoms are well controlled. Women with LP have a slightly increased risk (3%) of developing vulvar cancer, necessitating long-term surveillance, typically every 6-12 months.
Lichen sclerosus (LS) is an inflammatory skin condition primarily affecting the skin of the vulva and the area around the anus. It can develop at any age but is most commonly seen after menopause. The exact cause of LS is unknown, but it may be related to autoimmune processes, where the body’s immune system mistakenly attacks its own tissues. LS is not contagious and cannot be transmitted to others.
Common Symptoms of LS
- Itching in the genital and anal areas.
- Skin soreness, particularly when urinating.
- Changes in skin color, which may appear white or red.
- Alterations in the appearance of the vulva, such as shrinking or flattening of the labia minora or clitoral hood. The vaginal opening may also become narrower.
- Discomfort during sexual intercourse.
Diagnosis is typically made by a specialist who will review your medical history and perform a physical examination of the vulva. In some cases, a biopsy (a small skin sample) may be taken to confirm the diagnosis.
Treatment
While there is no cure for LS, the goal of treatment is to manage symptoms and maintain as normal a structure as possible:
- Steroid ointments are highly effective in reducing or eliminating itching.
- Regular moisturizing of the affected skin is crucial, and it’s important to avoid using soapy or perfumed products on the affected area.
- Surgery is rarely a treatment option for LS but may be considered to widen the vaginal opening if it significantly affects sexual intercourse or urination.
Follow-Up Care
If diagnosed with LS, you will likely undergo regular follow-ups with your specialist until your symptoms are well-managed. Long-term monitoring is important due to a small risk (3-5%) of skin cancer associated with LS. It is recommended that individuals with LS have at least an annual check-up to monitor for potential complications.
Vulvar cancer is rare, but before it develops, there typically is a pre-cancerous phase formerly known as Vulval Intraepithelial Neoplasia (VIN) and now referred to as High-Grade Squamous Intraepithelial Lesion (HSIL) of the vulva. Our goal is to identify and treat this pre-cancerous condition early to prevent the development of cancer.
Risk Factors
Some types of vulvar cancer are linked to chronic inflammatory conditions such as lichen sclerosis or lichen planus. Therefore, regular follow-ups with your specialist are crucial if you have one of these conditions. Additionally, the Human Papilloma Virus (HPV), which also causes cervical pre-cancer and cancer, can lead to vulvar pre-cancer. Regular cervical screenings are essential if you have vulvar pre-cancer, especially since persistent HPV infections, which are more common among smokers and individuals with weakened immune systems, increase the risk of developing pre-cancerous changes.
Common Symptoms
Pre-cancer of the vulva may appear as lumps or bumps on the vulva, sometimes resembling warts, with variable color changes including red, white, brown, or black. Symptoms often include vulvar soreness and occasionally itching.
Diagnosis
A detailed examination of the vulva, potentially using a microscope (vulvoscopy), is essential for assessing suspicious lesions. If pre-cancer of the vulva is suspected, a biopsy will be performed under local anesthesia in the clinic to confirm the diagnosis.
Treatment Options
Treatment plans are personalised based on individual needs and circumstances, and it is strongly advised for all women with vulvar pre-cancer to quit smoking to reduce the risk of persistent or recurrent disease. Treatment may be surgical or medicinal:
- Surgery: This is generally the preferred method, involving the removal of affected tissue under general anesthesia, often as a day procedure. The area is usually closed with dissolvable sutures. Alternatively, heat or laser treatments might be used.
- Medication: Imiquimod cream, used off-label, may treat vulvar pre-cancer by boosting the local immune response when applied to the lesion. Side effects can include burning, redness, and irritation. Treatment duration can be up to four months, as directed by your specialist.
Recurrence and Follow-Up
Pre-cancer of the vulva can recur; therefore, ongoing surveillance is necessary after treatment. If you have a history of recurrent vulvar pre-cancer, long-term specialist follow-up is likely needed. Initially, follow-up appointments are scheduled every three to six months. If no recurrence is observed, these may shift to an annual basis.
Bleeding after intercourse is a relatively common issue and can be caused by various factors. If you notice bleeding during or after sex that persists for more than three months, it’s advisable to consult a specialist. The severity of bleeding can vary from light spotting to heavy bleeding similar to a menstrual period.
Common Causes of Bleeding After Sex
- Pelvic Infection: Often accompanied by pain and discharge, pelvic infections can cause bleeding. It’s wise to undergo an STI screening if you experience these symptoms.
- Cervical Ectropion: This is a benign condition where glandular cells from inside the cervical canal appear on the outer surface of the cervix. These cells are delicate and may bleed upon contact during intercourse. While treatment isn’t always necessary, bothersome symptoms can be addressed with a minor heat treatment procedure performed under local anesthesia in a clinic.
- Vaginal Atrophy: In post-menopausal women, decreased estrogen levels can lead to dry and thinning vaginal tissues, causing bleeding from friction during sex. Treatments include local estrogen therapy or vaginal moisturizers.
- Cervical Polyps: Benign growths on the cervix can also cause bleeding when disturbed. These are typically removed easily in a clinical setting.
- Contraceptives: Some forms of birth control can lead to bleeding after sex.
- Cervical Cancer: Although rare, it’s important to rule out cervical cancer as a cause of bleeding after sex. In the UK, cervical cancer occurs in approximately 9 out of every 100,000 women. Regular cervical screening greatly reduces the risk of developing cervical cancer.
Diagnostic and Treatment Approach
If you experience post-coital bleeding, it’s crucial to see a specialist who may perform a colposcopy—a detailed examination of the cervix using a microscope—to determine the cause. Treatment will depend on the underlying reason for the bleeding and the severity of the symptoms.
Vulvodynia is recognised as a chronic pain syndrome characterised by burning pain on the vulva that persists for at least three months without any visible signs of vulval abnormalities. The pain is believed to be caused by hypersensitivity of the nerve fibers in the vulvar skin, which send abnormal pain signals to the brain.
Incidence and Prognosis
Vulvodynia is relatively common, yet many women are hesitant to discuss it and often delay seeking medical advice. The reasons some women develop vulvodynia while others do not remain unclear, though it may start with nerve irritation possibly triggered by an infection such as thrush. Vulvodynia is not infectious or contagious. The prognosis can vary widely; some women may experience an improvement in symptoms without treatment, while others may suffer from persistent symptoms over many years. However, most women achieve some level of symptom control with appropriate treatment.
Classification
Vulvodynia is categorised based on the occurrence of symptoms:
- Provoked Vulvodynia: Pain occurs with specific triggers such as touching the vulva, sexual intercourse, cycling, or inserting tampons.
- Unprovoked Vulvodynia: Pain occurs spontaneously or intermittently without an apparent trigger.
Common Symptoms
- Persistent burning, soreness, or pain of the vulva
- Pain during sexual intercourse, often severe enough to make sex very difficult or impossible
- Discomfort during smear tests
Diagnosis involves a detailed patient history and a physical examination. There are no specific tests to diagnose vulvodynia.
Treatment should be overseen by a specialist in vulval diseases and often involves multiple therapies. Treatment goals typically focus on managing pain and achieving pain-free sexual intercourse. Treatment approaches may include:
- Topical anesthetic agents
- Specialist physiotherapy
- Medications to modulate abnormal nerve impulses
- Steroid injections
- Psychosexual therapy
- Water-based vaginal lubricants
- Vaginal dilator therapy
- Cognitive Behavioral Therapy (CBT)
- Acupuncture
- Surgery, specifically vestibulectomy, which is considered only for select cases of Provoked Vulvodynia where it is deemed likely to be effective. Surgery is a last resort due to the risk of exacerbating symptoms.
Follow-Up
Management plans are highly personalised and will vary from one patient to another. Regular follow-up appointments are essential to monitor the effectiveness of treatment and adjust as necessary.
Vulval Self Examination Leaflet
Provides instructions on how to conduct a vulval self-examination, crucial for detecting potential abnormalities early. Vulval cancer affects over 1,000 women in the UK annually, and some inflammatory skin conditions may progress to cancer. Click here to view the leaflet.
Vulval Self Examination Video
Demonstrates how to perform a vulval self-examination. Early detection of vulval cancer, which affects approximately 1,400 women in the UK each year, can lead to more conservative and less invasive treatments. This video is part of the EDuCATE study. Click here to watch the video.
SOCIETIES
- British Association of Dermatologists: Offers advice and leaflets specifically authored by dermatologists. Click here for more information.
- British Association for Sexual Health and HIV (BASHH): Provides guides and support related to sexually transmitted infections. Click here for resources.
- International Society for the Study of Vulvovaginal Disease (ISSVD): Features a comprehensive list of topics on vulvovaginal health. Click here to explore.
- Vulval Pain Society (VPS): An excellent resource for those suffering from vulval pain, including guidance on pain-free smear tests. Click here to visit.
DERMATITIS
- Eczema Society: Patient leaflet offering insights into managing dermatitis. Click here to read the leaflet.
GENERAL ITEMS
- Pelvic Floor – Incontinence Focus: Covers bladder training, pelvic floor exercises, and surgical options. Click here for more information.
LICHEN PLANUS
- UK Lichen Planus (UKLP): A valuable site for those affected by Lichen Planus. Click here to learn more.
- Budesonide Foam for Vulval and Vaginal Erosive Lichen Planus: Information on an alternative treatment to prednisolone suppositories. Click here for the factsheet.
- ISSVD – Lichen Planus Leaflet: Offers patient information specifically about Lichen Planus. Click here to view.
LICHEN SCLEROSUS
- 10 Facts About Lichen Sclerosus: Provides essential information about Lichen Sclerosus. Click here to read more.
- British Association of Dermatology – Lichen Sclerosus Leaflet: Detailed patient information on managing Lichen Sclerosus. Click here for the leaflet.
- Crib Sheets and Monitoring Guides: Includes various resources for patients and clinicians on managing Lichen Sclerosus.
- Taking a Punch Biopsy of the Vulva: Guidelines for clinicians. Click here for instructions.
- Living with Vulval Lichen Sclerosus – A Short Film: A film aimed at healthcare professionals to increase awareness of Lichen Sclerosus. Watch the film here and provide feedback via this survey.
NORMAL VULVA
- Leaflets on Normal Vulva: Educational resources for adult women and adolescents to understand what a ‘normal’ vulva looks like.
VULVODYNIA
- Vulvodynia – Vulval Pain Society: Offers a patient leaflet with detailed information on managing vulvodynia. Click here to access the leaflet.
