Vulvar Disorders

The vulva

The vulva includes the mons pubis, outer and inner labia, clitoris, vestibule (the area around the vaginal and urethral openings) and the Bartholin's glands, which produce lubrication. Vulvar skin is thin, moist and sensitive, and it changes with hormones throughout life.

Common vulvar disorders

Infections

Skin conditions (dermatoses)

• Contact dermatitis: red, itchy, burning skin from soaps, wipes, pads, spermicides, fragrances or medicines.
• Lichen sclerosus: white, thin, crinkled skin, intense itching, fissures and scarring; most common after menopause; needs long-term steroid ointment; small cancer risk.
• Lichen planus: painful red erosions, sometimes with white lacy streaks, often also in the mouth and vagina.
• Lichen simplex chronicus: thick, leathery skin from chronic scratching.
• Psoriasis and seborrheic dermatitis: red, well-defined patches.

Hormonal changes

After menopause, low estrogen causes thinning and dryness, see atrophic vaginitis. Symptoms include dryness, burning, pain with sex and urinary symptoms. Breastfeeding causes similar temporary changes.

Cysts and lumps

• Bartholin's cyst and abscess: a swelling at the lower side of the vaginal opening; abscesses are very painful and need drainage.
• Epidermoid (sebaceous) cysts, skin tags, lipomas, varicose veins of the vulva in pregnancy.
• Hidradenitis suppurativa: recurrent painful lumps and draining tunnels in skin folds.

Pain conditions

• Vulvodynia: chronic vulvar pain for 3 months or more without another identifiable cause. Provoked vestibulodynia (formerly vulvar vestibulitis) causes pain with touch or penetration at the vaginal opening.
• Vaginismus: involuntary muscle tightening with penetration.

Inflammatory and systemic conditions

Behcet's disease (recurrent genital and mouth ulcers), Crohn's disease affecting the vulva, and autoimmune blistering diseases.

Precancer and cancer

Vulvar intraepithelial neoplasia (VIN) and vulvar cancer are uncommon. Signs include a persistent itch, a lump, an ulcer, a raised red, white or dark patch, or bleeding. HPV-related types occur in younger women; others arise in lichen sclerosus in older women.

Symptoms

• itching, burning or soreness
• pain, especially with sex, tampons, sitting or tight clothing
• rash, redness or swelling
• white, thin or thickened patches
• blisters, sores, ulcers or cracks
• lumps or warts
• discharge or odor

Diagnosis

A primary care doctor, gynecologist, dermatologist or vulvar specialist will:

• take a history of symptoms, products used, sexual health, menstrual and menopausal status, and skin conditions elsewhere
• examine the vulva, sometimes with magnification (vulvoscopy)
• take swabs for yeast, bacteria and herpes, and test for STIs
• do a cotton swab test to map pain in suspected vulvodynia
• take a biopsy of persistent, unusual or non-healing areas, which is quick and done under local anesthetic
• use patch testing for suspected contact allergy

Treatment

• Vulvar care: wash with plain water or a soap-free emollient, avoid fragranced products and douches, wear cotton underwear, use unscented pads or alternatives, and apply a barrier ointment such as petroleum jelly.
• Infections: antifungals, antibiotics or antivirals as appropriate.
• Dermatoses: potent topical steroid ointments for lichen sclerosus and lichen planus, with ongoing maintenance.
• Menopausal changes: lubricants, moisturizers and low-dose vaginal estrogen.
• Vulvodynia: pelvic floor physical therapy, topical lidocaine, nerve pain medicines, cognitive behavioral therapy and sometimes surgery.
• Cysts and abscesses: warm soaks, drainage, Word catheter placement or marsupialization.
• Precancer and cancer: surgery, laser or topical treatments, guided by specialists.

Frequently asked questions

What are the most common vulvar disorders?

Common vulvar disorders include yeast infections, contact dermatitis from soaps and pads, lichen sclerosus, genital herpes, Bartholin's cysts, vulvodynia and menopausal dryness. Most are easily treated once diagnosed.

What causes vulvar itching?

Common causes are yeast infections, irritation or allergy to products, lichen sclerosus, lichen simplex chronicus, and menopausal dryness. Less often, scabies, pubic lice or precancerous changes cause itching. Persistent itching should be examined.

When should I worry about a vulvar lump or sore?

See a doctor for any vulvar lump, sore or patch that does not heal within 2 to 3 weeks, bleeds, or changes color or size, especially after age 50. A biopsy can quickly rule out precancer or cancer.

Is lichen sclerosus serious?

Lichen sclerosus is a long-term skin condition that is not contagious. Untreated, it can cause scarring and a small increased risk of vulvar cancer. Regular use of strong steroid ointment controls symptoms and reduces these risks, so ongoing follow-up is important.