Vulval and vaginal problems haven’t received much attention until quite recently, but in the past 10 years or so many doctors have tried to develop theories and treatments for these distressing conditions.
Unfortunately, many chronic vulvo-vaginal symptoms are still not properly understood. This has led to a number of conflicting opinions about their causes, and therefore their possible remedies.
The aim of this guide is to demystify vulval problems by offering an alternative to the current ways of explaining and treating these conditions.
Many women suffer in silence from annoying and distressing vulval symptoms, either because of embarrassment or because they believe (or have been told) that nothing can be done to help. We have known patients whose stories went back 25 years or more.
Vulval discomfort can take a wide variety of forms. Some of the words our patients use to describe their discomfort are:
- vaginal discharge.
It is important to understand that a particular symptom does not necessarily mean a particular diagnosis. For example, many women believe that an itch always means that they have vaginal thrush (candidiasis, monilia). This is just not true. In fact, we have found that any vulval symptom may be due to just about any vulval diagnosis.
A particular feature of vulval problems is that discomfort can often remain unnoticed until it becomes severe. This is why a patient will often state that her primary concern is painful sexual intercourse, and is surprised when we show her (using a mirror) how badly inflamed her vulval skin is.
Some women with badly inflamed vulval skin do not even notice discomfort on entry to their vaginas, but will seek help from their doctors only when they have deep dyspareunia (abdominal pain during sex because of pelvic muscle spasm). These women are not ‘neurotic’: the natural lack of pain sensation in their vulval and vaginal regions has allowed the inflammation to become severe without their realising it.
Cycles of vulval discomfort
Sometimes, vulval discomfort may be worse at a particular time of the month, often at period time. We think that this ‘cycling’ discomfort is usually due either to thrush or to an allergy to the body’s natural oestrogen production. Oestrogen allergy is something that you may not have heard of. It has been suspected for some time, and recently proven to exist by research done by Dr Fischer and her colleagues. It should be stressed, however, that the oral contraceptive pill does not cause or exacerbate an oestrogen allergy, which is caused by a woman’s own natural oestrogens.
You may have had the frustrating experience of being told by your doctor that they cannot see any visible abnormality on your vulval skin, even though you are experiencing a lot of discomfort in this area. We believe that almost all vulval problems are due to various types of skin disorders: the problem with recognising these skin problems is that they do not look the same as when they occur on ‘outside’ skin, for example, the hand.
The local conditions of heat, wetness and friction modify the ‘text-book’ signs of skin disease when it occurs on the vulva. These conditions also make these skin signs much more subtle. This is why many doctors may think that your vulval skin looks ‘normal’, when in fact there may be a subtle (but still significant) rash on it.
Vulval symptoms: often a skin problem, not a gynaecological one
Most of the women we see with vulval symptoms actually have ordinary ‘common or garden variety’ dermatitis (also known as eczema). We believe these usually simple diagnoses are often missed by doctors and health nurses because they are looking for a ‘gynaecological’ diagnosis, and therefore don’t think about the possibility of a dermatological cause for these symptoms.
These women are often referred to gynaecologists who haven’t been trained in dermatology. The result, in our opinion, is diagnostic terms that can be misleading, such as ‘vestibulitis’ and ‘vulvodynia’. Not surprisingly, the treatments that have been developed from these diagnoses don’t work very well. This is why there are so many frustrated doctors, and so many unhappy patients.
While it is true that skin problems on female genital skin will be modified by the local conditions of heat, wetness, friction, and hormones, we want to state very clearly that from our research, the fundamental cause for almost all vulval symptoms is some sort of skin problem, not a ‘gynaecological’ one.
Even when a skin diagnosis is considered, the treatment is often not effective. We have discovered that this is because dermatological treatment principles need to be modified in the following ways to work effectively on vulval skin.
- Treatment needs to be continued for much longer than on ‘outside’ skin.
- Much more attention should be paid to eliminating all forms of friction, and to eliminating all contact of this skin with any sort of chemical at all.
- Long-term cases of vulval dermatitis are often complicated by secondary infections. The organisms responsible are almost always ‘normal’ residents of the vagina, and may therefore be ignored by either the pathologist or the treating clinician. Failure to deal with these infections, however, can lead to treatment failures.
There are a number of much more uncommon causes for vulval skin problems, and we will outline these at the end of this guide. However, we want to state once again that any vulval discomfort you might have is far more likely to be caused by dermatitis than by any of the other diagnoses we will describe.
By far the most common cause for vulval symptoms is dermatitis (also known as eczema). Many women with dermatitis are atopic. This means that they may suffer from such allergic conditions as hay fever, asthma or dermatitis (‘sensitive skin’). Often they become itchy if they wear pure wool clothes, do housework or gardening, or use a soap or bubble bath. Dermatitis is made worse by irritation or allergy.
Think for a moment about all the rubbing that your vulval skin has to put up with: panties (especially G-strings); panti–liners and pads; pantihose; gym clothes; jeans—the list is endless!
When you have sexual intercourse, the rubbing involved is merely the last straw in a long line of irritants. If your vulval skin is healthy, and your partner understands how to arouse you properly, then sex does not cause pain or discomfort. Having sex is not the main problem: the big problem is the inflammation of your vulval skin from all the other irritants.
Since vulval skin is just skin, your problem ‘down there’ might be due to an allergic reaction to any one of a number of chemicals. It is very easy to bring vulval skin into contact with chemicals that could set up an allergy. Here are just some examples.
- Toilet paper often contains perfume and colourings.
- Almost all soaps, cleansers and bath additives contain perfumes and preservatives that might give you an allergy (even hypo-allergenic products).
- Talcum powder can give you an allergy, as can some brands of personal lubricant.
- Vaginal creams for fungal infections may actually give a woman a vulval skin allergy and make her itch worse, as can creams used for haemorrhoids (‘piles’).
- Increasing numbers of women are becoming allergic to the latex in condoms.
Dermatitis is made worse by:
- wetness and
It is therefore not surprising that so many women suffer from chronic vulval discomfort.
Dermatitis treatment: the recipe
- Vulval skin is meant to be wet and warm! Unfortunately, this means that it takes much longer to treat dermatitis in this area than it would on, for example, your hand. Even a mild case takes a minimum of at least one month to improve. More serious cases of dermatitis often take 3 to 6 months.
- The wetness and warmth of vulval skin also means that it is very easy to keep it inflamed, and therefore very hard to reduce any inflammation. In everyday life, this means that you can’t have a ‘day off’ from the treatment, or you may cancel out the gains you have previously made. It also means that you will have to give up completely (at least for several months) any personal hygiene routines or clothes that have been keeping you irritated.
- Ignoring the above 2 points explains why vulval dermatitis often fails to settle, even if you have been using a treatment programme similar to ours. Successfully treating vulval dermatitis requires great persistence!
Spend some time thinking about the (apparently) harmless activities that might be making your vulval skin irritated. It is essential that you eliminate these activities, at least until you are well again. Whatever else is on your list, we strongly suggest you implement the following suggestions.
- No soap, bubble bath and essential oils.
- Use a soap substitute from your chemist (not from a supermarket)—it must be 100 per cent free of soap and perfume. Plain water is also a perfectly satisfactory cleanser.
- Try not to rub and scratch, even with wash cloths or towels.
- Use toilet paper without perfume or colouring.
- Wear 100 per cent cotton underwear, and ensure it is not too tight.
- No pantihose, G-strings or tight trousers.
- Use tampons instead of sanitary pads, where possible.
- No panti-liners in between periods, and no talcum powder or perfume.
- Don’t douche–it will ruin the natural balance of your vagina and vulva.
- Before commencing sex, protect your vulval skin with a thin coating of petroleum jelly, vegetable oil or glycerine. (But don’t use petroleum jelly or oil if you use condoms.)
No medications will ever work unless you use them in conjunction with our ‘environmental’ recommendations. However, most women require a moisturiser and a steroid preparation to achieve adequate control of their dermatitis symptoms.
When we use this term, we don’t mean the moisturisers you would normally use on other parts of your skin, which can often cause dermatitis. The safest moisturiser is (you guessed it) petroleum jelly. Use a thin smear any time your vulval skin feels uncomfortable. It is surprisingly well absorbed and can be used as often as you like.
These medicines come in a variety of strengths, and most can be obtained only on prescription. However, most of our patients need only a very low-dose type called 1% hydrocortisone ointment. This is available without a prescription in most countries. (1% hydrocortisone also comes as a cream, but we have found that the cream form gives some people allergies.)
Put a thin film of this ointment onto every area that feels inflamed. Do this 2 or 3 times a day. Don’t be afraid to apply it all the way into the entrance of the vagina, as this is actually still part of the vulval skin, and is almost always involved in vulval dermatitis.
Length of treatment
You should stick to the recipe faithfully for a minimum of one month. If there is no obvious improvement after this time, then you and your doctor need to find out why. There are 3 reasons for a lack of success.
- Not adequately sticking to the recipe. Most of the time, this is because a patient has not been applying the steroid ointment properly to the most inflamed areas (which are usually in skin folds, or deep inside the vaginal entrance) or has been continuing a personal hygiene habit which is keeping the skin irritated.
- Secondary infections. The most common infection to occur in dermatitis-affected vulval skin is a fungal infection (thrush). Ideally, your doctor should have performed a vaginal swab when you first consulted them about your problem, and treated any infection at the same time as treating the dermatitis. However, many women self-medicate with thrush treatments from the pharmacy, and consult their doctor only when this has not worked.
A swab taken within 2 weeks of using thrush medication may be falsely negative. This is why your doctor should always take another vaginal swab if simple dermatitis treatment is not working, as a fungal infection may have been missed initially.
A germ called Streptococcus may less commonly cause secondary infections. A vaginal swab will also pick this up. Your doctor will be able to treat this with either oral or vaginal antibiotics.
- You do not have dermatitis. It is our contention that at least 7 out of 10 women with vulval symptoms have dermatitis as their fundamental problem. However, a minority of patients we see have other causes for their vulval discomfort. The two other most common diagnoses we see are:
This a common inflammatory skin condition which most often occurs on the scalp, elbows and knees. It is one of the causes of dandruff. The symptoms, skin appearance and treatment of vulval psoriasis are very similar to dermatitis, but it often requires a tar preparation (a special one designed for delicate skin) to control it, as well as a recipe similar to the one described above.
No one knows why this disease starts or continues. Lichen sclerosus is an auto-immune skin disease which most commonly occurs on the vulval skin. Most cases occur in women of Anglo-Celtic origin. Again, treatment principles are very similar to that of dermatitis. However, untreated lichen sclerosus may sometimes cause cancer in the affected skin (unlike dermatitis which does not cause cancer if left untreated).
It is thought that proper long-term treatment of vulval lichen sclerosus will reduce the risk of cancer to very low levels. Therefore, the major difference between the treatment for dermatitis and for lichen sclerosus is that it is essential to stay on appropriate treatment, even when you have no symptoms. It is also essential to be referred to a gynaecologist or dermatologist who is experienced in the management of lichen sclerosus.
See your doctor
It is perfectly safe for you to use our ‘recipe’ for no more than one month, to see if it helps your vulval symptoms. However, we want to emphasise that if your problem does not settle after this time, you should promptly consult your family doctor. They will be able to check for other, less common vulval problems, and advise you further.
Dr Gayle Fischer is a specialist dermatologist who practises in Sydney. She has written extensively on vulval skin problems, and is a frequent speaker on this topic at medical conferences. Dr Jennifer Bradford is a specialist gynaecologist who practises in Sydney. She is interested not only in vulval skin problems, but also in women’s hormonal disorders and chronic pelvic pain.
Dr Fischer and Dr Bradford conduct a joint private clinic where they see women with complex vulval conditions.
To find out more, go to Combined Clinic for Vulval Disorders