Sex Hurts!!! Part 2- Vulvar skin issues

Your vulva is sacred

The vulva is a sacred area, am I right? It's sensitive, and only seen by a few chosen folks in your adult life. Being a gynecologist, the fact that I'm one of those people is special, and I take it seriously. But showing me that sensitive area is one thing. Showing it to a sexual partner is another. If you're not sure what's going on down there, you may find yourself embarrassed or uncomfortable with sex, especially oral sex, because he/she is looking there too.

Vulvar skin disorders are one of the most common things that cause issues in your nether-regions, and are often a source of awkwardness with sex. They can cause itching, discharge, pain, and just generalized discomfort. And often times, those symptoms cause sexual dysfunction; either you're avoiding it altogether, or it hurts.

Where is my vulva, exactly?

Let's do a very quick anatomy lesson. The vulva is the area of skin around the outside of your vagina, encompassing all of your external genital organs. Here's a nice pictorial. You'll notice the internal structures in relation to the outside structures in this picture.

The different types

There's several types of vulvar and vaginal skin disorders. Here's a short list of the most common ones I see and treat. We'll go into more detail in a minute:

- Contact dermatitis
- Lichen simplex chronicus
- Lichen sclerosus and lichen planus

Contact dermatitis

Ok, ladies, this one's important!! This is one of the most common causes of itching and pain on the vulva. It's also the easiest to treat! The skin on your bottom is very sensitive. Many women are "allergic" to stuff that touches their vulva. A common list of allergens:

Pads (especially scented ones), soaps, laundry detergent, feminine wipes/sprays, condoms, latex, vulvar and vaginal creams.

First things first...stop putting this stuff on your bottom. Removing the irritant is the most important part of the treatment. It's not always easy to figure out what exactly is the cause, so I recommend not putting ANYTHING on your vulvar skin if you're having itching or discomfort there. Water is sufficient for washing your vulvar skin; you don't even need soap! And like I tell my patients, the vagina is like a self-cleaning oven. If you interrupt the vagina's normal flora, the self cleaning part doesn't work. So, no douches, wipes, sprays etc...up inside the vagina or on the vulva.

What you'll get from the gynecologist is a moderate to high dose steroid cream. This will clear up the skin reaction, and voila! Back to normal.

Lichen Simplex Chronicus (LSC)

This is the fancy medical term for eczema (atopic dermatitis) of the vulva. Yep, you can get eczema down there. For some of women, it's the only place they get it. In fact, it's pretty common. So, LSC is an chronic inflammatory disorder of the skin which usually starts with some type of allergic trigger (see above). It can be isolated, or you can have other hypersensitivity reactions- like allergic asthma, bad seasonal allergies, and random skin rashes.

This type of skin disorder is an itch/scratch/itch cycle. It itches SOOOOO much that people wake up at night scratching. They avoid social situations due to it, and find really creative ways to scratch their bottoms in public. These people will say it feels really good to scratch, but then it hurts afterwards. With repetitive scratching, the skin eventually reacts by coming thicker and can get oozy. This skin thickening just perpetuates the cycle of itching. Diagnosis is usually just with a physical exam, but if I'm not sure, I might do a small biopsy to confirm it.

Treatment: BREAK THE CYCLE.

Unfortunately, this issue tends to be chronic and recurrences are common. So, breaking the cycle of itch/scratch/itch tends to be ongoing. It's important to identify and remove the trigger if it's still there. And then I use a constellation of meds to stop the itching and reduce the desire to scratch. Anxiety and depression are common with this, so I treat these too. 

Lichen Sclerosus (LS) and Lichen Planus (LP)

These are two separate chronic inflammatory disorders of the vulva. I'm lumping them together because they're kinda similar in their symptoms and how they are treated. We're not really sure exactly what causes them, but popular scientific opinion is that they're autoimmune related. Most likely there's a genetic susceptibility that's activated by a trigger, like a trauma (childbirth or genital piercing...). The reason we think they're autoimmune related is that a lot of people with LS and LP have another autoimmune disease too, like Hashimoto's thyroiditis or vitiligo, and show blood testing consistent with autoimmune skin issues.

The most common symptom of LS is itching, which is at it's worst at night. Chronic scratching then causes pain and breaks in the skin. These cause pain with sex. 

The most common symptoms of LP are pain and soreness.

Unfortunately these are unquestionably life-long diagnoses with their ups and downs. They can't be cured, but can be treated. In fact, treatment is really important because if untreated you can get scarring of your vulvar organs (like the clitoris) and eventually they can lead to cancer. A biopsy might be needed if I'm not sure, and to rule out cancer at the time of diagnosis. Treatment is medical with close monitoring for life to watch for cancer.

Resources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3691475/
The vulvar dermatoses. Krapf MD et al.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5419035/