Every year women should seek a proper medical examination of their physical state simply as a matter of preventative care. As healthcare providers, our job is not only to evaluate and treat disease and dysfunction, but to provide necessary education for the best healthy outcomes. This physical should always include an assessment of our urogenital system. Unfortunately, proper vulvar care is rarely discussed. Explaining what the vulva is and the basics of good care are a good place to start.
Know Your Vulva
Mons Pubis: The fat pad lies over the pubic bone. It is covered with hair and provides cushioning during intercourse. It contains sebaceous glands that secrete pheromones to induce sexual attraction.
Labia Majora: The larger outer lips which often hide the inner vulva. These contain fat and are covered with hair. It covers the labia minora, clitoris, vestibule, vestibular bulbs, Bartholin’s glands, Skene’s glands, urethra and the vaginal opening. It engorges with blood and appears edematous during sexual arousal.
Labia Minora: These inner lips do not contain fat and do not have hair. The anterior folds of the labia minora encircle the clitoris forming hood of the clitoris. It descends obliquely to form the borders of the vestibule. It engorges with blood and appears edematous during sexual arousal.
Clitoris: The glans, or body, of the clitoris is the small part of this organ that is visible externally. It lies beneath the meeting point of the inner labia, just below the mons pubis. It contains many nerve endings, is highly sensitive and engorges with blood during arousal.
Urethral Opening: This is the external opening by which urine passes out of the body. The urethra connects the bladder to the vulva.
Vestibule: The inner circular area between the labia minora and the opening to the vagina. It contains the opening to the urethra and vagina.
Hart’s Line: This is a line of demarcation between the inside of the inner labia minora and the vestibule. This marks a change in the skin from the outer keratinized skin to the smoother skin of the vestibule. The outermost surface of the skin called the stratum corneum stops here, making the skin in this area thinner than the surrounding tissue. It gives it a lighter/whiteish color. The other parts of the vulva containing the stratum corneum have the thickness and color of the rest of your skin.
Vaginal Opening: The point at which the vagina meets the vulva.
Posterior Fourchette: The bottom meeting point of the labia minora. It lies between the vaginal opening and the perineum.
Perineum: This is a bridge of skin and muscle which separates the fourchette from the anus.
Bartholin’s Glands: These are two pea-sized glands located slightly lateral and posterior to the vaginal opening. They secrete a mucus-like substance into the vagina and within the borders of the labia minora. This acts as a lubricant to decrease friction during intercourse and a moisturizer for the vulva.
Skene’s Glands: These glands lie on either side of the urethra. They secrete a substance to lubricate the urethral opening. It is also believed to act as an antimicrobial fighting against urinary tract infections (UTI).
Vestibular Bulbs: These are two bulbs of erectile tissue that begin near the inferior side of the body of the clitoris and extend toward the urethra and vagina. These engorge with blood during arousal and exert pressure on the clitoris to induce pleasure.
Anus: This is the external opening of the bowel. It is often included in the vulva as many skin conditions of the vulva can involve this area as well.
Now, how do we properly care for this area?
The vulva has a pH of around 5.0-5.5, which is mildly acidic. The pH scale runs from 0 to 14, with 0-6.9 as acidic, 7 neutral and 7.1 to 14 being basic. When this balance is tipped toward the basic end of the pH scale, the healthy biome of the vulva is disrupted. Soap has an average pH of 10. When we cleanse this area with soap, we can develop dryness, redness and itching of the vulva, and burning with urination. In addition to effects of pH, soap breaks down the connections between skin cells, making skin a less effective barrier and drying it out.
The vagina has an average pH of 3.5 to 4.5, which makes it moderately acidic. As vaginal pH rises, we can develop growth of the wrong microorganisms which thrive in higher pH environments and inhibit our normal vaginal bacteria. Common microbial overgrowth conditions of the vagina are: Bacterial vaginosis (pH 4.5), vulvovaginal candidiasis (4-4.5) and trichomoniasis (pH 5-6). These conditions can all produce vaginal discharge that irritate the vulva; bacterial vaginosis in particular can give off a “fishy” odor.
That thinner delicate skin inside of Hart’s Line is susceptible to dryness with use of soap products and makes it prone to irritation especially with products containing a high osmolality. Osmolality is the concentration of particles per kilogram. Many products sold for vulvar use have a high osmolality, which dehydrates and kills cells. The Bartholin’s Glands and Skene’s glands can become inflamed and painful in a dry, high pH, high osmolality environment. Your risk of UTI’s will also increase because of the poor conditions surrounding the urethra.
Artificial fragrances, colors, petroleum products, parabens, chlorhexidine, and polyquaterniums have no place in vulvar care at all ages.
Of note, menopause raises our vulvar pH to greater than 5 through no fault of our own. As estrogen lowers, so do our protective vaginal secretions. These changes cause the vulvar pH to rise and vulva to become drier. This negatively affects the delicate tissue inside Hart’s line, making menopausal women more susceptible to urinary tract infections and painful sex. This can also occur during breast feeding, as estrogen production decreases while we nurse. Extra vulvar care with moisturizers and lubrication may be needed during both times.
Loose breathable fabrics are best for healthy vulvas. Cotton is best, it is breathable, absorbent and can help prevent yeast infections. Synthetic materials like nylon and spandex do not breathe. They trap heat and moisture creating a great breeding ground for yeast infections. Change your underwear more frequently if you are having increased vaginal discharge (can occur during ovulation or arousal) or sweat (summer months or exercise). Panty liners can cause chafing and irritation so it is best to change your panties instead. Consider going without underwear at night or wearing loose boxer shorts to allow air to the vulva.
Use care when wiping after toileting. Tugging and pulling with dry toilet paper is damaging to the vulva. Pat dry, do not rub the vulva with heavy friction. Bidets are a great alternative to toilet paper.
Finding a proper vulvar wash that is pH balanced with a low osmolality is the first step in proper vulvar care. Finding a good daily vulvar moisturizer may be necessary during times of menopause, breastfeeding, bacterial vaginosis, and reproductive cancer treatments. Do not use products containing toxic ingredients. There are many companies out there wanting your business and may resort to unsavory practices to reel you in. Go shopping with an informed list of what to avoid and what to include and you will be investing in the best vulvar care.
Jane Vela has been a physical therapist for 26 years. Her Colorado clinic specializes in women’s care and pelvic floor dysfunction. She treats urinary incontinence, urinary urgency-frequency, bowel dysfunction, dyspareunia, vulvodynia, vaginismus, coccydynia, pelvic organ prolapses as well as providing post-partum, post-surgical and post-mastectomy rehabilitation. As a person who has experienced labor, pelvic surgery and menopause, she finds it rewarding to empower others by sharing her personal experiences in addition to her professional knowledge.
Webinar: The Vagina: A Self-Cleaning Oven? (coming soon)