What's Not Normal Below the Belt

Now you know what’s normal when it comes to the vulva (if you missed it, go back and read my previous blog on normal vulval anatomy. Hooray – that’s great!

But what about when things seem, well, not quite right? This is where it’s important to know what your normal anatomy is – because how will you know when things aren’t right if you don’t know what’s normal in the first place? Some of the things that can go wrong can be related to life changes such as having a baby or menopause. But sometimes there can be no apparent reason for your symptoms. Either way, it’s good to know what kinds of problems can occur.

For those who want the quick version, if you have any of the following PLEASE SEEK MEDICAL ADVICE:

Pain in the vulva or vagina with normal touch, intercourse or when having a wee
Discharge that smells funny or look funny (eg discoloured)
Itching in the vulva or vagina
Bleeding that is not related to your menstrual cycle
Skin changes (eg dark spots, rashes or lumps) that seem new or unusual

These can all be symptoms of different problems in the vulva and need to be checked out by a doctor. Don’t try to self-diagnose because chances are you can get it wrong. It’s common for different problems to have several overlapping symptoms, and others can be harder to pick. Let’s look at some of the potential problems further.

Yeast infections

Yeast infections are more commonly known as thrush, or in the medical field as candidiasis. I’m starting with this one, as I see a lot of women who have diagnosed themselves with thrush (sometime multiple times) and treated it with an over-the-counter medication such as Canestan, only to finally work out it was never thrush in the first place.

You may recall all women have normal, healthy bacteria in the vagina. Thrush is an over-growth of bacteria - most commonly candida. It can be more common in women with high oestrogen levels or who have a high sugar diet, but some women just seem more prone to it regardless.

Thrush will typically cause a range of unpleasant symptoms including a thick, white discharge (like cottage cheese), itching, swelling, redness, burning pain and pain with intercourse. However, you may not get all of these symptoms, and as we’ll see below, many of these symptoms can be from other causes too. If you have self-treated for thrush and the problem has not resolved, see your doctor to make sure you’ve got the right diagnosis.

Sexually Transmitted Infections (STIs)

Most women think STIs will give symptoms, such as itching, a rash or discharge – and some definitely do, but not always! Many STIs can be asymptomatic some or most of the time. If you are under 25 years old, sexually active (especially if you have had more than one partner or have recently changed partners) and you do not use condoms, it’s best to get regular screening for STIs just in case. For more information, you may like to look at the Health Direct information on STIs.

Pain

Pain can be divided into many categories. Some women have pain only when they attempt insertion (eg sex, a tampon, or when having a smear test). Some have pain with any touch or pressure to the vulva externally. Other women complain of pain much or all of the time, without any apparent provocation, which may be felt in the vulva, vagina or low abdomen. These pains can have very different causes. Let’s look at a few of the common ones.

Pain with sex or insertion is known as dyspareunia and can severely impact women’s quality of life. If you have previously been able to have sex without pain and this is a new problem, there are a few possible causes.

If you have recently had a baby, there may be scar tissue from a tear or episiotomy which can sometimes be sensitive as it heals.
If you are breast feeding, or alternatively if you are at the other end of life and have been through menopause, you will be low on oestrogen. This can make the vulva and vagina less well-lubricated and elastic, so the tissue will be drier and more easily damaged.
New onset pain can also be from something like an infection, such as thrush gonorrhoea or bacterial vaginosis – but they typically also cause discharge and itching too.
Some vulval skin conditions can also cause pain with intercourse.
Of course, if you also have pain with urination, you need to check for a urinary tract infection.

If you have pain only when applying external touch or pressure to the vulva, the most likely cause is vulvodynia. This is when the tissue and nerves in the vulval region become very sensitive and start reacting to normal touch and pressure (eg, from a bike seat, tighter clothing or even underwear) as a threat, giving a pain response to protect you. Vulvodynia is a diagnosis of exclusion, meaning all other potential diagnoses have been ruled out. You can find more information on vulvodynia on the Pelvic Pain Australia website.

The other potential diagnoses they need to rule out are things like infections of any sort, skin conditions or local irritation to the vulva. Local irritation can include reactions to perfumes or dyes. This is why it’s not recommended to use any “feminine hygiene” sprays, washes or douches down below, or even regular soap. Your vulva simply does not need these things to get clean, and they may cause allergic reactions. You may even need to switch to low allergen washing powder if you have developed vulval skin irritation. Low oestrogen related to breast-feeding or menopause can also cause vulval irritation, as the dryness can promote itching, which further irritates the skin. There can also be other causes of irritation such as an ingrown hair or an abscess from a blocked gland. The latter can happen in the Bartholin’s glands near the vaginal opening and can be very painful!

But what if sex has always been painful or you seem to have pain much of the time, even without touching the area? One possible cause may be endometriosis. This will typically start with pain associated with the menstrual cycle and give pain low in the abdomen, but I have seen women who also experience pain in the vulva or vagina with endometriosis. Endometriosis and vulvodynia can co-exist. Quite often both conditions will be associated with spasm and tension in the pelvic floor muscles, which like any tight muscle, can also become painful. Again, you should see your doctor to help get a diagnosis or ask to see a gynaecologist if your GP seems unsure.

Discharge, funny smells, itching and bleeding

It is not uncommon for these symptoms to occur together. However, it is of course possible to have only one of the above symptoms. Typical causes include:

Infections – these include thrush, STIs (eg, chlamydia, gonorrhoea and herpes) but also bacterial vaginosis (BV), which can give a greyish discharge with a fishy odour. Many women with BV have no symptoms at all.
Menopause – as mentioned above, the low oestrogen associated with menopause can cause symptoms, broadly described as genito-urinary symptoms of menopause (GSM). This can include dryness, itching and discharge related to a change in pH in the vagina. You can read more about GSM symptoms in a previous post.
Irritation from feminine hygiene products – as above, don’t waste your money on feminine washes or sprays! However, if even regular pads and tampons are irritating you, there are alternatives such as low allergen products and menstrual cups.
Skin conditions – we will cover these below.
Pubic lice – these are uncommon, but cause an intense itch (but no discharge or odour).
Cancer – again this is rare, but can cause bleeding (typically with intercourse). However be aware this is not the only cause of bleeding.

Always get checked if you have discharge that is discoloured (yellow, green, brown, grey or blood-stained) or smells unusual. Itching and unexpected bleeding should also be investigated.

However, it is important to remember that some discharge is normal. It is completely normal for your discharge to be white or cream, to change in consistency during your cycle (eg, from thinner, to more viscous, like egg whites) and to have up to a small teaspoon worth of discharge daily.

Skin changes

There are many different types of skin changes that occur in the vulva, just like there are on the skin anywhere else on the body. We have already discussed the reasons for a few of these, including GSM (skin will be drier and more frail). Anything that causes itching can also make the skin look redder and irritated. Here are some other possible causes:

Genital warts are a type of STI that can cause various skin changes. Sometimes they look like a raised area that may be smooth or scaly, and often a different colour to the surrounding skin. Other times they may be flatter. Genital warts should always be checked as some vulval cancers can look like warts in the early stages.
Genital herpes is another type of STI mentioned above, but unlike some of the other STIs, it typically causes the vulval skin to form a blister or ulcer. There may also be local pain and a discharge with herpes.
Lichen sclerosus is not common but should not be missed. It typically appears as patches of white, thinner skin, often in a figure-8 pattern around the anus and labia minora. However, if left untreated, it can cause fusion of the labia minora or clitoral hood to the surrounding skin, or even partial or complete closure of the vaginal introitus. While the skin changes are the most common signs, lichen sclerosus may also cause itching, pain and dyspareunia. Lichen sclerosus should be monitored as it carries an increased risk for squamous cell carcinoma (skin cancer) of the vulva.
Lichen planus looks quite different to lichen sclerosus, with skin patches looking darker, red or raised. Unlike lichen sclerosus, these patches may also be found inside the vagina as well as on the vulva. It also typically causes itching, pain and dyspareunia.

The bottom line is there are many types of problems that can occur in the vulva, and many of them have overlapping symptoms – and they are not all thrush! While many of these conditions are fairly uncommon, but all should be checked out, especially if the symptoms are new or bothersome. Luckily in most cases the problem will be treatable, and sometimes with simple solutions.

So please don’t put up with a painful, itchy or smelly vulva! Just ask for help.

Yours in pelvic health,

Jenny.

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