HS

VULVOVAGINAL
HEALTH & HYGIENE
Dr. Inndu Kashyaapp PT
MPT Ortho
Ortho & Women’s Health Physiotherapist
Menstrual, Sexual and Pelvic Health Educator
Ergonomist & Metabolic Disorders Therapist
Co-founder- HealthSpecifics
HealthSpecifics Academy (HS-A regtd. Under GOI)
HealthSpecifics Prevention & Rehabilitation Clinic
HealthSpecifics Homecare
HS MedTech
VULVOVAGINAL HEALTH & HYGIENE
Vaginal health is a reflection of the overall health of the body.

But, a lot of women are not quite comfortable talking about it. Some may even
ignore common symptoms of infection, making the situation worse for them. Did we
ever have a problem checking in with a doctor about a fever or cold? Then we
should not feel ashamed or awkward talking about the vaginal health as well. It is
the 21st century, after all, humans boast of wireless technology and high tech health
services, it is high time that we stop overthinking on trivial matters and take our
health a bit more seriously.

Unhealthy or sick vulva and vagina bring with itself a lot of troubles which includes
but are not limited to reduced orgasm, vulvovaginal pain, loss of sexual desire and
even pose a threat to our fertility.
Normal vaginal flora, acidic vaginal pH, and vaginal discharge are all components of
the innate defense mechanisms that protect against vulvovaginal infections.

Vaginal ecosystem is colonized from the very first hours of the birth of a female and
remains throughout her life until death (Romero et al., 2014)

Women of childbearing age produce about 1 to 4 mL of vaginal fluid, containing 108 to

109 bacterial cells per mL (Danielsson et al., 2011).

Vulvovaginal disease are very common with dysbiosis

ANATOMY
 1. Anterior labial commissure
2. Clitoral body covered by the
prepuce
3. Clitoral glans
4. Labia minora: the lateral parts form
the prepuce (hood) of the clitoris, the
medial parts form the frenulum of the
clitoris
5. Labia majora
6. External urethral orifice
7. Duct of Skene's gland
8. Ducts of minor vestibular glands
9. Labia minora
10. Duct of Bartholin's gland
11. Vaginal orifice
12. Hymen
13. Frenulum of labia minora
14. Posterior labial commissure.
http://www.tup.com.cn/upload/books/yz/069176-01.pdf
VULVA https://www.facebook.com/media/set/?set=a.129759896119274&type=3
VULVA

Read at https://www.facebook.com/media/set/?set=a.129759896119274&type=3

DIFFERENT PATHOLOGICAL
PRESENTATIONS OF VULVA-

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 HS
CLITORIS

During the response to

sexual arousal the bulbs fill
with blood, which then
becomes trapped, causing
erection. As the clitoral bulbs
fill with blood, they tightly cuff
the vaginal opening, causing
the vulva to expand outward.
This puts pressure on nearby
structures that include the
corpus cavernosum of clitoris
and crus of clitoris, inducing
pleasure.
Most women are unaware of the sprawling extent of what lurks iceberg-like beneath the surface of their tender-parts.
VAGINA

Elastic lumen of approximately 7.5 cm long (elastic nature may be attributed to the fibromuscular
structure) connecting the external and internal organs of reproduction

From cervix up to vaginal orifice in perineum running obliquely upward and backward at an angle
of 45° (In the dorsal lithotomy position the vagina is directed posteriorly toward the sacrum but its
axis is almost horizontal in the upright position)

Lies between urethra and rectum

Lower vagina is a little constricted as it passes through the urogenital hiatus in the pelvic
diaphragm. Laterally, at about 2.5 cm from the introitus—the levator ani

Vaginal lumen has got 3 layers: outer layer of areolar tissue, middle layer of smooth muscle, and
inner lining of stratified squamous epithelium

Mucosa has a characteristic pattern of transverse ridges and furrows known as rugae which is
hormonally sensitive, responding to stimulation by estrogen with proliferation and maturation. The
mucosa is colonized by mixed bacterial flora with lactobacilli predominant
 The vagina is lined by stratified
VAGINAL MUCOSA non-keratinizing squamous
epithelium, which is variable in
thickness and structure depending
on life stages

The vaginal epithelium consists of

three cell layers: superficial,
intermediate, and basal capable of
storing glycogen under the
influence of estrogen

In the pre-pubertal and the

postmenopausal women, the
epithelium is thin and characterized
by a thin atrophic epithelium which
is susceptible to infection and
frequently shows degenerative and
inflammatory changes
 The appearance of the hymen changes with exposure to
estrogen, which causes the hymen to be paler in color,
HYMEN more elastic, more redundant, and less sensitive to touch.
As a result, the appearance of the hymen changes from
infancy to early childhood to adolescence. The
unestrogenized hymen is exquisitely sensitive, which
should be taken into consideration during a physical
examination. The infant hymen is typically thick and
redundant, a result of maternal estrogen exposure in utero,
usually with an annular or nearly annular (with a cleft at 12
o’clock) configuration (Berenson et al., 1991; Berenson,
1993, 1995; Heger et al., 2002a). Within the first 3 years of
life as the effects of maternal estrogen exposure wane,
superficial notches (less than half the width of the hymenal
border) in the border of the hymen can develop or become
more visible (Berenson and Grady, 2002). Notches can be
complete in the ventral aspect of the hymen. Complete
notches in the dorsal rim of the hymen (between 3- and 9
o’clock), however, do not occur normally, and should raise
concerns for penetrating trauma (Heger et al., 2002a).
HYMEN
Visualization of the hymen
may be obscured by labial
adhesions, also termed labial
agglutination, Agglutination
commonly recurs prior to the
onset of endogenous estrogen
production in adolescence
(Kumetz et al., 2006) and for
the same reason can occur in
women after menopause.
HYMEN
HYMEN
HYMEN
COLOR
 PHYSIOLOGY
(Influence of ovarian hormones)
VULVAR EVOLUTION FROM INFANCY TO ADULTHOOD
HS
The vulva, or the external female genitalia, is under endocrine control and manifests secondary
sex characteristics.

At birth the labia, the prepuce and the clitoris may appear rather prominent, probably as a
result of maternal endocrine stimulation. Similar evidence of estrogenic stimulation may be
seen in the breasts and in the internal genitalia of the newborn. These changes disappear
rapidly after birth.

During infancy and childhood the labia minora and majora remain small, of tissue paper
thinness and almost transparent.

With the onset of puberty these structures begin to grow rapidly and gradually take on normal
adult appearance. The labia minora develop as separate distinct structures, the labia majora
become more rounded and fuller and stand out more prominently, and the preputial folds and
the clitoris become sharply demarcated. The growth of labial and pubic hair in the typical
feminine pattern completes the development of the normal adult
Hormonal fluctuations driving the female life cycle highly modulate the
functional anatomy of the urogenital and pelvic tract
Estrogen and androgens (testosterone) are vital to maintain normal structure and
function of the vagina and surrounding uro-genital tissues.
During reproductive life, vagina, vulva, vestibule, pelvic floor muscles, endopelvic
fascia, urethra and bladder trigone display a significant amount of receptors
The vulva and vagina can be thought of as three separate and distinct organs
due to their embryological (prenatal) development-
Very early after conception the cells divide into three tissue types- ectoderm,
endoderm, and mesoderm
The ectoderm forms the tissue of the outer vulva, which includes the labia majora,
the interlabial sulcus, the outer labia minora, the hood of the clitoris, the clitoris, and
the perineum
The vulvar vestibule, which starts at Hart’s line on the inner aspect of the labia
minora and extends to just inside the hymen, is derived from the endoderm
The vagina is mostly comprised from tissue coming from cells of mesodermal origin
Because these tissues are derived from three different origins, it is logical they
would respond differently to different hormonal states (such as too much, too little,
or an imbalance in hormones) and to specific insults such as infections, allergic
reactions, chemical irritation, and trauma
ESTROGEN & ITS FUNCTIONS & DYSFUNCTIONS

Hormonal fluctuations driving the female life cycle highly modulate the functional
anatomy of the urogenital and pelvic tract. Etrogen and androgens are vital to
maintain normal structure and function of the vagina and surrounding uro-genital
tissues.
During reproductive life, vagina, vulva, pelvic floor muscles, endopelvic fascia,
urethra, and bladder trigone display a significant amount of estrogen receptors (which
decline with menopause and may be restored by the use of systemic and local
estrogen treatment).
Vaginal and urinary tract originate from same embryologic tissue that are both
estrogen dependent.While vestibule is dependent upon the testosterone.
Estrogen effect on bladder and pelvic floor muscles

Trigone (area of the urinary bladder) formed from the same embryonic bud as the anterior
vagina, represents a distinct anatomic zone of the bladder and demonstrates similar
cytological modifications under hormone stimulation to vaginal cells.

Similar to other skeletal muscle, androgen receptor are highly prevalent throughout pelvic
floor muscle.
Estrogen effect cervix and vagina

Squamous epithelium of the cervix and vagina is non-keratinising and is composed of a

continuous layer of stratified (multi-layered) flat cells. Stratified squamous epithelium has a
mainly protective function but also plays a vital role in the maintenance of vaginal pH.

A unique feature of the layers of the vaginal epithelium is their permeability to microbes as
well as cellular and molecular mediators of immune defense. This loosely attached layer of
cells creates a microenvironment that plays an important role in fostering endogenous vaginal
flora while deterring invasive microbial species (do not express de novo proteins involved in
pathogen recognition and defense).
Estrogen effect on cervix and vagina

Normal proliferation of the epithelium leads to the formation of moist and thick rugae on the
mucosal surface of the vagina and glycogen released by exfoliated epithelial cells is hydrolyzed
into glucose. Then, glucose is metabolized mainly by lactobacilli into lactic acid, creating an
acidic environment (pH = 3.5–4.5) that discourages the growth of pathogenic bacteria and
fungi

Vaginal perfusion also is regulated by androgens and estrogens in the context of baseline
blood flow and during sexual arousal

(Testosterone and estradiol differentially regulate the expression of nitric oxide synthase and
arginase, key proteins regulating vaginal blood flow)
Estrogen effect on lower urinary tract and clitoris

Estrogen is an important regulator of tissue growth and function in the lower urinary tract;

However, testosterone plays an important role as well. Androgen receptor is localized to motor
neurons innervating the urethral sphincter and the pubococcygeus muscle, suggesting that
testosterone supplementation regimens may be somewhat effective in ameliorating urinary
symptoms and urogenital tissue atrophy.

Estradiol and testosterone are also necessary for maintenance of clitoral tissue morphology and
signaling pathways that regulate vascular responsiveness of the clitoris during sexual arousal.

(The actions of androgens can be distinct from those of estrogens and the effects of testosterone do
not necessarily require its conversion to estradiol by aromatase)
 Also reduced
vaginal secretion

Vaginismus
The innate defense system of the female mucosal genital tract involves a close
and complex interaction among the healthy vaginal microbiota, different cells,
and various proteins that protect the host from pathogens-
Vaginal lactobacilli and lactoferrin represent two essential actors in the vaginal
environment-
Lactobacilli represent the dominant bacterial species able to prevent facultative and
obligate anaerobes outnumber in vaginal microbiota maintaining healthy microbial
homeostasis. Lactobacilli exert their protective effects by several mechanisms: (i)
microbial competition for the nutrients and for adherence to the vaginal epithelium; (ii)
reduction of the vaginal pH by the production of organic acids, especially lactic acid,
through the degradation of glycogen released by vaginal cells thus exerting selective
antimicrobial activity against non-resident microbiota; (iii) production of antimicrobial
substances, such as bacteriocins and hydrogen peroxide (H2O2) able to suppress the
growth of several microorganisms; and (iv) modulation of the local immune system
In addition to lactobacilli, lactoferrin, an iron-binding cationic glycoprotein, is a
multifunctional glycoprotein with antibacterial, antifungal, antiviral, and antiparasitic
activities, recently emerging as an important modulator of inflammation. Lactoferrin is
strongly increased in lower genital tract mucosal fluid of women affected by Neisseria
gonorrheae, Chlamydia trachomatis, and Trichomonas vaginalis infections promoting
both innate and adaptive immune responses.
Also the cervicovaginal fluid (CVF) exerts a significant microbicidal activity as well as
anti-inflammatory activity

Vaginal dysbiosis is associated with bacterial vaginosis (BV), uper respiratory tract
infections/diseases such as pelvic inflammatory diseases (PID) and sexually transmitted
diseases (STDs)

(Bacterial vaginosis is a clinical diagnosis that requires at least three of the following features: (1) vaginal
pH > 4.5; (2) thin, watery, fishy-smelling discharge; (3) wet mount showing > 20% clue cells, and (4)
positive “amine” odor test (performed by adding 10% potassium hydroxide to a drop of vaginal discharge
on a slide and smelling the distinctive odor that results from released volatilized amines). Risk factors for
bacterial vaginosis include: black ethnicity, cigarette smoking, use of intrauterine device, oral sex, new or
multiple sexual partners, having a female sexual partner, frequent douching, sexual activity during
menses, and lack of hydrogen peroxide-producing lactobacilli. BV, in turn, is believed to be a factor in the
development of STDs, pre-term birth, pelvic inammatory disease, and infertility)
VAGINAL FLORA

Vaginal microflora composition is better understood

Vaginal ecosystem is colonized from the very first hours of the birth of a female and
remains throughout her life until death

Women of childbearing age produce about 1 to 4 mL of vaginal fluid, containing 108

to 109 bacterial cells per mL

One of the most important defense mechanisms for reproductive function

VAGINAL FLORA

MECHANISMS

● These Lactobacilli prevent colonization by other bacteria in the vagina (including pathogens) via
competition for epithelial cell receptors and through inhibition of growth by generation of
antimicrobial compounds (hydrogen peroxide and bacitracin) in collaboration with innate host
defenses (e.g. periodic hormonal cycling promoting glycogen release and constant sloughing of
bacteria-containing epithelial cells) to maintain a healthy vaginal ecosystem

● Bacteria form a adhered monolayer on the vaginal mucosa and produce antimicrobial compounds

● Produces lactic acid which maintains the normal vaginal pH between 3.5 to 4.5

● Bacteriocins, an antibiotics that inhibit the growth of harmful microorganisms within the vagina

● Arginine deaminase enzyme which metabolizes arginine into citrulline and ammonia depriving
anaerobic pathogens of this amino acid necessary for their growth
VAGINAL FLORA

COMPOSITION

It was previously thought that a healthy vagina was dominated by Lactobacillus, which is a non-sporing,
Gram-positive bacilli that produce lactic acid, resulting in an acidic environment (pH 3–4).

In some healthy women, Lactobacilli are absent and replaced by other lactic acid–producing bacteria, such
as Atopobium vaginae, Megasphaera spp., and/or Leptotrichia spp.

In some cases, asymptomatic, reproductive-age women are colonized by potentially pathogenic species (e.g.
Gardnerella vaginalis, Staphylococcus aureus, Candida albicans)

thus, the definition of healthy versus unhealthy vaginal microbiome is complex.

(VULVAR FLORA Various studies of healthy women have shown that the microbiota of the vulva is
diverse, with no single species common to all women. Vulvar flora may also affect the proliferation of
exogenous pathogens that cause vaginal and urinary tract infections)
VAGINAL FLORA

GET EFFECTED BY

Composition of the vaginal microflora fluctuates as a function of-

- Internal factors- age, hormonal shifts (e.g. during menarche, menses, pregnancy and infections)
- External factors- hygiene practices, sexual intercourse, antibiotics, and HRT

Several studies suggest differences in normal vaginal flora based on ethnicity too.

An individual’s skin microbiome appears to be affected by birth mode (cesarean vs vaginal birth),
which may impact immune development and have longer term implications for microbial diversity.
Vaginal environment undergoes overtime shifts in the representation and abundance of
microbial key species that are influenced by factors that may include age, hormonal
fluctuations, sexual activity, use of medication, and hygiene
● Menstrual cycle changes the vaginal ecosystem
Under the influence of estrogen in the proliferative phase of the cycle, the whole epithelium
thickens and is multilayered ( increased mitosis of the basal layers).
During the secretory phase of the cycle, the intermediate layers become thick and the cells
stuffed with glycogen.
Glycogen content of the vaginal epithelium co-variates with estrogen levels (breakdown of
glycogen by resident healthy vaginal microdata produces an acid pH in the vagina, which
deters infections). In general, high levels of estradiol may favor a lactobacilli-dominant
environment.
(It is important to underline that during menses the decrease of this important natural defense
glycoprotein is balanced by the presence of neutrophils at least partially, when lactoferrin
concentration and its antimicrobial activity when the epithelial barrier is disrupted. )
● Aagaard et al. showed that microbiome was enriched in L. iners, L. crispatus, L.
jensenii, and L. johnsonii . The increase in lactobacilli may be due to the increase in
estrogen levels that occurs during pregnancy although further investigations are needed
to better understand the relationship between specific species of Lactobacillus and
estrogen levels.
● Menopause is one another factor.
● Clinical trials based on Nugent score endpoint and questionnaires have revealed a
reduced bacterial vaginal rate in women who use estrogen-containing contraceptives.
The effects of progestin-containing contraceptives such as depot medroxyprogesterone
acetate (DMPA) and levonorgestrel are less clear.
● However, use of OCP by decreasing estrogen synthesis suppresses the production of
hLf as well as immunoglobulins
CERVICAL MUCUS

Mainly composed of mucin, which protects the vaginal mucosa and optimizes its barrier role against
microbial colonization
VAGINAL DISCHARGE

For a year or two before puberty, until after menopause, it is normal and healthy for a woman to
produce a vaginal discharge, consisting of bacteria and desquamated epithelial cells that slough from
the vaginal walls together with mucus and fluid (plasma) produced by the cervix and vagina

The quantity and texture of this change during the menstrual cycle: vaginal discharge is thick, sticky,
and hostile to sperm at the beginning and end of the menstrual cycle when estrogen is low and gets
progressively clearer, watery, and more stretchy as estrogen levels rise prior to ovulation.
What can impact VV health-

- Unprotected sex, Forceful sex

- Hyper/hypo estrogenic state
- Diseases such as diabetes
- Weak immune system
- Treatments/drugs such as Antibiotics immunosuppressants, chemo, RT
- Hormonal Contraceptives
- Chemical based products
- Wrong VV hygiene practices
- Infections and STDs
- Psychological stress
- Alcohol and smoking
- All the causes leading to female sexual dysfunctions (painful penetrative disorders)
- Cancers & skin diseases
CAUSES FOR UROGENITAL ATROPHY

● Menopause (most common cause)

● Lack of sexual activity
● Pregnancy or recent childbirth
● Breast feeding
● Hysterectomy
● Bilateral oophorectomy
● Premature ovarian failure
● Pelvic radiation therapy
● Chemotherapy
● Immune disorders
● Oral contraceptives
● Medications such as antidepressants, allergy & cold
medications
● Intolerance to douching products or harsh soaps
● Alcohol consumption
● Heavy Cigarette smoking
● Stress, Anxiety or emotional upsets
ESTROGEN DISRUPTORS
Smokers metabolize their estrogen faster

With the onset of menopause as the estrogen levels dip, the pelvic floor muscles
often get thinner dryer and tend to develop several trigger points inside the pelvic
floor, which may lead to pelvic floor muscle tightness or pelvic pain during
menopause

Irritant may cause or trigger the contact dermatitis in the vestibule - This diagnosis is elusive
because the external genitalia and vestibular tissues often look perfectly normal when this is
occurring. To complicate matters, contact dermatitis results from irritation caused by a number of
sources. Eg. it is believed that the secretions from the altered micro-flora can trigger contact
dermatitis in the vestibule
ESTROGEN
Breastfeeding induced low estrogen

Vaginal dysbiosis

Gynaecological cancers (eg. breast cancer), chemotherapy, radiation therapy &

hysterectomy/oophorectomy -

Some of the breast cancer treatment works by blocking the natural and important
hormones like estrogen and progesterone which are essential for tissue growth but
are responsible for growth of all kinds of tissues (including cancer cells as well)
ESTROGEN
We kno that estrogen is essential for normal female sexual development and for the
healthy functioning of the reproductive system. The abundance of estrogen
receptors in both dermis and epidermis. So skin conditions involving these areas
are more commonly affected.

Pragya A. Nair J Midlife Health. 2014 Oct-Dec; 5(4): 168–175.

ESTROGEN

Lichen sclerosus

● Severe itching
● Discomfort or pain
● Smooth white spots on your skin
● Thin, crinkly patches of skin
● Vulvar skin that easily bruises or tears
● Painful fusion (sticking together) of vulvar skin
● Bleeding
● Blisters or ulcerated lesions
● Painful intercourse
● Scarring
● Painful urination or defecation caused by irritation, fusion and scarring
Symptomatology of urogenital atrophy due to lack of estrogen

Vaginal atrophy:-

(A) Pale, dry, shiny vulvar tissue

and loss of adipose tissue in the
labia majora and labia minora.

(B) Prepuce and clitoris are often

pale and reduced in size

(C) Introitus may be narrowed and

friable.

(D) Vaginal walls lack rugae and

may be pale and/or erythematous.
Symptomatology of urogenital atrophy due to lack of estrogen

The initial symptom is often lack of lubrication during intercourse. Eventually, persistent vaginal
dryness may occur.

Loss of tissue elasticity by inducing fusion and hyalinization of collagen fibers and fragmentation of
elastin fibers.

Mucosa of the vagina, introitus, and labia minora becomes thin and pale and appears less hydrated.

Vaginal canal becomes shorter and narrow because the vaginal rugae, the epithelial folds that allow
for distensibility, progressively disappear.

Significant reduction of vascular support leading to a decrease of the volume of vaginal transudate
and of other glandular secretions.

Both estrogens and androgens contribute to pelvic nerve-stimulated genital blood flow, tissue
response to neurotransmitters and sensory threshold to stimuli.
Symptomatology of urogenital atrophy due to lack of estrogen

Over time, intercellular acid mucopolysaccharide and hyaluronic acid are significantly reduced in
the dermal layer. Progressive dominance of parabasal cells with fewer intermediate and superficial
cells. This means the vaginal squamous epithelium is quite completely estrogen deprived.

Therefore, it becomes friable with petechiae, ulcerations, and eventually bleeding after minimal
trauma.

Because a major contributor to vaginal moisture is plasma transudate derived from the
subepithelial vasculature, increased sympathetic innervation may cause vasoconstriction, leading to
vaginal dryness and vaginal wall hypertonus. Furthermore, a greater density of sensory nociceptors
may contribute to hypersensitivity and result in symptoms of pain, burning, and itching.

LUTS (lower urinary tract symptoms) because estrogen receptors are present also throughout the
lower urinary tract & can regulate bladder smooth muscle contractility
Symptomatology of urogenital atrophy due to lack of estrogen

With the onset of menopause as the estrogen levels dip, the pelvic floor muscles often get thinner dryer
and tend to develop several trigger points inside the pelvic floor, which may lead to pelvic floor muscle
tightness or pelvic pain during menopause.

Decreased blood flow to urethral tissues, causing sphincter fibrosis and loss of resistance, and urethral
mucosal thinning that compromises the ability of the urethra to form a continent mucosal seal through
coaptation. Similar to atrophy of the vagina, bladder muscle fibrosis from estrogen deprivation would
be expected to lower functional capacity and promote urgency and/or urge incontinence and dysuria

Estrogen is an important regulator of tissue growth and function in the lower urinary tract; however,
testosterone plays an important role as well. Androgen receptor is localized to motor neurons
innervating the urethral sphincter and the pubococcygeus muscle, suggesting that testosterone
supplementation regimens may be somewhat effective in ameliorating urinary symptoms and
urogenital tissue atrophy
Symptomatology of urogenital atrophy due to lack of estrogen

A thinner vaginal epithelium is also associated with a significant reduction of glycogen which
translates into a lower amount of lactobacilli causing an increase in vaginal pH (between 5.0
and 7.5).

The subsequent decrease of vaginal hydrogen peroxide allows the growth of other pathogenic
bacteria (staphylococci, group B streptococci, and coliforms) causing atrophic vaginitis,
vaginal discharge and odor.

Indeed, lactobacilli diversity and abundance significantly decreased following menopause

and the vaginal microbiota of women with mild or moderate atrophy had a distinct bacterial
community state, which may predispose to develop vaginitis and other uro-genital infections.
Symptomatology of urogenital atrophy due to lack of estrogen

The neurovascular and neuromuscular substrates of the pelvic area are also impaired because the vulva, as
well as the pelvic floor and the urinary tract, manifest similar anatomical and functional changes.

Entry dyspareunia, irritation, burning and itching of external genitals may be the result of the stenosis of
the vulvar introitus.

Hymeneal carunculae and the vestibule display less elasticity and the urethral meatus appears prominent
and more vulnerable to trauma.

The prepuce of the clitoris atrophies, exposing the gland to irritation from clothing, prolonged sitting, and
sexual contact.

Several changes of the urinary system (reduced urethral closure pressure, reduced sensory threshold in
the bladder, and, in some cases, increased risk of rUTIs) may be observed as a consequence of the
thinning of the urinary epithelium and weakening of the surrounding tissue
Symptomatology of urogenital atrophy due to lack of estrogen
TREATMENT OF UROGENITAL ATROPHY
doctors assume their patients will tell them if they’re in pain, whereas patients assume their doctors would ask
about such serious symptoms.The main therapeutic goal in managing VVA is to relieve symptoms and restore
the vaginal environment to a healthy premenopausal state. However, despite the high prevalence and negative
impact on the quality of life, VVA is underreported by patients, undiagnosed by health care providers, and
undertreated. Gynecologists should proactively start an open discussion with patients on urogenital
symptoms. Treatment should be started as early as VVA occurs and should be maintained over time. As there
are many treatment options, therapy should be individualized.

Estrogen therapy-
Systemic or local (cream, rings, tablet)

Following symptom are seen when patient uses more than recommended or against advice-
1. Breast pain 2. Vaginal bleeding 3. Systemic absorption 4. Endometrial hyperplasia
TREATMENT

Contraindication for estrogen therapy-

• Undiagnosed vaginal bleeding • Current breast cancer • History of endometrial cancer • Pregnant •
breastfeeding
• Caution with liver disease • Risk of thromboembolic disorder
Note that the use of vaginal rings is not recommended in women with prolapse of the genitals. It is also
necessary to warn a woman about the possible expulsion of the vaginal ring.

Vaginal Dehydroepiandrosterone (DHEA)-

The vaginal metabolism of DHEA into estrogens/testosterone leads to the activation of estrogen and androgen
receptors in the three layers of the vaginal wall

Selective estrogen receptor modulators-

These are structurally different and given among women in whom estrogen preparations are contraindicated.
TREATMENT

Laser therapy-
It improves the vascularization of the vaginal mucosa, stimulates the synthesis of new collagen and matrix
basic substance in the connective tissue, thickens the vaginal epithelium with the formation of new papillae,
replenishes glycogen in the vaginal epithelium, allows restoring the balance of the mucosa and therefore
improves the symptoms of atrophy caused by a lack of estrogen.

Pelvic floor physiotherapy-

It improves blood flow in vulvovaginal tissues, PFM relaxation capacity, and vulvovaginal tissue elasticity in
postmenopausal women with GSM and UI. Address the weak and tight muscles! Female may present with
pain during sex even with the use of lubricants!
TREATMENT
Other supportive measures-
Vaginal moisturizers • Replenish vaginal moisture by adhering to the vaginal wall. • May be used regularly
every 2-3 days.
Lubricants • reduce friction and discomfort from dryness during intercourse without causing irritation or
damage to diaphragms or condoms
Lubricants and vaginal moisturisers are effective in relieving discomfort, friction and pain with penetrative
sex. Lubricants are used at the time of intercourse, whereas vaginal moisturisers provide longer term relief.
Lubricants can be water-based or silicone-based. Water-based lubricants are non-staining and have fewer side
effects than silicone-based lubricants. However, the efficacy of lubricants depends on the osmolality, pH and
additives of each individual product. High osmolality, >1200 mOsm/kg, is associated with irritation, contact
dermatitis and cytotoxicity. Oils, such as olive or sweet almond oil, are alternatives.

Moisturisers rehydrate dry tissues by changing the fluid content in the vaginal epithelium, absorbing and
adhering to it, mimicking vaginal secretions, and lowering the pH. The effect lasts about three days.
Moisturisers contain polymers for adherence and other additives that effect osmolality and pH.

Foreplay https://www.wellandgood.com/sexual-penetration-techniques/

Relaxation techniques
TREATMENT
Sex therapy-
Women may experience a variety of emotions as a result of vaginal atrophy, and a therapist can offer support
to women struggling with urogenital discomfort, incontinence, aging, body image concerns, or low self-esteem.
In couples therapy, a therapist can help the woman and her partner communicate about the changes to her
body and how these changes can affect their relationship. The therapist can assist the couple in exploring a
variety of sexual activities that may be less irritating to the vagina, such as oral sex, manual stimulation,
sensual touch, and the use of vibrators.

Vaginal health prevention-

● Try to avoid soap if possible, however, if you feel the need to use it, make sure it’s unscented and
very gentle.
● Don’t use washcloths, these can harbor bacteria which can be irritating.
● Use cotton underwear.
● Avoid using tight clothes around the area.
● If you go swimming, make sure to change out of the wet clothes after you are done.
Differential diagnosis for urogenital atrophy
TESTOSTERONE
TESTOSTERONE

With the understanding that the vestibule is comprised of tissue distinct from that of the outer vulva or
the vagina, we can now ask how this difference affects its function. The tissue of the vestibule
contains openings of several glands- the Skene’s glands, the Bartholin’s glands, and the minor
vestibular glands. These glands, when stimulated by hormones, make mucin, an extremely slippery
substance that acts as the primary lubricant during intercourse, giving women the sensation of feeling
“wet” during arousal.

However, when most people think of the hormone that is most necessary for vulvar or vaginal health,
they think only of estrogen. Interestingly, these glands don’t rely on estrogen, or progesterone, but
instead depend on testosterone and other very similar hormones that we collectively call
“androgens.” These androgens act on a hormone receptor called the “androgen receptor” in the cells
of these glands to cause the production of mucin.
TESTOSTERONE
ORAL CONTRACEPTIVE PILL

Unfortunately, most of women have no idea how these medications work and often have not been told
of their potential side effects

Worse yet, many women are given oral birth control pills for non-contraceptive reasons: erratic mood,
recurrent migraines, irregular menses, menstrual cramping, endometriosis, and even acne.

One recent study found that women using a hormonal contraceptive method experienced less
frequent sexual activity, arousal, pleasure, and orgasm and more difficulty with lubrication (Smith).

It is not uncommon for young women on OCPs to report pain with intercourse (called dyspareunia) as
well. Some women may not experience dyspareunia but can present with other symptoms like urinary
urgency, urinary frequency, recurrent urinary tract infections (UTI) or yeast infections. All of these
things can happen with OCP use, but often go unrecognized or ignored.
TESTOSTERONE
ORAL CONTRACEPTIVE PILL

OCPs prevent the pituitary gland from producing normal levels of two important signally hormones, follicle-
stimulating hormone (FSH) and luteinizing hormone (LH).

In addition, the synthetic hormones in OCPs, which are metabolized in the liver, induce the liver to increase
production of a protein called Sex Hormone Binding Globulin (SHBG). SHBG binds to sex hormones,
preferentially to androgens, rendering them inactive.

The combined effect of decreased ovarian production of androgen from the ovary and increased production of
SHBG result in a reduction of greater than 75% of “bioavailable” or “free” androgens.

Much of the attention regarding the adverse effects of OCPs focuses on nausea, headache, breakthrough
menses, breast tenderness, or blood clots. Many prescribers of OCPs don’t bother to ask if you’re having
pain with intercourse. As long as you’re not getting pregnant, they don’t really care. Some feel uncomfortable
asking; others simply don’t want to hear about it. Still others may not recognize the aforementioned
symptoms as being at all related to oral contraceptive pills. But that doesn’t mean it isn’t happening to you. If
you don’t feel heard by your physician or health care provider, find someone that will listen.
The game of testosterone

The vulva and vagina can be thought of as three separate and distinct organs due to their embryological
(prenatal) development. Very early after conception the cells divide into three tissue types- ectoderm,
endoderm, and mesoderm.

The ectoderm forms the tissue of the outer vulva, which includes the labia majora, the interlabial sulcus,
the outer labia minora, the hood of the clitoris, the clitoris, and the perineum. The vulvar vestibule, which
starts at Hart’s line on the inner aspect of the labia minora and extends to just inside the hymen, is
derived from the endoderm. The vagina is mostly comprised from tissue coming from cells of
mesodermal origin.

Because these tissues are derived from three different origins, it is logical they would respond differently
to different hormonal states (such as too much, too little, or an imbalance in hormones) and to specific
insults such as infections, allergic reactions, chemical irritation, and trauma.
The game of testosterone

A recent study presented by our group at the International Society for the Study of Women’s Sexual
Health (ISSWSH) Annual Meeting showed that more than 90% of women with vulvodynia have pain
confined to the tissue of the vulvar vestibule, and not the outside vestibule or inside the vagina.

With the understanding that the vestibule is comprised of tissue distinct from that of the outer vulva or
the vagina, we can now ask how this difference affects its function. The tissue of the vestibule contains
openings of several glands- the Skene’s glands, the Bartholin’s glands, and the minor vestibular glands.
These glands, when stimulated by hormones, make mucin, an extremely slippery substance that acts as
the primary lubricant during intercourse, giving women the sensation of feeling “wet” during arousal.

Interestingly, these glands don’t rely on estrogen, or progesterone, but instead depend on testosterone
which acts on the “androgen receptor” in the cells of these glands to cause the production of mucin.
The game of testosterone

To visualize this, you may think of the androgens as a key that fits into a lock (androgen receptors) which open
factory doors to allow the machines (the glands) to make mucin. Unfortunately, this system may malfunction in
several ways.

First, you can imagine that if there are not enough keys- low levels of androgens- then the locks cannot open and
the factory will not work. Secondly, if the locks are rusty or sticky – a poorly functioning androgen receptor- then
the doors of the factories will not open and the machines will not work. Use of OCPs can cause both problems of
low androgens and “sticky” androgen receptors. And lastly, some women genetically have “stickier” or “inefficient”
androgen receptors which make them even more susceptible to the negative effects of OCPs.

OCP causes negative pressure on hypothalamus preventing production FSH & LH and ultimately estrogen,
progesterone and testosterone while exogenous estrogen and progesterone which are metabolised in liver includes
liver to produce SHBG which binds to ex hormones rendering them inactive. This combined causes 75% reduction
in androgens. Third impact is that drosperinine (component of some OCP) also binds to androgen receptors
rendering it sticky (inactive).
The game of testosterone

Studies show shrinkage of their labia minora, a reduction in the diameter of the vulvar vestibule, a
reduction in clitoral blood flow, microscopic structural changes in the mucosa of the vulvar vestibule that
makes them more susceptible to tears and fissures when exposed to trauma. The women were treated by
having them stop OCPs and by applying a compound that contained topical estrogen and testosterone to
the vestibule with vestibular pain dropped from 7.5 to 2 after three months of treatment.

To note there is a hypothesis that female with genetically inefficient androgen receptor are more prone.

Unfortunately, for many women, just stopping OCPs does not cause the vulvodynia to resolve. This is
because even after stopping OCPs the levels of SHBG frequently do not go back down to the levels they
were before stopping OCPs. This leads to persistently low free androgens and the persistence of the
vestibulodynia.
The game of testosterone

Also unfortunately, the progestin in OCPs can inhibit the androgen receptor so using topical
hormones without stopping OCPs typically does not work.

Pain returns after restarting OCPs so recommend IUDs for patients who need contraception after
their vestibulodynia has resolved.

It is crucial to distinguish between pill types in order to not miss important associations.

OCPs that contain either of the progestins drosperinone or etonogestrel appear to cause a greater
risk than OCPs that contain progestins with less “anti-androgenic” properties.

OCPs with lower levels of Ethinyl Estradiol might cause a greater risk of developing vestibulodynia
than OCPs with higher doses of Ethinyl Estradiol.
VULVOVAGINAL HEALTH ISSUES
(What to look for)
Know what is normal (and abnormal) for you
- External & Internal anatomy
- Skin color & texture
- Discharge
- Odor

Changes during pregnancy

- Swollen vulva
- Darken color
- Vaginal discharge
- Varicose veins

Changes post pregnancy

- Vaginal dryness

If vaginal dysbiosis happens

- Vaginitis (know the causes and risk factors)

Changes during menopause transition and post-menopause

- Genito-urinary syndrome of menopause (GSM)
Vulvovaginal self screening

1. Wash your hands with soap and water, or put on gloves.

2. Remove your clothing below the waist.
3. Put the pillow up in front of a wall. Sit up with your back
against the pillow, and bend your knees with feet near your
buttocks
4. Hold the mirror out in front of your pelvic area as shown in the
image. Use a flashlight to look better.

5. Examine the vulva for small cuts, sores, or lumps.

6. Gently spread the vaginal lips, and hold the flashlight or
mirror with the other
7. Gently insert one finger into your vagina. The inside of the
vagina may feel similar to the roof of your mouth. If you feel
any sores or growths along the vaginal wall, you need a doctor.
8. Gently remove your finger and look at your vaginal
discharge. If you notice an unusual color or foul odor, see a
doctor.
9. Look for any other swelling, lumps, or unusual changes.
You can now close your knees and stand up.
Vulvovaginal self screening

Consult a gynecologist if-

● Change in the color or odor of vaginal

discharge
● An excessive amount of Vaginal Discharge
● Vaginal redness or itching
● Vaginal bleeding between periods, after sex or
after menopause
● A mass or bulge in vagina
● Pain during intercourse
● Vaginal bleeding between periods
● Vaginal Bleeding after sex or after menopause
● A mass or bulge in the vagina
● Pain during sexual intercourse
VAGINITIS

It is infectious or noninfectious inflammation of the vaginal mucosa, sometimes with inflammation of the
vulva. Symptoms include vaginal discharge, irritation, pruritus, and erythema. Diagnosis is by testing of
vaginal secretions. Treatment is directed at the cause and at any severe symptoms.
Etiology of Vaginitis

The most common causes of vaginitis vary by patient age. Vulvitis and vulvovaginitis have some of the same
causes. Children

- Usually involves infection with GIT flora

- Poor perineal hygiene (eg, wiping from back to front after bowel movements; not washing hands after
bowel movements; fingering, particularly in response to pruritus).
- Chemicals in bubble baths or soaps
- Foreign bodies (eg, tissue paper)
- Specific pathogen
- Sexual abuse can result in STIs
Vaginitis

Women of reproductive age

In women of reproductive age, vaginitis is usually infectious. The most common types are

● Bacterial vaginosis
● Candidal vaginitis
● Trichomonal vaginitis, which is sexually transmitted
Normally in women of reproductive age, Lactobacillus sp is the predominant constituent of normal vaginal flora.
Colonization by these bacteria keeps vaginal pH in the normal range (3.8 to 4.2), thereby preventing overgrowth of
pathogenic bacteria. Also, high estrogen levels maintain vaginal thickness, bolstering local defenses.

Factors that predispose to overgrowth of bacterial vaginal pathogens may include the following:

● An alkaline vaginal pH due to menstrual blood, semen, or a decrease in lactobacilli

● Poor hygiene
● Frequent douching
Vaginitis may result from foreign bodies (eg, forgotten tampons). Inflammatory vaginitis, which is noninfectious, is
uncommon.
Vaginitis

Postmenopausal women

In postmenopausal women, a marked decrease in estrogen usually causes vaginal thinning, increasing vulnerability to
infection and inflammation. Some treatments (eg, oophorectomy, pelvic radiation, certain chemotherapy drugs) also
result in loss of estrogen. Decreased estrogen predisposes to inflammatory (particularly atrophic) vaginitis.

Hormonal changes during menopause can result in a more alkaline vaginal pH, which can predispose to overgrowth of
vaginal pathogenic bacteria.

Poor hygiene (eg, in patients who are incontinent or bedbound) can lead to chronic vulvar inflammation due to chemical
irritation from urine or feces or due to nonspecific infection.

Bacterial vaginosis, candidal vaginitis, and trichomonal vaginitis are uncommon among postmenopausal women but
may occur in those with risk factors.
Vaginitis

Women of all ages

At any age, conditions that predispose to vaginal or vulvar infection include

● Fistulas between the intestine and genital tract, which allow intestinal flora to seed the genital tract
● Pelvic radiation or tumors, which break down tissue and thus compromise normal host defenses

Noninfectious vulvitis accounts for up to 30% of vulvovaginitis cases. It may result from hypersensitivity or
irritant reactions to hygiene sprays or perfumes, menstrual pads, laundry soaps, bleaches, fabric softeners,
fabric dyes, synthetic fibers, bathwater additives, toilet tissue, or, occasionally, spermicides, vaginal lubricants
or creams, latex condoms, vaginal contraceptive rings, or diaphragms.
BACTERIAL VAGINOSIS
BACTERIAL VAGINOSIS (BV)

Formerly known as non-specific vaginitis, BV is characterized by a change in the vaginal flora composition, with a
dramatic depletion of Lactobacilli due to a significant overgrowth of obligate or facultative anaerobes previously a minority
in the vagina, such as Gardnerella vaginalis, Atopobium vaginae, Ureaplasma urealyticum, Mycoplasma hominis,
Prevotella, Peptoniphilus, Megasphaera, Mobiluncus, and several fastidious and uncultured bacteria, including BV-
associated bacteria (BVAB-1 to 3).

The factor triggering this overgrowth of anaerobic bacteria is unknown. It is linked to an alkaline vaginal ecosystem due
to an increase of vaginal pH following the loss of Lactobacilli protective effects

The bacteria present in the microbiota of BV form a biofilm on the vaginal epithelium and secrete a cytotoxin capable of
killing the epithelial cells.

n addition, G.vaginalis produce proteolytic enzymes able to degrade proteins and decarboxylases that convert amino
acids. Not being degraded, the amine compounds become malodorous (fishy odor: “Whiff test”)

Subsequently, cytotoxicity resulting from the combination of organic acids present in the vagina during BV and bacterial
polyamines leads to the production of a vaginal discharge caused by the exfoliation of vaginal epithelial cells.
Furthermore, this bacterium, cover the vaginal epithelial cells, causing the formation of “clue-cells”, a specific
characteristic of Bv
BACTERIAL VAGINOSIS (BV)

RISK GFACTORS - SEXUAL ACTIVITIES

It has been evaluated at 18.8% for non-sexually active women, 22.4% for women with one lifetime partner
and 43.4% and 58% for women having 2-3 lifetime sex partners and those having ≥ 4-lifetime sex partners,
respectively (Koumans et al., 2007)

In this dynamic, sex workers had a higher bacterial vaginal diversity but a much lower abundance of
Lactobacillus species than women who are not engaged in sex work (Wessels et al., 2017)

BV-related bacteria can be found in the penile skin, urethra , spermatozoa, and prostatic fluid microbiota.
Furthermore, biofilm fragments have been found in their urine and sperm, suggesting that male partners are
a reservoir (Swidsinski et al., 2010a; Swidsinski et al., 2010b). Nevertheless, there is no corresponding illness in male
partners (Verstraelen et al., 2010).

Use of condoms by male partners also prevents acquisition and recurrence of BV

BACTERIAL VAGINOSIS (BV)

RISK GFACTORS- HYGIENE PRACTICES

One study found that patients who did not wash their vaginal region were more susceptible to BV than those
who often washed the vaginal region, a prevalence of 53.9% and 40.2%, respectively.

Higher in patients who do not change their underpants frequently compared to those who change it more
frequently (57.6% versus 36.9%) (Bitew et al., 2017).

Other sexual sanitary habits, including vaginal douching and washing as well as cigarette smoking , certain
contraceptive methods like disposable intra-uterine devices and stress may also enhance the risk of
developing BV.
BACTERIAL VAGINOSIS (BV)

COMPLICATIONS

10-30% of pregnant women with BV give birth prematurely, a preterm delivery often accompanied by perinatal
mortality, up to 70% worldwide (Svare et al., 2006; Afolabi et al., 2016).

During pregnancy, BV increases the risk of preterm labor, late miscarriage, intrauterine fetal death, preterm rupture
of the membranes, amniotic fluid infections, chorioamnionitis, post-abortion and postpartum infections in these
women
BACTERIAL VAGINOSIS (BV)

COMPLICATIONS

In non-pregnant women,

bacteria involved in BV can initially cause cervicitis, endometritis, salpingitis, and UTIs.

After damage of the cervix, bacteria can migrate from the lower to upper genital tract, reaching the uterus and
fallopian tubes and causing illnesses such as pelvic inflammatory disease (PID), post-hysterectomy infections, and
even cervical cancer or tubal infertility

Likewise, BV is associated with significantly increased rates of acquiring HSV, HIV, papillomavirus and
transmission of the pathogens causing syphilis, chancroid, gonorrhea, trichomoniasis, and chlamydia
Vulvar Pathology

Bartholin cyst and abscess: Bartholin's glands are glands that produce secretions to lubricate the vulva and vagina. This gland can
become obstructed and form a cyst containing the buildup of lubricant. If the cyst becomes infected, it then progresses to become
an abscess. This condition tends to affect females of reproductive age. Bartholin cyst/abscess presents as a swelling located
posterolateral to the vaginal orifice. This infection may result from infection with Escherichia coli, Chlamydia trachomatis, and
Neisseria gonorrhoeae.

Lichen sclerosus: The vulva region is a sensitive region that may be prone to irritations. In lichen sclerosus, the vulva is under
chronic irritation resulting in itching. This itching causes the patient to scratch, and over time the trauma from scratching will
cause the vulvar skin to undergo lichenification (thickening). Lichen sclerosus is the thinning of the epidermis and
thickening/fibrosis of the dermis. It appears as white parchment paper like lesions. This condition affects prepubertal and
postmenopausal females with an increased risk of vulvar cancer. The treatment is topical steroids.

Lichen simplex chronicus: In lichen simplex chronicus, the vulvar region undergoes hyperplasia of the epithelium. This condition
presents as a thick, leathery vulvar skin due to chronic scratching and rubbing. This condition is not associated with an increased
risk of cancer.

Imperforate hymen: In pubertal females that reach the age of menarche, but do not have menses is called primary amenorrhea. One
cause of primary amenorrhea is imperforate hymen. These females present with monthly pain and pressure in the lower abdomen,
but not excretion of mense. On physical examination, there will be a blue, brown round bulging mass protruding from the vagina.
The mass protruding from the vagina is a collection of the menstrual products getting trapped due to an imperforate hymen. The
treatment for this condition is incision and drainage of the mass.
Neoplastic

Vulvar carcinoma: Cancer of the vulvar region is rare. The most common cancer involving the vulvar region is squamous cell carcinoma.
This malignancy could be due to a transformation of leukoplakia or due to the infection from HPV16 or HPV18. Lichen sclerosus can also
progress to vulvar cancer.

Extramammary Paget Disease: Paget disease of the vulva is usually a type of carcinoma in situ. This condition presents as scaling plaques,
crusting, pruritus, ulcers, and erythema. But there is no risk for underlying malignancies.

Sexually Transmitted Infections

Urinary Tract Infection https://www.facebook.com/healthspecificsphysio/photos/a.485847396277522/602579587937635/

Endocrine issues in external genitalia Since the development of the female external genitalia is dependent on hormones. The vulva region
can be affected by endocrine-related conditions. The endocrine system is the system that influences/controls the secretions of hormones. If
there is a defect in the endocrine system, males can present with female external genitalia. One example of males with female external
genitalia is in "androgen insensitivity syndrome" (AIS). In AIS, androgen receptors are insensitive to androgens. The insensitivity of these
receptors makes them unresponsive to testosterone and androgens. Then the external genitals will default into developing into female
external genitals. While females can undergo virilization if there is an excess of androgens such as in "congenital adrenal hyperplasia"
(CAH). In CAH, there is a defect in the adrenal production of aldosterone and cortisol, which results in all the aldosterone and cortisol
precursors getting shunted to the production of androgens in the adrenal glands. The excess androgens affect the female external genitalia by
making them more masculine. The clitoris becomes larger (clitoromegaly) and the fusion of the labia majora. The fusion of the labia majora
will make it appear more scrotal-like.
DO NOT CLICK

Healthy vulva & Hypoestrogenic vulva

 DO NOT CLICK
Acute candidiasis & chronic changes

DO NOT CLICK
Molluscum contagiosum

Dermatitis Lichen sclerosus

Bartholin’s cyst

Vulvar cancer

DO NOT CLICK Genital warts Herpes

Why get dark skin?

Vaginal washes help to maintain hygiene and give a comfortable fresh feeling, but they
do not lighten the skin
Darkening of the skin in private areas is caused because of sweating and keratinisation
(scaling and peeling) of the skin, due to the use of harsh soaps
Wearing tight, synthetic undergarments for prolonged periods does not allow the skin
to breathe, and retains the moisture from the sweat, causing infections and darkening
Darkened skin should not be alarming, unless it is accompanied by some other signs
VULVOVAGINAL HYGIENE
 RCOG guidance on care of vulvar skin
• Most women with a vulvar disorder (e.g. contact dermatitis, vulvovaginitis) need advice about vulvar
skin care and how to avoid contact irritants.
• Washing with water can cause dry skin and make itching worse. Use a small amount of soap
substitute and water to clean the vulva.
• Shower rather than bathe and clean the vulva only once a day. Overcleaning can aggravate vulvar
symptoms (e.g. symptoms of contact dermatitis). An emollient may be helpful.
• Avoid using sponges or flannels. Just use your hand. Gently pat dry with a soft towel.
• Wear loose-fitting silk or cotton underwear. Avoid close-fitting clothes. Wear loose-fitting trousers or
skirts and replace tights with stockings. You may prefer to wear long skirts without underwear.
• Sleep without underwear.
• Avoid fabric conditioners and biological washing powders. Consider washing underwear separately
in a non-biological laundry detergent.
• Avoid using soap, shower gel, scrubs, bubble bath, deodorant, baby wipes, or douches on the vulva.
RCOG: Royal College of Obstetricians and Gynaecologists
RCOG guidance on care of vulvar skin

• Some over-the-counter creams, including baby or nappy creams, herbal creams (e.g. tea tree oil,
aloe vera), and “thrush” treatments, may include irritants.
• Avoid using panty liners or sanitary towels on a regular basis.
• Avoid antiseptic (as a cream or added to bath water) in the vulvar area.
• Wear white or light colored underwear. Dark textile dyes (black, navy) may cause an allergy, but if
new underwear is laundered before use, it will be less likely to cause a problem.
• Avoid using colored toilet paper.
• Avoid wearing nail varnish on fingernails if you tend to scratch your skin.

RCOG: Royal College of Obstetricians and Gynaecologists

 MECA guidelines on female genital hygiene.
• Women of all ages require daily intimate hygiene to keep their genital area clean.
• The vulva is susceptible to contact dermatitis. Take care to avoid contact with irritants.
• Use a hypoallergenic liquid wash with mild detergency and pH 4.2 to 5.6.
• Avoid bar soaps and bubble baths, which are abrasive and have a more alkaline pH.
• Lactic acid–based liquids with an acidic pH may augment skin homeostasis and have been shown to be helpful in
vaginal infections as an adjuvant therapy but not as a treatment.
• Vaginal douching is not recommended.
• Wear loose-fitting cotton underwear and minimize wearing tight clothes.
• Change underwear frequently.
• Do not use talcum powder.
• Use any perfumes and deodorants sparingly (after allergy testing).
• Change tampons and sanitary pads frequently.
• Before and after intercourse, cleanse the vulva from front to back, especially the clitoris and vulvar folds.
• Do not cleanse the vulva vigorously or irrigate the vagina.
• Use a safe method of pubic hair removal and take care to avoid sensitivity and scarring.
• Postpartum care should include frequent cleansing, drying, and using pads as necessary. Maintain dryness over any
sutures. Do not use any creams.
• Wash hands prior to children’s genital care. Use separate towels.
MECA:MECA: Middle East and Central Asia.
SOme wrong practices

The use of conventional panty liners (i.e. with a non-breathable back sheet) is a widespread practice but
can increase the temperature, skin surface moisture, and pH of the vulvar skin, thereby significantly
changing the microclimate of the vulva.

Extensive pubic hair removal may cause skin microtrauma and subsequent spread of infectious agents
throughout the pubic area. Severe consequences may include vulvovaginal irritation and infection and
spread of STI (e.g. molluscum contagiosum and HSV). In a recent study of pubic hair removal
practices, over half of women reported removing all pubic hair and the majority experienced one or
more complications due to removal. Pubic hair serves as a physical barrier for the vulvovaginal area
and complete removal could lead to increased susceptibility to infections, although more data are
needed to establish this link.
Femine hygiene product
Gentle vulvar cleansing is desirable, and evidence suggests that it is an important aspect of female intimate
hygiene and overall vulvovaginal health. Because of the risks associated with internal washing/douching,
external feminine washes are considered more appropriate for intimate health, particularly those containing
lactic acid, with an acidic pH that augments skin homeostasis and may serve as a helpful adjunct therapy in
women with vaginal infections or taking antibiotics. Vulvar cleansing may be a useful adjunct for women with
odorous vaginal discharge, and daily use of a feminine wash may reduce the risk of recurrence of bacterial
vaginosis. In addition, clinical practice guidelines recommend women to use a pH-balanced hypoallergenic
cleansing agent for daily vulvar cleansing. These external washes need to be carefully formulated for mild,
gentle cleansing without impacting the natural flora, particularly in cultures where women may use these
products frequently. It is also important for intimate feminine hygiene products to be assessed clinically to
ensure that they are well tolerated and provide targeted antimicrobial and other health benefits without
negatively impacting the natural vulvovaginal microbiota.
Douching
Douching solutions often contain petroleum-based ingredients and those same icky endocrine disruptors,
phthalates. Most doctors recommend against douching, as it can alter the vaginal flora and necessary
acidity of a healthy vagina.

Vaginas naturally have both good and bad bacteria, and douching can lead to an overgrowth of harmful
bacteria. This overgrowth can cause yeast infections and bacterial vaginosis. Even worse, if you have an
existing infection, douching can actually push the bacteria further up into the uterus and ovaries. That can
lead to pelvic inflammatory disease, a very serious condition.

The American College of Obstetricians and Gynecologists warns that there are other complications related
to douching, including increased susceptibility to STIs, RTI and pregnancy complications.
Femenine wash products

The pH (potential of hydrogen) is a unit that measures the acidity or alkalinity of a substance or an environment. The intimate area
is a delicate ecosystem characterised by a pH that is slightly more acidic than that of the rest of the body. This acidity is
one of the mucous membranes’ natural barriers against infections, because it enables the development of the protective vaginal
flora. That is why it must be maintained when washing your intimate area.

It ranges from 0 to 14:

• Below 7: the pH is said to be acidic. • Around 7: the pH is said to be neutral. • Above 7: the pH is said to be alkaline or
basic.
The intimate area is made up of two very distinct zones which do not have the same pH:
• In the vagina, the pH is acidic, typically within the 3.5 to 5.5 range. It varies significantly depending on where the
measurement is taken, the point in the menstrual cycle, the age of the woman, the possible presence of thrush or an infection,
etc. This acidity is naturally regulated by the lactobacilli (protective bacteria) which make up the vaginal flora and it prevents the
overgrowth of pathogenic bacteria.
• On the vulva and in the perineal and perianal zones, the pH range is wide and can vary from 4.5 at the opening of the
vagina to 8 in the skin areas
Femenine wash products

We say “physiological” pH when a product has a pH close to that of the body area on which it is meant to be applied. For
intimate hygiene products, the vagina’s pH is not taken into account, because only the external parts (vulva, pubic area,
perianal area) should be washed, not the vaginal cavity.

An intimate hygiene product must therefore be chosen according to the pH of the external parts of the intimate area, as well as
the intended use:

• For daily use when no disorder is present, products with a pH somewhere between 4.5 and 7 will be suitable. Outside
of this range, the product would be too harsh and would strip the skin and mucous membranes.

• In case of thrush (proliferation of Candida type fungi), a very common condition, the recommendation is different: as
Candida tend to develop more easily in an acidic environment, using an alkaline hygiene product will help to prevent their
proliferation. Thus, you should choose a slightly alkaline product with a pH ranging between 7 and 9 to fight against thrush.
Femenine wash products

A vulva is a mucous membrane with a very discriminating ecosystem. Disruption of this balance can cause many issues such
as yeast infections, urinary tract infections, foul odor, inflammation, itchiness, and burning. These immediate symptoms aside,
fragrance oils in particular have been found to contain known endocrine disruptors. These chemicals interfere with the body’s
hormones and are known to cause developmental, reproductive, and neurological issues.

One of the main hormone-disrupting ingredients commonly found in personal hygiene products are phthalates, which can have
a significant effect on reproductive systems. Not only can they contribute to gynecological disorders and infertility, but these
plasticizers can be passed down through generations.
Panties

Cotton, breathable and clean undies (wash undies before use if they are brand new). Do not let sweat get accumulated.

Your choice of underwear says a lot about you. You might wear a thong or tight nylon lace underwear when you’re feeling extra
frisky, or avoid wearing comfortable cotton panties because they kind of look like grandma undies. Don’t let looks fool you.

The best underwear for your intimate area should be loose and made of materials that allow air circulation – such as cotton and
linen — as these can wick away sweat and do not cause discomfort.

Synthetic materials like polyester and rayon that might make you look sexy are actually not breathable, leaving moisture
trapped inside, which can irritate the skin. It gets especially worse at some points during your menstrual cycle as your body
temperature is elevated and you sweat more. A moist environment is the perfect breeding ground for harmful bacteria, which is
why you should also always change your underwear after a workout.
Panties
What about shaving and waxing?
Razor specially (shaving, plucking, tweezing and even waxing) may lead to ingrown hair and ultimately papules and may
lead to bacterial folliculitis. Stop hair removal practices(stop completely if possible) at least for month to heal the papules.
Laser and hair removal creams are options but creams may be harsh for the skin.
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