Queefing- the feminine way to pass gas

UM, PARDON ME?

I've been seeing a lot of questions lately in my office and online about "queefing". Whomever came up with the term queefing, in my humble opinion, is an absolute genius! So, what exactly is the definition of queefing? According to Dictionary.com:

NOUN: Slang: Vulgar. an expulsion of air through the vagina.

Anybody else a little irritated with the use of the word "vulgar "there? As if women are trying to be sexual about passing gas through the vagina. Truth be known, there's not a real term for passing wind from the vagina. "Why," you ask? Probably because men don't do this, so it's never been added to the "non-slang" dictionary. In medical literature the phenomenon of farting from your lady parts is known as either "vaginal wind", or "vaginal air." There are only a few literature articles on the subject, listed in the wee tiny print below. Some of the info here is collected from those articles, some of it's just from my experience, both personal, and with patients. (Yes, I queef on occasion. As you'll find out, most women do!)

Queefing FAQs

Since there seems to be a lot of confusion about queefing, so let's tackle the most common questions.

How common is queefing?

In the general population, we just don't know for sure. One literature review, says it's between 1 and 69%. The single article I could locate on the topic of prevalence found that 69% of women pass gas via the vagina at least twice a week. Let's go with 69% as the best number we've got. Asking around my office and my female friends, most women will admit they've queefed before, even if it isn't a regular problem.

How does the air get in there?

Vaginal air can come from two places. First, it can get in the vagina from something called a fistula. A fistula is a little opening between the bowel and the vagina, most often seen after traumatic prolonged vaginal delivery, or after vaginal/pelvic surgery. This can be diagnosed in your doctor's office or with imaging, like a CT or MRI.

The most common way for air to get into the vagina is from outside the body. The classic time is during sex. With repeated penetration, the penis pushes air from outside up into the vagina. After sex queefs are by far the most common. Air can also get inside the vagina during exercising, especially activities like yoga where your bum is up in the air. Some people suck air up inside the vagina while shifting around in their chairs at work, or while moving around in their sleep. When you're sitting or lying down, the pelvic floor tends to be less tight, and allows for air to seep up in there. Then when you stand up, it comes out.  This is particularly the case in ladies with tight pelvic floor muscles. The tightness of the muscles seems to help suck in the air, and keep it trapped.

Does a queef smell bad?

If a man farts in the forest, and no one is there to appreciate it, does it smell? Depends on how you think about it. In order for something to smell, a nose must be there to inhale the chemicals that produce a signal in the brain of a particular odor. When you pass flatus (that's the actual medical term for rectal gas) most of the time it has little or no odor. Rectal gas is a combination of swallowed air and byproducts of the microbes living in your gut. Certain foods notorious for gas (like broccoli and milk) are partly broken down by bacteria in your gut, which produces hydrogen sulfide. That chemical is what gives smelly farts their odor.

Is queefing dangerous?

Nope. Not in the least. If it's associated with a fistula, it'll need to be fixed. But classic passage of vaginal air that's trapped is common, and normal. It doesn't hurt, and is not dangerous. But it can be embarrassing. Many times a queef makes a noise similar to a fart. That sound can draw attention, obviously, and women with regular queefs tend to feel shameful about it. 

Is there anything I can do to reduce or stop it?

There's no literature on this. These recommendations come from experience and from a little medical logic. If you queef mostly after sex, using a good lubricant can help. When the penis slides more easily, it doesn't push as much air up in there. Good lubricants are generally either water or silicone based. You'll need to use one that's pH balanced. The lubricants I recommend to my patients are "Good Clean Love", "Desert Harvest Glide", and "Uberlube". If you're one that queefs after sitting too long at work, getting up regularly will reduce the likelihood of having the sound.

What's next?

If you queef more than twice a week, you may have a pelvic floor issue. You can always come by my office to talk about the sensitive topics like this. We'll figure out if your queefs are concerning or just the garden variety "gentle wind". You can make an appointment with me at Nurture Womens Health. 

https://www.ncbi.nlm.nih.gov/pubmed/28494270

https://www.ncbi.nlm.nih.gov/pubmed/26241266

https://www.ncbi.nlm.nih.gov/pubmed/14677001

Christmas hurts! Why pelvic pain flares during the holidays.

Holiday Heart attacks

Ok, this blog is supposed to be about pelvic pain...why are we talking heart attacks? Work with me here, and we'll get to the pelvic pain in a minute.

There's a really disturbing thing that happens, specifically on Christmas day and New Years. It's not the weird red-clad man climbing into strangers homes, dropping off gifts, and stealing cookies. It's the rate of sudden cardiac death. More people die of heart attacks on Christmas day and New Years than any other day in the year. Seriously? Yes. And it's not just old people who have no one to celebrate with. It's across the board.

For many of us, Christmas is fun, and exciting. But it's also a little stressful, right? Having to plan gifts, parties, buy the right ugly sweater to impress what's-his-name from the office. We have to deal with crazy uncle Ed who always makes the most inappropriate remarks during dinner. There's also the many out there that don't like Christmas because of lack of social support, or the memory of the loss of a loved one. The stress of the holidays is problem #1. The food of the holidays is problem #2.

Problem #1: STRESS

There's these chemicals called catecholamines that are the way your body responds to stress. Ones you might have heard of are norephinephrine and epinephrine. These chemicals activate the sympathetic nervous system. They're made in your body naturally, and can also be created from some of the foods we eat. They're what make your heart race and give you the feeling of shortness of breath when something startles you. It's an activation of the fight-or-flight response. During the stress of the holidays, these chemicals tend to run amok. They're at high levels in your blood. Whether that's from uncle Ed embarrassing you in front of the new boyfriend, or the stress of getting the right gift for mom.

Those stress hormones aren't good for your blood pressure and heart rate. They give you the necessary jolt to run away from a bear, if you live in Alaska. But if you're in Cedar Rapids, Iowa, it's unlikely you're being chased by a bear. And raising your blood pressure and heart rate isn't good for long periods of time.

Problem #2: The FOOD

Taking in excess amounts of alcohol and certain foods puts you at increased risk of a heart attack due to an enzyme in the foods that prevents the breakdown of catecholamines. The levels of stress hormones rise when they're not broken down properly, leading to sustained rises in blood pressure and heart rate.

What the heck does all this have to do with Pelvic Pain??

When you're in acute pain, like from slicing your finger while cutting potatoes, your sympathetic nervous system gets activated. The fight or flight response gets you to quickly move the knife away and grab the bleeding finger to slow the blood loss. This is a good deal, because sympathetic activation lets your brain know that the pain signals are important. They make you move the knife instead of continuing to cut.

When you're in chronic pain, elevated sympathetic nervous system chemicals make it hard for your brain to decide if pain signals are important or not. On the side of caution, the elevated catecholamines lead the brain to think that pain signals are important, so they're processed more rapidly.

When your sympathetic nervous system is all amped up for long periods of time, you get increased processing of pain signals. In patients with fibromylagia, the higher the activation of the sympathetic nervous system, the higher the magnitude of pain.

Holidays = stress + foods that prevent catecholamine breakdown

Stress + high catecholamine levels = high sympathetic nervous system activation

High sympathetic nervous system = increased pain processing

You're not crazy if you feel like your pain is worse around the holidays. It really is!

Do I just suffer through the holiday season, then?

ADD PIC

No, ma'am, you need not suffer. There's some good techniques to lower the sympathetic nervous system. The sympathetic nervous system has an arch enemy called the parasympathetic nervous system. Its whole deal is to lower blood pressure, lower heart rate, and calm you down. It's at its best when you're chilling, like taking in rays on the beach. Now, most of us don't have a beach nearby. If you do, I'm jealous. For the rest of us land-lubbers, we can activate the parasympathetic nervous system a few other ways. Doing something super relaxing, like getting your nails done, or having a massage can work wonders.

Other options include deep breathing and meditation. Deep belly breathing will trigger your parasympathetic system. Deep breathing involves taking slow deep breaths through your nose, pretending they're going into your stomach instead of your chest. Hold the breath for a few seconds, and then release it slowly. Meditation is also very good at triggering the parasympathetic system. Meditation is getting your mind to clear. That sounds super hard, but it really isn't. There's a few apps that you can get on your phone that will help you learn how to meditate. "Headspace" is a good one for newbies. 

As Always

If you're having worsening pelvic pain during the holidays, I may be able to help with some of my techniques too. I'd love to see you for an exam and treatment at Nurture Womens Health. You can make an appointment to see me and we'll figure out how to lower your pain, and your risk of heart attack!

Rescources

https://www.ncbi.nlm.nih.gov/pubmed/22678655

https://www.ncbi.nlm.nih.gov/pubmed/26816852

https://www.ncbi.nlm.nih.gov/pubmed/25963185

https://www.ncbi.nlm.nih.gov/pubmed/25786044

Why having sex is good for your vagina

Listen up, Ladies!

First, I'd like to commend my colleague, Dr. Jen Gunter, for gracefully addressing all of the media coverage of her vagina recently. Reading her rebuttal to all the men who had the gall to critique her vaginal aroma was the highlight of my month! One phrase she used in discussing vaginal health was "the vagina is a self cleaning oven." I've used this phrase with my patients too. There's a lot of confusion out there about vaginal odors due to the entire section of Walgreens dedicated to it. I agree that this whole section of the store should be removed. Another catch phrase I use a lot with my more mature patients is "The vagina is a use it or lose it kind of organ" You'd be surprised at the reactions I get. Most women either raise an eyebrow, or full out laugh. Beautiful ladies, I'm serious. The vagina needs to be used regularly when you're heading into menopause or you'll lose the ability to use it, potentially forever.


I've uttered "the vagina is a use it or lose it kind of organ" to an average of two women per week lately. As a pelvic and intimate pain specialist, one of the more frequent sexual issues I see is vaginal atrophy (dry vagina). I deal with this all the time. Women entering the end of their fertile years are at risk for "dry vagina." This is a frustrating and potentially disfiguring disorder of the vagina near to and in menopause. Up to 80% of women aged 65+ have problems with sex mostly due to dryness!

Sex and Midlife Estrogen

When you enter into the menopausal change, your ovaries start to poop out. They slow and eventually nearly stop the production of estrogen. Estrogen is the hormone that is responsible for keeping your lady parts moisturized. It also helps keep the vagina stretchy enough to allow your partner to enter. About 50% of women that are post-menopausal have vaginal atrophy with dryness. This typically starts within a few years of finishing your periods, but it can start when your periods get irregular and start spacing out, even years before they completely stop.


With reduced estrogen, there's less cells at the surface of your vagina. This causes problems with a host of things including lubrication, vaginal elasticity, thinning walls, and increased risk of tearing with sex. Ugh! There's also a change to the good bacteria in your vagina which leaves you at risk for discharge and bad bacterial overgrowth.

Why sex hurts in menopause

With a dry vagina, having sex begins to get uncomfortable. When your vaginal elastic qualities start to diminish, as you can imagine, putting an erect penis in there starts to hurt. If you don't have sex regularly, it hurts all the more because eventually the reduced elasticity turns in to a narrowing vagina. This isn't easy to fix once it's happened. It can get so bad that the vaginal entrance becomes tight and stiff, and the lips can even get stuck together!

Low estrogen = dry vagina and smaller opening = painful sex.

How, exactly, do I need to use my vagina?

This is a topic of some debate. The first thing to consider is that once the vagina starts to narrow, it's hard to stretch it back out. If you're in a relationship where his penis can be used to keep things stretched, then by all means that's an option. But only about 25% of women are able to orgasm with penetration, and orgasm helps with all this dryness stuff too. If you're not in a relationship, then consider obtaining a "sexual enhancement device." This is my politically correct term for a BOB (battery operated boyfriend), also known as a vibrator. The vibrator is much more likely to encourage orgasm with clitoral stimulation. Having orgasms regularly seems to help with the dryness, as it pulls in extra blood flow to the area. You may find it's a little more difficult to obtain orgasm after menopause, and that's ok. Keep working at it.

How do I get this treated?

Using your vagina regularly won't prevent it from being dry in menopause. That's an estrogen issue. What can be done to treat this? The best way to improve your vaginal dryness is with prescription estrogen. You'll need your doctor to discuss this with you, because there's a handful of medical conditions that make it dangerous to use estrogen. A history of breast cancer is one of the biggies. Other than estrogen, there are a few things that can help with dryness. DHEA vaginally is one thing that's being studied. There's also a few over-the-counter meds and prescription ones that help with dryness.


If you have vaginal dryness and aren't using your vagina, you're in a bad spot. Please get in to talk to your doctor about estrogen replacement. If you don't have a doc to do this for you, I can see you in my office! Please go to Nurture Womens Health and make an appointment to talk about vaginal dryness and painful sex. And buy yourself a fun Christmas present this year! A BOB will fit nicely in your stocking.

References:
https://www.ncbi.nlm.nih.gov/pubmed/28885410
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4389697/
https://www.ncbi.nlm.nih.gov/pubmed/28885410

Sex Hurts!!! Part 5- Vaginismus

"Sex is impossible- my vagina just won't cooperate!"

It's not an uncommon problem, sadly, to have an uncooperative vagina. Remember my "dreaded speculum exam" post? This is it...the most common cause of a painful speculum exam. Now, as you've seen in other posts, it's not the only reason. But it can cause some serious issues in your relationship, and obviously may make sex painful or impossible.

What is Vaginismus?

Vaginismus is when your vaginal muscles tighten up spontaneously, without your intentional help. This makes penetration with sex, or even placing a tampon, painful or almost impossible. It can also push things out of the vagina after they've been placed there.

For some people this happens with the very first time of trying to have sex. It can lead to what we call unconsummated marriages and is pretty common in some cultures. It can also start after having had no issues in the past. 

Primary Vaginismus

This is when you've never successfully had sex. Nothing, or at least a penis, has ever been in there. The partner may say it feels like there's some type of barrier when he tries to penetrate, or that "the hole is too small." Sometimes other muscles get in on the action and tighten up. Women often hold their breath. Primary vaginismus is often caused by societal ideas, family expectations, personal thoughts about sex, or cultural practices. But it can also be related to unusual anatomy or sometimes a history of abuse. 

Secondary Vaginismus

This is when you've been able to perform before without problems, but now you're getting painful vaginal tightening. Something almost always triggers this. It could be something as awful as rape, or as simple as a urinary tract infection. It's really common with marital issues, especially cheating. Once the trigger problem is treated and fixed, like antibiotics for the infection, the vagina may continue to tighten. This is a "knee jerk" type reaction that has been programmed. It's like Pavlov's dogs that salivated when a bell was rang because they associated the bell with food. If your brain associates pain with sex, it may tighten the vagina up without your conscious permission.

What does it feel like?

For you ladies, it can feel anywhere from mild discomfort, burning with tightening, to severe tightness, or a complete inability to allow anything in there. If something is forced inside it will cause severe pain. For your partner, it feels like a barrier, a wall, or a really tight vaginal opening. I've seen cases so bad that I couldn't get a single finger in for an exam.

What can be done for this?

If this seems like an awful diagnosis, I can assure you it's treatable. But, it requires some work on your part. There's some psychology that's in play with this diagnosis, so counseling is usually involved. It can be on the fun side, like a sex therapist, or more intellectual like counseling. The most important first step is education. Other therapies include dilators, medications, and injections.

Techniques for treatment include:

1. Education about your body, the vagina, and the muscles in the pelvic floor.
2. Physical therapy to teach you how to relax the muscles
3. Vaginal dilators. These you can purchase online and use at home. You start with a really small dilator and place it inside for 10-15 minutes every day. Once you can insert it without pain, you go up a size. It can take months to get up to the size you'll need to be able to have pain-free sex, but the work is worth it! You'll need to continue dilating for a while, usually 6-12 months to get full effect.
4. Injections of botox. This is obviously done by a trained expert.
5. Therapy- either sex therapy, or counseling, or both.

As Always

As always, if you have questions, or think you might have vaginismus, please make an appointment to see me at Nurture Womens Health.

Resources:

https://www.ncbi.nlm.nih.gov/pubmed/24894201
https://www.ncbi.nlm.nih.gov/pubmed/28363809

Sex Hurts!!! Part 4- Vulvar Pain Syndromes

"It hurts to place a tampon, like REALLY hurts"

If this is you, there's a good chance you might have a vulvar pain issue going on. If it hurts to try placing a tampon, or trying to have sex, or worst of all having a speculum exam, listen up!! There's hope, ladies!

Um, ok, but what's Vulvodynia?

So, this just means pain in the vulva that lasts for a long time without an identifiable cause (like an infection or yeast). The vulva includes the vestibule, the clitoris, the urethra, inner and outer labia (lips), the perineum, and the area above the clitoris called the mons pubis. For diagnosis purposes, vulvodynia can be pain all over the vulva, or just in certain parts of the vulva. It can come and go, or be constant. If it's all over the vulva, it's called generalized. If it's just in a certain place, it's localized. The localized is then further split in to the particular areas that hurt. Even more, it's classified by whether it hurts all the time, or just with touch, which is called provoked. So, to clarify:

Vulvodynia
     Generalized
     Localized (can be provoked or not)
Vestibulodynia (just the vestibule hurts)
Clitorodynia (just the clitoris hurts)


This kind of pain usually feels like burning, or like a knife stabbing. But not everyone is the same, so it can feel like throbbing or uncomfortable pressure too. When it's generalized, the pain is all over the vulva. Usually it gets worse with activities like sitting on a hard surface, riding a bike, or having sex.

Take me to Church!

I think it's fitting that the entrance to your vagina has the same name as the entrance to a church, don't you? Yep, the vestibule of a church is the outer courtyard or the entrance room. The vestibule of your vagina is the skin just around the vaginal opening.

So, vestibulodynia is...?

Yes!! It's pain just in the vestibule. Remember, that's the skin just around the outside of the vagina, including the outer hymenal ring and the opening to your urethra (where you pee from). If you take a mirror and look at your bottom...yes I'm serious...it appears just a little more pink that the skin around it.

If the pain is localized to just this area, it's often provoked, meaning it only hurts when TOUCHED. This kind of pain tends to be tearing or sharp. This area gets touched with a handful of activities, like trying to put in a tampon, attempting to have sex, or having a speculum or pelvic exam at the gyno's office. If I know on the front end that you have pain with these activities, I'll do something called the q-tip test. I'll touch a q-tip gently to areas around the vestibule, and if it hurts, that's not normal! Touching a q-tip anywhere on your skin shouldn't hurt.

What causes these issues?

To make it short and sweet, we don't know. Like, science doesn't actually know. There are some theories though. Most of us in the field think that there's at least an inflammatory and immune system up-regulaton. This may be triggered by yeast infections, or by muscles that are too tight. But to be honest, it's really still a mystery. That doesn't mean we are empty handed for treatments, but it DOES mean that not every treatment works for everyone, because we're not really sure what we're treating. Sounds lovely, right? So, to treat this, you and I are going to have to be partners, and be willing to try a few things to figure out what works.

What treatment options are we talking about?

1. Stop putting stuff on your vulva. Please see Sex Hurts!! Part 2 under the contact dermatitis part
2. Creams/ointments for the skin:
anesthetics like lidocaine
hormone ointments or creams (sometimes I get these mixed with the lidocaine)
prescription topical steroids
alternative creams- compounding pharmacies make these for you
3. Female pelvic physical therapy- this is a biggie!!
4. Nerve blocks
5. Nerve Stimulation
6. Surgery
7. Complimentary medicine- chiropractic, acupuncture, herbals
8. Counseling and mindfulness techniques

As Always

If you think you have vulvodynia or vestibulodynia, please make and appointment with me at Nurture Womens Health and I'll be happy to figure out what's going on with your "church".


Resources:
https://www.ncbi.nlm.nih.gov/pubmed/22951941
https://www.ncbi.nlm.nih.gov/pubmed/26132928
https://www.nva.org/
http://www.turner-white.com/pdf/jcom_may10_vulvodynia.pdf

Sex Hurts!!! Part 3- Fibroids and Endometriosis

Cramps suck!

Having cramps at the time of your period is expected. Most women just pop a couple of ibuprofen and go on with things. But deep cramping pain during sex is different and awful. It can completely disrupt a marriage and cause you to avoid sex altogether. Why are you having deep pain with sex? It can be several things. Endometriosis is a well know cause of pain with and after sex. A few recent literature articles are also pointing towards fibroids being associated with deep sexual pain. So let's dive in and see what info is out there.

Deep dyspareunia

This is the medical term for pain way down inside while having penetrative sex. It's usually a sense of cramping or intense pressure and sometimes my patients will say it feels like "he hits something" that causes the cramps which can last for hours.

Sometimes this is just a uterus that's tipped backwards (retroverted) and he's hitting the top of the uterus with deep thrusting. Usually this just causes cramping during, but not after, sex. This is easy to fix with changing positions; like going doggy-style or side-lying instead of missionary position.

If changing positions doesn't help, it may be fibroids or endometriosis causing the cramping. 

What is a fibroid and how does it cause pain with sex?

Fibroids are benign (non cancer) growths of the muscle tissue of the uterus. They can be in a lot of different places including inside the cavity of the uterus, growing inside the uterus wall, or growing off the edge of the uterus. They most often cause pain and heavy bleeding with your periods, and are a common reason for hysterectomy in the US. Deep pain with sex has recently been associated with an increased likelihood of finding fibroids on ultrasound, and especially with fibroids that are at or near the top of the uterus.

So what do we do about it? If you have deep pain with sex and we can't find a reason other than fibroids, I'd consider either removing the fibroids or doing a hysterectomy. As far as I'm aware, there isn't any literature proof that removing the fibroids or doing a hysterectomy resolves deep pain with sex, but it would stand to reason that it should. Most of my patients that have hysterectomies for fibroids wish they'd done them sooner as their lives in general improve, and especially their sex lives. Here at Nurture Womens Health, I do out-patient hysterectomies using the DaVinci robotic system. You'll go home the day of surgery, and have about a 2 week recovery.

After I finish my "sex hurts" series, I'll do more general blogging on fibroids and pelvic pain, so keep tuned for more info.

What is endometriosis and how does it cause pain with sex?

Endometriosis is when the tissue you shed every month with your period gets up in to your abdomen, attaches to a surface and starts growing there. Science isn't really sure exactly how this happens, but there are a few theories including the most popular one, retrograde menstruation (bleeding during your period out into your abdomen). Endometriosis is a BIG subject that I'll give a lot more love to in blogs to come. But for now, how does it relate to pain with sex?

Pain with sex related to endometriosis is most often caused by a sub-set called deep infiltrating endometriosis. Deep infiltrating endometriosis is when the cells growing in your abdomen invade deep in to the tissues of the pelvis. There are some studies that show any type of endometriosis can cause pain with sex, though.
How is it treated?

This is a really big topic...so I'll keep it simple for now and go in to more detail in later blogs. There's a lot of discussion among the specialists about how to treat endometriosis. My biggest addition to the conversation is that endometriosis is rarely the ONLY cause of someone's pelvic pain. Usually it's accompanied by pelvic floor dysfunction and can be associated with several other things, too. Endometriosis also often involves the bladder and bowel, so it's not as easy as "cut it out" when it comes to treatment. Things that can be done to treat endometriosis include, but are not limited to:


- Hormonal manipulation with birth control
- Leuprolide- an injectable med that makes your body think you're menopausal (imagine the side effects...)
- Orilissa- a new oral medication for endometriosis and fibroids
- Laparoscopic removal of visible implants and scarring
- Hysterectomy, with or without removal of ovaries (this is controversial)

More to come

As I said earlier, fibroids and endometriosis are HUGE topics and have a lot of bearing on pelvic pain in general. This very short synopsis was just about their relation to pain with sex. Please stay tuned to this blog for more information on both of these medical conditions. And as always, if you have been told or think you might have fibroids or endometriosis, please call or go online and make an appointment to see me at Nurture Womens Health.


Resources:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5503180/
https://www.ncbi.nlm.nih.gov/pubmed/22910685
https://www.ncbi.nlm.nih.gov/pubmed/24165172
https://www.ncbi.nlm.nih.gov/pubmed/18660692/
https://www.ncbi.nlm.nih.gov/pubmed/26246414
https://www.ncbi.nlm.nih.gov/pubmed/24366116
https://www.ncbi.nlm.nih.gov/pubmed/26363387
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-42302015000600507&lng=en&nrm=iso&tlng=en

Sex Hurts!!! Part 2- Vulvar skin issues

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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.

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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

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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)

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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.


As always, if you think you might have one of these skin issues going on, please make an appointment with me at Nurture Womens Health in Frisco!

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/