Care of the Vulva Patient Information

This information is relevant to anyone suffering from vulval symptoms; whether it be itching, soreness or burning pain. Looking after the vulva is an essential part of management of all vulval conditions.

• Avoid contact with potential irritants
• Do not over-clean the area (once daily is optimal)
• Try not to scratch
• Keep the skin well moisturised
• Apply topical treatments as directed by your specialist
• Use an appropriate vaginal lubricant with intercourse as recommended by your specialist

• Do not use perfumed / soapy products
• Do not use feminine wipes / toilet wipes
• Wear loose clothing rather than tight trousers or jeans
• Wear cotton underwear
• Avoid wearing pyjamas and underwear in bed
• Where possible avoid pantry liners / sanitary towels and, when necessary, choose products without chemicals
• Seek treatment for urinary incontinence

Do not over-clean the area
Many women with vulval conditions feel unclean and have a tendency to over-wash / douche. This practice can actually do more harm than good as it disrupts the skin’s natural bacterial makeup making the area feel more irritated. Best advice is to have a warm bath daily.

Try not to scratch
Easy to say! The problem with scratching is that it leaves the skin more sore and damaged. It is important to keep finger nails short and avoid nail varnish. If scratching at nighttime is an issue, wear cotton gloves in bed. Rather than itching the vulva, try applying some moisturiser that has been kept in the fridge or some ice that is wrapt in a thin cloth.

Keep the skin well moisturised
This will help condition the skin and a moisturiser should be applied at least once daily. Your specialist will advise a good emollient to use.

Apply topical treatments as directed by your specialist
Although it can be tempting to apply a range of treatments to the vulva, often, less is more. Your specialist may prescribe some ointment to use and it is important to follow the advice regarding application. Medication will be reviewed at each visit.

Use an appropriate vaginal lubricant with intercourse
Patients with a vulval condition often find that it also has an impact on their ability to have intercourse. Arousal, in particular, can be affected especially when a woman experiences pain with sex. A natural water based lubricant is ideal and your specialist can discuss this in more detail with you.

Lichen Planus Patient Information

Lichen planus (LP) is an inflammatory disorder that can affect women at any age but is most common after the menopause. Inflammation can affect the skin of the vulva, inside the vagina, in the mouth or elsewhere on the skin. We do not understand why some women get LP but it may be an autoimmune condition; where the body’s own immune system attacks itself. It is not infectious or contagious.

• Soreness of the vulval skin
• Raw appearance of skin with breakdown
• Painful intercourse
• Persistent vaginal discharge (can be bloody)
• Change in appearance of the vulva with loss of labia minora (vulval lips) and flattening of the clitoral hood
• Blockage within the vagina making sex or having a smear test impossible
• Vulval itching

Diagnosis
The diagnosis can usually be made by taking your history and performing an examination at a consultation with a vulval specialist. Occasionally, a biopsy (small piece of skin) is taken to confirm the diagnosis.

Treatment
LP is a chronic condition for which there is no cure. Treatment aims to improve symptoms and prevent further inflammatory change. The course of LP varies for each patient but often symptoms come and go. Sometimes symptoms disappear completely over time. Mainstay treatment is with steroid ointment to the skin and vaginal steroid preparations. It is important to avoid vulval irritants such as soapy and perfumed products to the area and a daily moisturiser helps improve the quality of the skin. If the condition proves difficult to treat then steroid tablets or medication to lower the immune system can be used.
When the vagina is involved, vaginal dilators and specialist physiotherapy may be recommended. It is extremely rare for surgery to be indicated in the management of LP. Division of scar tissue within the vagina is the most common indication.

Follow up
Your specialist will see you regularly until symptoms are well controlled. Women with LP have a small increase (3%) in risk of developing a cancer of the vulva. For this reason you will require long term surveillance, usually on a 6 - 12 monthly basis.

Lichen Sclerosis Patient Information

Lichen sclerosis (LS) is an inflammatory skin disorder that most often affects the skin of the vulva and around the anus.
It can occur at any age but is most common after the menopause. We do not understand why some people get the condition. It is not an infection and you cannot pass the condition on to other people. It is thought that LS may be autoimmune in nature (where the body’s own immune system attacks itself).

• Itching of the skin around the opening of the vagina and the anus
• Soreness of the skin, especially when passing urine
• Skin colour changes - can be white or red
• Change in the appearance of the vulva. Some women may notice that the labia minora (vulval lips) or the clitoral hood have shrunk and appear flattened. The opening of the vagina may narrow.
• Difficulty with intercourse

Diagnosis
This is usually made by a specialist in the clinic by taking your history and examining the vulva. Rarely, a biopsy (small piece of skin) is taken to confirm the diagnosis.

Treatment
There is no cure for LS; it is a chronic condition. Treatment aims to control symptoms and preserve normal structure as far as possible.
Steroid ointment is very effective at stopping or reducing itching. Moisturising the skin is important and it is essential to avoid soapy / perfumed products on the vulva. It is rare that surgery forms part of the treatment of LS. The main indication for surgery is to widen the opening of the vagina as this can help to improve discomfort with intercourse or prevent difficulty passing urine.

Follow up
If you are told you have LS, your specialist will want to see you regularly until symptoms are under control.
If you have a diagnosis of LS you should be on long term follow up. This is because having LS is associated with a small risk (3-5%) of developing a skin cancer. You should be seen once a year as a minimum.

Bleeding After Sex Patient Information

Bleeding after intercourse is a common symptom and there are several reasons why it can happen. If you have experienced bleeding with sex for more than three months then you should see a specialist. Bleeding can range from light spotting to a heavy 'period-like' bleed.

• pelvic infection, particularly if bleeding is associated with pain and discharge. Getting an STI screen is always a good idea if you have bleeding with sex.
• an ectropion is a normal finding on the cervix. It is a collection of glandular cells originating from the within cervical canal that have migrated onto the outside of the cervix. These glandular cells are delicate and bleed easily with any contact and so women will invariably complain of bleeding with sex due to the penis touching the cells. An ectropion does not necessarily need any treatment but if symptoms are bothersome, the cells can be removed or destroyed using a heat treatment. This is a minor procedure done in clinic using local anaesthesia.
• in women that are post-menopausal, the tissues of the vagina become dry and atrophic due to lack of oestrogen. This can cause the vagina to bleed with friction from sex. Relaxing oestrogen in the vagina or using a vaginal moisturiser can be very effective.
• benign polyps (fleshy growths) are a common finding on the cervix that can bleed with contact. Polyps are usually easily removed in the clinic.
• some contraceptives can cause bleeding with intercourse.

Bleeding after sex can be a sign of cervical cancer and so it should always be investigated. That said, cervical cancer is rare in the UK (9 cases per 100,000 women) and post-coital bleeding is a common symptom. Cervical screening is an effective way of preventing cervical cancer and if you have regular smear tests your risk is extremely low.

If you suffer from bleeding after sex, see a specialist so that a serious cause (such as cervical cancer) can be excluded. A colposcopy examination of the cervix will be performed. This involves looking at the cervix in detail using a microscope.
Treatment of bleeding with sex is on an individual basis and depends on the cause of the bleeding and how bothersome the symptoms are.

Pre-cancer of the Vulva (VIN) Patient Information

Cancer of the vulva is rare. Before a cancer forms, there is a pre-cancer phase. This has long been called VIN (Vulval Intraepithelial Neoplasia) but this term has now officially been replaced by High grade Squamous Intraepithelial Lesion (HSIL) of the vulva.
We aim to diagnose and treat vulval pre-cancer before it becomes a cancer.

Some vulval cancers are associated with chronic inflammatory conditions such as lichen sclerosis or lichen planus. For this reason, if you suffer from one of these disorders you should have regular follow up with your specialist.
Other vulval cancers are caused by a virus; Human Papilloma Virus (HPV). This is the same virus that causes pre-cancer and cancer of the cervix. It is very important that you have regular checks of the cervix if you suffer from pre-cancer of the vulva.
It seems that some women struggle to 'shift' HPV and the longer it remains active in the body, the more chance it has to cause pre-cancerous change. We know that smokers are more likely to have persistent infections as are women with reduced immune systems (eg transplant patients or those women taking immune reducing therapies such as methotrexate).

Common Symptoms
Pre-cancer of the vulva can present in a variety of appearances. Patients usually notice lumps or bumps on the vulval skin. These can sometimes look warty. There is usually a colour change but this is very variable. Lesions can be red, white, brown or black. Often, patients complain of vulval soreness and, less commonly, itching.

Diagnosis
Examining the vulva can reveal whether a lesion is likely to be pre-cancer. Sometimes a microscope is used to perform a detailed examination (a vulvoscopy). If your specialist thinks you have pre-cancer of the vulva, a biopsy (small piece of tissue) is taken to confirm the diagnosis. The biopsy can be taken in clinic using some local anaesthesia.

Treatment
The options available for treating pre-cancer of the vulva are surgical or medical.

• Surgery is the 'gold standard' and usually involves cutting away the disease. This is done as a day case procedure in theatres under general anaesthesia. Dissolvable sutures are used to close the skin. Sometimes, the disease is treated by heat or laser treatments.
• Medicine called Imiquimod can be used (off license) to treat pre-cancer of the vulva. It works by stimulating the immune system locally when it is applied to the lesion. Common side effects are burning sensation, redness and irritation. It is usually applied for up to four months but your specialist will direct you.

Many factors are taken into account when planning treatment and your specialist will tailor your treatment to your individual needs and circumstances. All women with pre-cancer of the vulva are advised to stop smoking.

Recurrence
It is not uncommon for pre-cancer of the vulva to recur in time. Even after treatment, you will need to be kept on surveillance some time. If you are someone that has had recurrent vulval pre-cancer, it is likely that you will need long term specialist follow up.
Stopping smoking will improve your chances of not experiencing recurrent disease.

Follow up
Expect to be seen by your specialist every three to six months initially after treatment. If there are no signs of recurrence, follow up can often be on an annual basis.

Vulvodynia Patient Information

Vulvodynia is a pain syndrome. The diagnosis is made when a woman has experienced burning pain on the vulva for at least three months and there is no vulval abnormality on examination. The condition is due to the nerve fibres in the skin of the vulva being over-sensitive. This results in the nerve fibres over-firing and sending abnormal signals to the brain that the woman then feels as pain.
Vulvodynia is a common condition but women are often embarrassed to talk about it and delay seeing their doctor.
We do not understand why the condition affects some women and not others. There is a thought that an infection with thrush may create the initial nerve irritation. Vulvodynia is not infectious or contagious; you cannot pass it on to anyone else. The prognosis of vulvodynia is very variable. Some women’s symptoms improve over time spontaneously whilst other women have symptoms for many years. Most women will get some symptom control with treatment.
Vulvodynia is classified according to when symptoms occur. If a woman only has pain with touching of the vulva such as during intercourse, riding a bike or inserting tampons it is termed Provoked Vulvodynia. If the symptoms are persistent or come and go randomly, it is termed Unprovoked Vulvodynia.

• Burning and soreness anywhere over the vulva
• Pain with intercourse, often making sex impossible
• Pain with smear tests

Diagnosis
A diagnosis is made by taking a detailed history and performing an examination in clinic. There is no diagnostic test for the condition.

Treatment
Vulvodynia is a complex condition that should be managed by a specialist in vulval disease. Treatment often involves a combination of therapies and is dependent on whether you have a diagnosis of Provoked or Unprovoked Vulvodynia. Aims of treatment are to control pain and achieve pain-free intercourse.

• Topical anaesthetic treatments
• Specialist physiotherapy
• Medication to try to reduce the abnormal nerve impulses (as tablets or as an ointment)
• Steroid injection
• Psychosexual therapy
• Water-based vaginal lubricants
• Vaginal dilator therapy
• Cognitive Behavioural Therapy
• Acupuncture
• Surgery (a procedure called a vestibulectomy). This is only offered to a select group of women that fulfil pre-operative criteria. It is used as a treatment for Provoked Vulvodynia but only in those women where it is deemed likely to be a successful treatment. Surgery has the potential of making symptoms worse and your specialist will advise on an individual case basis.

Follow up
Management of this condition will vary for each patient and should be tailored to the individual.