On this episode of Sex, Body, and Soul, I talk vulva health with OB-GYN Dr Jill Krapf, OB-GYN and specialist in female sexual pain. Vulva health, you ask? What the heck is that? Listen to the podcast to find out what exactly is a vulva (most people don’t know!) and how to care for it (moisturize! Seriously!) to keep your body healthy and pain free (particularly during sex). Did I have you at “vulva”? I hope so. Here we go!
First off, I promised you a definition of the vulva. What is it and how is it different than the vagina? Well, the vagina is the internal part, and believe it or not, there aren’t many nerve endings in it. The vulva is where the action is – both good and bad. It’s where 99% of sexual pleasure is derived, but also where 99% of the pain is located when it happens. Of course the vulva contains the clitoris - the only human body part dedicated solely to pleasure, I like to sing that from the hills. But the vulva is much more than just the clitoris. The vulvar area is also composed of the labia majora (the larger hair-bearing lips) and inside those are the labia minora. The labia come in all different shapes and sizes, and even on the same person one side may look different than the other. They are all beautiful!
But then, Dr Krapf blew my mind with what should be basic anatomy to us all but was news to me: internal to the labia minora is the vulva “vestibule” – the vaginal opening. The vestibule contains the urethra (tube that drains the bladder) and the gland openings that produce natural lubrication that allows that skin to stay healthy and supple, and prevents pain and friction with anything inserted inside the vagina. When people have vulvar pain, it is often localized to the vestibule, which is about the size of a postage stamp room. Check out The Body Agency’s Vuppet puppet to see a fun way to teach others about the vulva.
If you’re like me, you probably assumed that your gynecologist knows all about care “down there”. Not so! Many obstetrician/gynecologists actually know little about vulvovaginal conditions, especially pain. When Dr. Krapf was in her fourth and final year of residency training in obstetrics and gynecology (after four years of medical school), she did a surgery for something called vulvodynia, which she had never seen before. Vulvodynia is the general term for chronic pain or discomfort around the opening of the vagina with no identifiable cause. Considering how common discomfort can be in this area, you can imagine how shocking it is that her first encounter with this surgery was virtually at the end of her extensive training. Can you imagine?
When Dr. Krapf had this “a-ha” moment in the final stretch of her training, she underwent another year of training to learn more with a specialist who also treated older men with erectile dysfunction. When the men came in to the office with their wives, she noticed the women were not as happy as their newly invigorated husbands. In fact, they were experiencing pain with sex, which is very common as women age and their hormones change. After menopause, without hormones or sufficient activity in the region, many women experience what used to be called “vaginal atrophy”, which encompasses symptoms like vaginal dryness, discomfort or pain with sex, and recurrent UTIs that occurs when the estrogen levels drop. Fortunately, more is known about this so it no longer falls into the category of unknown pain origin (vulvodynia) and it is now known as “GSM” for genitourinary syndrome of menopause. These are not just a minor irritations – they can cause chronic itch and scarring as a result of tearing during sex. This is painful stuff that needs attention!
And vulvodynia is very common in all age groups. It can be a result of, for instance, a yeast infection, an STI, a urinary tract infection (UTI), irritation or hormones and vaginal dryness associated with perimenopause or menopause. Another nugget I learned on the podcast that I just can’t believe I had never heard before is that because there is only one type of nerve endings in the vestibule, any input to that nerve is going to feel similar. So when a woman feels discomfort in her vestibule and self-diagnoses (and treats) a yeast infection, she may well not in fact have a yeast infection at all – it could easily be something else.
Vulvodynia is a blanket term, and has many possible causes. Some I’ve already mentioned. Some may be autoimmune in nature or have a genetic component. And believe it or not, it can sometimes be caused or exacerbated by our old nemesis stress. (When I told Dr. Krapf about my aching vulva, she told me this could be because like many people, I am holding stress in my pelvic floor!) Because of this, it is so important to try to get to the bottom of what is causing the pain or discomfort as this will inform the proper treatment. For instance, vaginismus may require a combination of psychotherapy with desensitization, but other causes of vulvodynia like GSM requires something completely different.
Here is the takeaway: our vulvas can benefit from some basic skin care. It’s not hard, it doesn’t take long, and it doesn’t need to be expensive. Most women get out of the shower and moisturize their faces and maybe their bodies. Then we get dressed and walk around and sit on our vulvar area all day without a second thought. But if your hormones are changing (like after childbirth) or you are perimenopausal or menopausal, your vulva needs some extra care or the skin down there can crack. Ouch! Dr. Krapf recommends using a non-allergenic moisturizer on your vulva, like you would use on a baby. Vaseline or Aquaphor would work, or you can try my favorite, Hydrate Ever After by Sweet Spot Labs.
Other than that, keeping the vulva healthy is pretty easy. The vagina is self-cleaning so we don’t need any products in there, it can be washed with water. We should use a gentle body cleanser (not soap that can be drying) on the rest of the vulvar area, especially one that is dermatologist approved for sensitive skin. Steer clear of wipes if they contain any alcohol or fragrance. Find a gynecologist who is knowledgeable about your concerns who you can talk to (no subject should be off limits). And if you are approaching perimenopause or in menopause, you might want to consider finding a provider who is North American Menopause Society certified menopause practitioner (like Dr. Krapf) because believe me, many providers are woefully uninformed about the many ways that changing hormones can affect your body and mind!
If you or someone you know is experiencing pain with sex, give this podcast a listen and keep an eye out for Dr. Krapf’s upcoming book, When Sex Hurts, for some solutions.
Have a great day, go moisturize!