From how they look and smell to how they behave or feel during sex – Dr. Deyo Famuboni tells us what’s normal, and what’s not for a healthy vagina
It brings life to the world, pleasure, a source for drug administration and is part of what defines us as women, so we should embrace vaginal health and not ignore concerns we may have. Technically speaking, the vagina is the inner canal and the visible region is the vulva (and the lips or labia a part of this). We may sometimes find ourselves asking ‘is it normal down there?’ Here’s an ultimate guide to what’s normal, what can go wrong and what can be done about it.
Every vagina is different and as individual as our fingerprints. The labia majora (outer lips) can be large or smaller, smooth or slightly droopy. These are fat filled sacs with pubic hair designed to keep bacteria out as well as to make sex feel comfortable. Just like the rest of our skin, it changes with age and can become less firm. Protecting the vagina and urethra (where urine comes out from) is the labia minora (inner lips), which lies within the labia majora and is smaller and more sensitive. It also requires adequate nutrition, in particular good levels of protein to maintain the collagen within it. The clitoris can also appear different from person to person. An organ solely for pleasure, it extends backwards and can swell up in size when aroused. Pubic hairs can also have different shapes and extensions in people- from just below the belly button to the top of the thighs. In between the labia, you might notice tiny pimple like lesions. These are sweat and oil glands which produce fluid to keep the vagina lubricated and prevent friction.
Every vagina is different and as individual as our fingerprints
Women can sometimes be concerned about the appearance of their labia even if they are normal looking and cause no pain or discomfort. They may consider an operation called a labiaplasty – it is worth discussing this with your health care professional first because the appearance post-surgery may not be as expected and may not make you feel better. As it is an operation, there are also associated risks. Unless necessary, It is not recommended if under 18 years old as the labia may continue to develop even into early adulthood. Female genital mutilation is an illegal practice which can change the appearance of the vulva and narrow the vagina opening (called the intriotus). With both short and long term physical and psychological consequences, if worried about this for yourself or anyone else, it is important to contact the authorities and healthcare professional. Surgical ‘reversal’ is available to widen the opening.
From puberty to menopause, having some vaginal discharge is normal. The quantity can vary from person to person and throughout our cycle. The first few days of the cycle is your period, following this, the discharge can be white, creamy or yellow, thick and sticky. Ovulation then occurs and the discharge changes to slippery, clearer, stretchy and wet. Following this, if you don’t fall pregnant, it then changes to thick and sticky, becoming hostile to sperm. Discharge becomes abnormal if there are other symptoms with it or the colour and amount changes, for example, becoming chalky white with candida or frothy yellow or green with trichomonaisis, a sexually transmitted infection. It is therefore important to be sexually responsible. Hormonal contraceptions and having a condition where the inner lining of the cervix protrudes outward (called, ectropion) can also change the discharge so it becomes copious.
From puberty to menopause, having some vaginal discharge is normal.
Other causes of an increase in the amount of discharge include cervical polyps (a non serious growth on the cervix which can easily be removed), forgotten tampon, douching, allergic reaction for example to a spermicide, and rarely, a connection between the bladder or bowel and the vagina (a fistula). A condition we worry about is cancer and if affecting the vagina, cervix or lining of the womb, can also cause an increase and change in the type of discharge such that it becomes thinner and blood stained. Should this happen, see your health care professional, who would offer a vaginal examination to ensure it looks healthy and onward referral if required.
Just like the armpits, the skin around the labia has a lot of sweat glands. The vagina also produces fluid to keep it healthy and maintain balance at an acidic level. With exercise, it is normal to sweat more in these areas, so dont be alarmed if the crotch of your gym wear is damp after exercise. It is a good thing as it prevents friction, chaffing and overheating.
Taking the combined contraceptive pill irregularly can cause bleeding or spotting in between your periods. If it persists after taking it regularly then a visit to your Doctor is warranted. Other forms of contraception such as the mini-pill (the one with one hormone), the injection, the implant (the one in the arm) and the intra-uterine system (known as Mirena) can cause your periods to be irregular. As long as there no concerns regarding infections and scans, if indicated are normal, this tends to settle over time. Bleeding after intercourse also needs a review as it could be due to a polyp – this is a benign growth and easily removed. Other causes include changes on the cervix and cervical or rarely, vaginal cancer. With these, in addition to bleeding after intercourse, you may get copious amounts of discharge. A one off mild bleed after a particularly rough episode of intercourse is probably no cause for concern.
LUMPS AND BUMPS
Most commonly due to an ingrowing hair, this is more common in those with elliptical shaped hair shafts. Shaving or waxing contributes to this and can be best prevented by shaving or waxing in the direction the hair grows. Hair removal using a depilitator or laser by a trained professional also helps. Depilitators, however, can make the vulva skin dry and irritable. Other non-worrying lumps are remnant of the hymen (redundant, irregular bits of skin), which may become more obvious with weak pelvic floor muscles (causing a prolapse), or glands on either side of the vagina called bartholins which produce bits of mucous. These can become infected so if painful and swollen, require medical attention and drainage. Keep up with the pelvic floor exercises (kegels!). Just like with any part of the body, sebaceous cysts (fluid filled sac that is not infected or painful), warts, boils or abscesses can also occur around the vulva. A review by your doctor is warranted should these occur as if infected, would need treatment. The surface of the vaginal wall can also feel bumpy as it is made of tissue which can retract and expand when needed.
The vagina can become painful during sex. This is known as superficial dyspareunia and usually occurs when the vagina is too dry or inflamed because of an infection. Foreplay and lubrication helps. As opposed to superficial dyspareunia which is felt in the entrance or wall of the vagina, deep dyspareunia is pain in the lower abdomen or pelvis during sex and this can happen due to several conditions including endometriosis and fibroids. If you are concerned you have an infection or get deep dyspareunia, see your healthcare professional. Swabs and possibly a pelvic ultrasound can then be organised.
Sex can also be painful because of a condition called vaginismus. This is due to the muscles around the vagina going into spasm on attempted penetration. If severe, it can happen on inserting a tampon. It is good to discuss it with your doctor so that causes of this can be explored and treatment to gradually desensitise the vagina, such as dilators, is readily available. Also known as vaginal trainers, dilators are rod shaped instruments which come in graduated sizes. Used as part of a holistic treatment for vaginismus, it can help improve control of the pelvic floor reflexes and muscle tightening that contributes to vaginismus.
The most common, familiar reason for this is thrush, which is often accompanied with a chalky discharge. Easily treated by over the counter antifungals such as as canesten, if this is the first time or not settled with treatment, it is worth seeing your healthcare provider to rule out other causes. We can easily disrupt the normal vagina flora and protective layer of outer skin by using scented products, douching and over drying. This can lead to dermatitis- inflamed skin.
We can easily disrupt the normal vagina flora and protective layer of outer skin by using scented products, douching and over drying.
Other skin conditions can also affect areas around the vagina and cause itch. This includes eczema, lichen planus (itchy and sore white streaks or patches with discharge around the vulva and vagina) and the vulval dystrophies (disorders of the skin growth around the vulva) such as lichen sclerosus- an itchy, sore area around the vulva which then changes to a pale colour and the skin looks shrunken. These can be treated by vulval dermatologists, specialists in conditions affecting the skin around the vagina, which you can ask your GP for a referral to.
Refraining from douching (washing out the vagina), wearing cotton underwear or none, decreasing hot baths, always cleaning from front to back (and the area in between), refraining from tight clothes such as skinny jeans, changing condoms if you practice anal and vaginal sex or develop itching or a rash after using a condom, using water only and if you have to, non scented, hypoallergenic, pH-balanced washes and changing cloth washing products should you suspect a skin reaction can help in preventing not only the symptoms of itch but other infections.
There are so many reasons why your vagina might smell, from overgrowth of the normal bacteria because the vagina environment becomes less acidic (this is called bacterial vaginosis) to a retained (not lost) tampon or condom.
A fishy smell is usually due to bacterial vaginosis and is always advisable to have checked. Unless you have been diagnosed and treated with bacterial vaginosis previously and know the symptoms, treatment is available over the counter. Some women find this is triggered by their periods or intercourse. In this situation, using a lactic acid gel, such as Balance Activ, regularly can prevent a recurrence. It gives the vagina the nutrients it requires to remain in balance.
Like everything else in our bodies, good nutrition is vital in vaginal health. Nutrient-rich foods in general help to maintain a healthy acid level and prevent overgrowth of the bacteria that causes the fishy smell. Maintaining the good bacteria known as lactobacilli in the vagina is also helpful, hence why taking live active yogurt or probiotics has been linked to decreasing the occurrence of bacterial vaginosis. Retained tampons or condoms can easily be removed by your healthcare provider.
With the advent of increased cycling, numbness or pain has also become a fairly common problem. The pressure from sitting on a cycle sit can affect the skin and nerves in that area. It usually settles and can be prevented by wearing padded shorts and getting a good supporting firm cushion so you don’t sink into the seat. If there are other problems with it, like swelling, urine or bowel problems or back pain, or it persists, a visit to your doctor is warranted. Cycling is a great and fun way to increase fitness levels but some preparation beforehand is essential to prevent problems.
With the advent of increased cycling, numbness or pain has also become a fairly common problem
Passing urine can become painful and the most common reason for this is a urine infection. This can happen after sex and is best prevented by passing urine before and after to decrease any bad bacteria that may be hanging around. Also being well-lubricated during intercourse can be helpful to decrease any chaffing or sores. Urine incontinence can occur if the muscles become weak and cause a prolapse – see your doctor should this be of concern.
Rigorous cleaning, the use of hormonal medications (especially those with progesterone hormone), post pregnancy (as oestrogen levels drops), breastfeeding, other medications such as antihistamines and antidepressants and age all contribute to the vagina feeling dry. Discussing contraceptive choices with your health care professional will help to ensure you are on one without the side effect of vaginal dryness. As we get older and become perimenopausal and into the menopause, this can happen and there are vaginal moisturisers, lubricants and hormonal treatment that can help. These are available over the counter or on prescription. It is important to test a patch of skin, for example, your inner thigh, before using it freely. This is to ensure you are not allergic.
More from Healthista GP Dr. Deyo Famuboni
Deyo Famuboni is a London GP, follow her on Instagram @deyof