Medical Questions

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Information on Vulvar Disorders

Frederick R. Jelovsek MD

Worried about possible warts

Labial growth for a long time

Clitoral and vulvar sores

Vulvar lichen sclerosis treatment

Vestibular pain, keratosis and vulvitis

What causes seborrheic keratosis?

Red patches on the dry vulvar skin getting larger

Vulvar cancer and HPV 16

Itching, bruised, purple discoloration of vulvar skin

Round, flesh-colored bump above labia

Growth on vulvar lips that swells up

Enlarging tissue below the urethral opening

Tear or cut near clitoris

Morning vulvar irritation and burning urination

Clitoral pain - is surgery needed?

Varicose veins of the vulva

Itching after sex using condoms

Vulvodynia and HPV

Categories of vulvodynia

Irritant vulvitis or vulvodynia?

Support for Vulvar Problems

Healthshare at wdxcyber (HPV)
Healthshare at wdxcyber (Vulvar Dysplasia)
Vaginismus Support Group at Yahoo

Differential Diagnosis of

Vulvar Problems

Other Resources

VulvarHealth.org

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Worried about possible warts

I am 34 years old. I am worried I may have vaginal warts or something. I don't know what they are but they are new growths on my outer labia. I thought maybe they were "skin tags" and not anything to worry about but I seem to be getting a few more. Now one of them is sensitive, almost painful.

I have a regular D.O I see for my medical concerns but I am embarrassed to ask him about them. Please let me know if I should go have them checked out.. and if you might know what they are. I realize I have to go sometime because they are beginning to really make me self conscious sexually. If they are not a medical concern, they are at least becoming a personal one.

Growths like you describe on the vulva cannot really be diagnosed by description. You need to have your doctor look at them. Don't be embarrassed. Your doctor has probably seen those many times if they are warts (condyloma accuminata). What you have described can be consistent with condyloma but there are other possibilities also.

If the doctor thinks that's what they are, ask about treatment with Aldara®. This is a relatively recent treatment (cream) that allows you to treat at home three times a week. It is much less painful than the older treatments of chemicals that "burned". In my experience it has been quite effective.

Are you a smoker or do you have any conditions affecting the immune system? If you do, it may take a while to clear condyloma up.

Labial growth for a long time

I am 21 and for as long as I can remember I have had a small growth on the outside of my labia minor. I have never had a doctor check it out. Is this something that I should worry about?

It is not possible to say for sure without seeing the growth you are talking about. In general, if something like that has been present for many years and not changed in size, color, or firmness, it is most likely to be benign and possibly even congenital (from birth). At age 21 you might consider seeing a physician who does pelvic exams. See what that physician says.

Clitoral and vulvar sores

Over the past 4 years I have developed some unusual symptoms that many doctors cannot explain...tests are negative, therefore they do not know how to treat me.

Initially, the area around my clitoris (lips ?) becomes irritated, itchy and after about 2 days, the area becomes extremely sensitive and a clear sheath covers a small bloody area...not like a herpes sore. The sore is sort of long in shape, bloody, under a clear sheath, which comes off after I wipe, and is bloody underneath. The Dr. states it is NOT herpes even though I do test positive.

Now... not only does my vaginal area become infected by whatever this is but now my left eye become puffy, itchy, red and on the first day has a little bit of puss come out of it. The puffiness and redness continues for about a week...usually goes away before vaginal area is healed. Now..this past time I have an outbreak which includes my vagina, eye and now my lips and mouth are completely swollen and cracked and bloody. It seems each time I have an outbreak of whatever this is the next time I get it a new symptom accompanies all the others. The doctors think it is viral but I need to know if you have ever heard of anything like this.

I initially was put on Zovirax® which did not seem to help AT ALL...that is why they didn't think it was herpes. I am 34 years old, and my history includes osteogenic sarcoma at age 10 resulting in amputation and chemotherapy for 1.5 years. Could the chemotherapy possibly have compromised my immune system in some way. Blood tests always come back normal, as well as pap tests...I have had many tests and NO-ONE knows what this is.

The most problematic of all symptoms is vaginal area because it is very sensitive and bleeding. The bleeding does not come from my vagina. How can I heal it and is there anything I can do to prevent whatever these outbreaks are? I am DESPERATE for help here. The various doctors I have seen are clueless...so I am turning to anywhere possible for help. Thank you very much...

You describe a complex and unusual set of symptoms. It is difficult to diagnose any skin lesions without seeing them. A couple of things do come to mind about this.

The course you describe is consistent with viruses of the herpes family. When you said you tested positive for herpes, was that by culture or by blood antibodies? If it was by culture of the lesions, than this is a herpes infection even though it may not appear "typical". I assume that repeated cultures of the lesions have been done and herpes has not grown out with any of them. (it often difficult to culture herpes so I would say you need at least three attempts at culture before concluding this is not a herpetic outbreak). Make sure the doctor cultures or smears for chlamydia species since these are known to affect both the genital area and the eyes. You could have an unusual strain.

Herpes lesions can be long rather than round and often coalesce to be large. Zovirax® and other anti-herpetic medications don't really cure herpes. At best, taking it chronically can reduce the frequency of outbreaks, but the outbreaks still occur.

I have seen staph/strep bacterial infections that can look like herpetic lesions. I suspect they must have been very unusual strains because this is uncommon, but in those cases there was response to penicillin-type antibiotics to reduce episodes. Have you had any empirical trials of antibiotics?

The immune system definitely does play a role, especially if these are viral in origin. Be sure your thyroid tests are normal and that you don't have any liver disease such as hepatitis C or B or any HIV. Stress can play a role in herpes outbreaks so any stress reduction may help at least with the frequency.

Have any of the doctors you've seen been dermatologists? Gynecologists usually do ok with vulvar lesions but your problem is systemic and if you haven't seen an experienced dermatologist, that is one suggestion I could offer.

Vulvar lichen sclerosis

I think this site is very useful. My wife went for ten years with lichen sclerosus (fully manifested) on her vulva without her doctor diagnosing it. Finally this doctor was going to operate for a fused labia and my wife went to another doctor for a second opinion. In two seconds he knew it was -- lichen sclerosus and suggested a biopsy which we did.

To think of what we went through for ten years. My wife had an acute case and would often have her skin tear. A few times a year the always swollen area would rip and then get infected. This doctor had her sitting in a bathtub until it got so large it popped open. Sometimes it was eight days of suffering. We couldn't have sex much of the time during these ten years and when we could it was difficult for her.

The first doctor said there was nothing we could do. Temovate® finally took care of it in a few months once we had a proper diagnosis. I don't know what this doctor thought were all these white lesions and white staining all over. The more on the internet the better.

Thanks very much for your comments. It has only in recent years been shown that lichen sclerosis responds to anything. Temovate® 0.05% (clobetasol, a steroid cream) is now the treatment of choice. I've only known about it for about 4 years. It takes awhile for medical knowledge to disseminate and the volume is tremendous.

Vestibular pain, keratosis and vulvitis

I've been experiencing vestibular pain for about 3 years, and itchy spots on different parts of my vulva that have appeared and worsened over the past year. I've had 4 biopsies done within the past year, and the diagnosis is keratosis and chronic vulvitis, with a thickening of the affected cells, especially of the vestibule. My doctor doesn't know what to do and I've been waiting for months for her to get back to me. I wonder if anyone might know how keratosis starts and how it's treated.

I have never had any problems with my scalp whatsoever, and can only find information about keratosis affecting parts of the body that have been overexposed to the sun. I'm 26 years old and fair skinned.

The question about keratosis is difficult to answer because as a pathological change it is generalized. On the vestibule of the vulva (moist keratinized epithelium) it can simply be a reaction to chronic itching or rubbing and the entity you have would be vulvar vestibulitis. In that case its the chronic inflammatory response that needs to be treated.

If the keratosis is on the dry skin of the vulva (where the hair is), then the entity you are concerned about is seborrheic keratosis like one might get in the scalp. That usually has raised red or yellowish pink lesions that are similar to those in the scalp and usually don't have to be biopsied because they are typical. Vulvar vestibulitis usually doesn't have a visible raised lesion but it is merely red in color and sometimes just looks inflamed.

Vulvar vestibulitis is very difficult to treat. Many treatments have been tried but I know of none that are more than 50% successful. They range from applying cremes to injections to surgery that removes the skin. Sometimes this problem will just go away after several years. It must be some sort of infectious or inflammatory process because of the inflammatory cells that appear just under the dermis on biopsy. Many infectious agents have been looked for but none identified as the most likely cause.

Ask your doctor what entity she thinks this is. I'm sure she has heard of vulvar vestibulitis and her hesitation in getting back to you might be because of the poor treatment for this condition. Seborrheic keratosis, which is an entirely different process responds to steroid creams. The reason to know for sure is because you may need to see someone who specializes in vulvar disease. I've only seen about 10-12 of these in 29 years of Ob-Gyn so it's not very common for the general gynecologist.

What causes seborrheic keratosis?

The first problems occurred at the vestibule, but then just over a year ago I noticed the itchy patches on the dry skin of my vulva, so, as you say, that would be seborrheic keratosis. Can you tell me what might be causing it?

Cause for seborrheic keratosis is unknown.

Red patches on the dry vulvar skin getting larger

The patches are slightly red in color and the affected area is getting larger! It started with just one small spot, but now a large part of the dry skin is affected.

There is another entity that this could represent. Seborrheic keratosis is a somewhat "waxy", but not moist lesion. If the lesion is dry and "scaly" (and getting bigger) it could also represent psoriasis, or even a fungal infection such as tinea cruris, tinea corpora. Sometimes the dermatologist would be better to see than the gynecologist to diagnose lesions out on the dry skin.

Vulvar cancer and HPV 16

Is it possible to have vulvar cancer without testing positive for HPV 16 ?

Not all vulvar cancers are positive for human papilloma virus (HPV) 16. See the following abstract. In that study, 60% of the women with vulvar cancer were positive for any HPV DNA. Younger patients with vulvar cancer tend to test positive for HPV 16 in a higher percent and smokers were more likely to be positive. Also, HPV positivity varied by the type of vulvar cancer. In that study, only 39% of the typical squamous cell type of vulvar cancer was positive for HPV while 95% of the verrucous, warty, or basaloid type were positive.

Obstet Gynecol 1995 May;85(5 Pt 1):709-715

Prognostic significance of human papillomavirus DNA in vulvar carcinoma.

Monk BJ, Burger RA, Lin F, Parham G, Vasilev SA, Wilczynski SP

Department of Obstetrics and Gynecology, University of California Irvine Medical Center, Orange,USA.

OBJECTIVE: To determine the histopathologic, epidemiologic, and prognostic significance of
human papillomavirus (HPV) DNA in primary invasive vulvar cancer.

METHODS: From December 1981 through October 1992, primary tumor tissue from 55 newly diagnosed vulvar cancers was evaluated for the presence of HPV DNA. The DNA was extracted from tumor tissue and subjected to the polymerase chain reaction (PCR) using highly conserved consensus L1 primers that detect 25 different HPV genotypes and primers specific for HPV type 6/E6, type 16/E7, and type 18/E6 gene sequences. All PCR products were hybridized to type-specific radiolabeled probes. The association between the presence of HPV DNA and histologic, epidemiologic, and clinical characteristics was analyzed.

RESULTS: Thirty-three (60%) tumors contained HPV DNA. Patients younger than 70 years of age or who smoked were more likely to have HPV-positive vulvar cancers. Twenty-one (95%) of 22 tumors classified as basaloid, warty, or verrucous contained HPV DNA, whereas 12 (39%) of 31 typical squamous tumors contained HPV (P < .001). Two adenocarcinomas were negative for HPV. Tumors with or without HPV DNA did not differ with respect to International Federation of Obstetricians and Gynecologists stage (size and nodal status), tumor grade, or therapy. Using life-table analysis, the absence of HPV DNA and the presence of regional nodal metastasis were predictive of recurrence and death from vulvar cancer. When controlling for lesion size, age, tumor grade, and nodal metastasis using the Cox proportional hazards model, only HPV status remained an independent prognostic factor.

CONCLUSION: Human papillomavirus DNA is more common in vulvar cancers of young women who smoke than in older nonsmokers. Patients with HPV-negative tumors are at an increased risk of recurrence and death from vulvar cancer.

Itching, bruised, purple discoloration of vulvar skin

I am a 25 yr. old, mother of a 7 1/2 month infant. Have not had intercourse for approximately 1 1/2 weeks. My last menstrual cycle ended 2 1/2 wks ago.

The following symptoms presented 1 week ago beginning with irritation, itching, bruised sensation of labia and vulva. Purple/dark discoloration. One side of labia appears stretched or enlarged. Some odor (I know it's there, my husband says he doesn't notice). White or clear normal discharge. What is this discoloration of the skin?

Very difficult to say without seeing but sounds like a reaction to vulvar inflammation (not vaginal) but could also be venous blood or old hemorrhage.

Could this be a symptom of vaginitis?

Probably not primarily a vaginitis. Could be reaction of vulva to infection or allergy. Allergies to condoms, spermicides, lubricants, soaps and any deodorants put on the vulva are fairly frequent. I assume the problem started with itching about 3 days after intercourse. It could be a reaction to the scratching with or without a skin, hair follicle or sweat gland infection.

Spontaneous vulvar hematoma or hemorrhage is uncommon. It can happen after delivery but usually much more like hours to days, maybe 1-2 weeks. Thrombosis of a varicose vein in the vulva can happen just like in legs or a hemorrhoid but usually there is quite a bit of pain or discomfort with this. Sometimes a varicose vein can just pop out there. Most vulvar hemorrhages (if that's what this is) are due to some trauma like a straddle injury due to bicycle, skiing, amusement park rides etc. Rarely women can get spider bites when camping or other insect bites that can produce discoloration but there is usually a point of skin breakage that gives a clue.

This needs to be looked at by physician because if there is any bleeding in the vulva, infection can be a real problem. If it's just a varicose vein it may be followed but the doctor should be able to tell if the swelling is soft like a vein, brawny like a skin inflammation/infection, or discrete like an underlying vulvar mass. If it's a skin infection, it will need antibiotic treatment and possibly drainage.

Round, flesh-colored bump above labia

I have been in a monogomous relationship for the past 7 months. Before that, I was in a monogomous relationship for two years,(we lost our virginity to each other.) While treating a yeast infection, I noticed a small, round, flesh-colored bump right above my labia. I doubt that it could be a wart, since neither of my partners have any signs or diseases, and I just had an exam 5 months ago that found nothing.

These two facts don't rule against genital warts (condyloma accuminata) since they can grow quickly and partners can be exposed but not get any visible lesions.

Could it be something else?

Yes. There are other dermatological lesions that frequently occur, but the most common flesh-colored leson is condyloma accuminata.

There is no pain, itching, or inflammation. Could it just be a cyst?

Epidermoid cysts are quite common but usually they present as a bump under the skin rather than a flesh-colored lesion on the skin. Hair follicle or sweat gland cysts can be on the vulva but they appear red rather than flesh colored because usually there is a low grade inflammation present. You need to see your gynecologist for diagnosis.

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