Worried about possible warts
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
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
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
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
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?
Cause for seborrheic keratosis is unknown.
Red patches on the dry vulvar skin getting larger
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
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
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.
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
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.
Yes. There are other dermatological lesions that frequently occur, but the most common flesh-colored leson is condyloma accuminata.
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.