Vulva Age Related Changes

Age related changes

The appearance of the vulva changes significantly as we age.

Childhood. At birth vulvar tissue has been stimulated by placental estrogen (and progesterone). The hymen is plump and pale and the vaginal vestibule is swollen and pink. This lasts a few weeks. With loss of maternal hormones the vestibule and the vagina become thin and susceptible to minor trauma. Note that at birth the clitoris is quite prominent due to maternal hormones. The labia minora are tiny and the labia majora are plump fat pads. The whole area is hairless. The hymen has a smooth edge.

Reproductive age. With the onset of puberty the vulva will change under the influence of hormones and the genetic background of the individual. There is a varying degree of hair growth over the mons pubis, labia majora and perineum with variable pigmentation. The labia majora are fully developed and vary in size. The labia minora may have some slight notching at the edges and are more prominent than before puberty.

Post-menopausal age group. With gradual loss of estrogen the vulva will atrophy. The vestibular mucosa pales. Pubic hair thins and gradually the hairs themselves whiten and pigmentation fades. The labia majora atrophy and in some women become floppy. The labia minora can atrophy and almost disappear. The clitoris is somewhat larger as a result of a relative increase in androgens due to the decrease in estrogen. With aging and multiple deliveries and weakening of the pelvic floor musculature, there can be a tendency to prolapse of the urethra, bladder, uterus, vagina and rectum.

Atrophic Vulvovaginitis This is caused by estrogen deficiency affecting the tissues of the vagina and the vulva so that they become thinned and atrophic. Lack of estrogen causes thinning of the epithelial barrier function of the tissue and this tissue becomes more easily damaged by irritation and more easily infected by bacteria.

Lack of estrogen is caused by estrogen deficiency due to natural or surgical menopause is most common but this also occurs to some degree post-partum, with birth control pills, and breast feeding. Estrogen blockers like tamoxifen also cause estrogen deficiency at the tissue level

Patients complain of vulvar burning, dysuria (stinging or burning on urination), pruritus (itching), tenderness and dyspareunia (pain with sexual intercourse).

On examination the vaginal vestibule and vagina are pale, with thinned epithelium and loss of the vaginal folds. There can be introital stenosis, petechiae and fissuring and, less commonly, a malodorous discharge may occur.

Treatment is with estrogen replacement and this can be done with a patch, cream, ring or tablet. Irritants should be avoided because the tissues are thinned.