“Listen doc, I’m itching down there all the time and it’s driving me crazy. I know it can’t be a STD because I haven’t been intimate in years.”

Mikayla is 75 years old, and she is highly distressed that she is experiencing problems with her genital area and needs some help.

“I’ve been to five different doctors and none of them knows what’s going on.”

Vulvar symptoms such as itching, pain, lesions, or growths can result from a variety of disorders. The vulvar area is made up of skin, mucous membrane, glands, and hair bearing structures, so abnormalities can develop in many different ways. Problems can be due to infection, inflammation, or as a result of a benign or malignant process.

The most common symptom is itching

Because itching is so common—and because the vulvar area can react to a wide range of conditions—persistent symptoms deserve careful evaluation. Genitourinary Syndrome of Menopause (GSM) is a menopause-related cause of vulvar and vaginal discomfort that can include vaginal, vulvar, and urinary symptoms that affect quality of life and sexual satisfaction, and it typically worsens over time without treatment. Loss of estrogen may cause tissues to become thin and dry with decreased elasticity and lubrication, and symptoms can include burning, itching, or irritation of the vulva, lack of lubrication, vaginal dryness, and discomfort or pain with sexual activity. Urinary burning, urgency or frequency, and increased risk of urinary tract infections can also occur. Treatment options range from nonhormone over-the-counter lubricants (used as needed) and moisturizers (used regularly) to prescription therapies such as low-dose vaginal estrogen, vaginal DHEA inserts, and oral ospemifene. 

Other common causes of itching are yeast infection, folliculitis (from hair follicles), herpes simplex infection, and syphilis, which has other classic findings. Because not all vulvar or vaginal symptoms are menopause-related, it’s important to consult a healthcare professional if symptoms do not improve with treatment.

When a persistent problem needs to be taken seriously

Cancer can occur in the vulvar area but is quite rare. It is, however, the greatest concern whenever an unexplained, persistent problem occurs. Early diagnosis is paramount since treatment is possible when cancer is found at an early stage.

Concerning signs include:

• An ulcer that does not heal
• A mass that is fleshy and bleeds easily
• Hard nodules
• A warty looking growth
• A single lesion especially in postmenopausal women
• Lesions that are asymmetric, have irregular borders, or color variation
• A rapidly changing lesion, or one that bleeds and does not heal

A biopsy should be taken of any area of concern. This is easily performed in the outpatient setting with a local anesthetic.

Vulvar growths: what they can be

The vast majority of vulvar growths are benign and can be managed easily, but it is best to see your gynecologist to determine the cause.

Common growths described include:

• Genital warts, often appearing like miniature cauliflower, caused by human papilloma virus (types 6 and 11 cause over 90 percent). Treatment options include excision, a local acid solution done by a doctor, or medications prescribed for home use such as podophyllin and imiquimod cream.
• Molluscum contagiosum, a pox virus infection more common in immunosuppressed individuals, presenting as scattered pearly or translucent papules with an umbilicated center.
• Skin tags (acrochordon), which develop in areas of friction and are more common in obese or overweight women. These can be excised in the office with a local anesthetic.
• Cysts, including sebaceous or epidermal cysts in vulvar skin, and Bartholin’s cysts near the introitus. If a Bartholin’s cyst becomes infected it can form an abscess, which presents with pain and swelling and may rupture spontaneously or require incision and drainage.

There are also other unusual growths that can appear in the vulvar area. Examples include lipomas, leiomyomas, and fibromas, which tend to be benign but in rare cases can be malignant. Even hernias can present with growths in the vulvar area.

Vulvar patches and plaques

The vulvar skin can develop allergic reactions and autoimmune responses that cause patches or plaques. Symptoms may include itching or irritation, pain or discomfort, and flaking skin. On examination, a doctor may find changes in skin texture, erosions, white patches, and areas of redness.

Some of the more common causes described include:

• Lichen simplex chronicus, a dermatitis that develops from chronic scratching or rubbing, often related to a yeast infection or an allergic reaction to a chemical. The itch/scratch cycle can be difficult to break. Treatment may include topical steroid ointment and oral antihistamine medications.
• Lichen sclerosus, a condition in which the skin of the vulva is essentially destroyed. It presents with itching or irritation that worsens over years and can lead to pain with intercourse. The skin may look thin, wrinkled, and white, described as “cigarette paper.” High-potency steroid ointment is used, and continued monitoring is required because women with this condition are at higher risk of developing vulvar cancer.
• Vitiligo, an autoimmune skin condition in which there is a lack of skin color that appears as a notable, well-defined white patch. The skin is otherwise healthy in appearance, and treatment is best managed by a dermatologist.

Other causes include nevi and moles, dermatitis, psoriasis, and seborrheic keratosis. These tend to be benign, but lesions that change rapidly, bleed easily, have irregular borders, or are black in color should be evaluated immediately.

If you’re not getting answers

Vulvar problems can sometimes be difficult to diagnose. If you are experiencing problems and your gynecologist hasn’t been able to help, ask for a referral to a gynecologist or dermatologist who has a special interest in vulvar disorders.

It can also help to keep a record of all treatments prescribed and how long you used them. This can help a clinician determine the best approach.