Vulvar and vaginal physiology
The vulva
This is the outer part of your genitalia. There’s no such thing as a NORMAL vulva! The aim is to be comfortable with your vulva. We speak unfairly of labia majora and labia minora, whereas we should say labia externa and labia interna, so as not to imply that labia minora are necessarily hidden by labia majora. The most important thing is that your vulva is comfortable and always slightly moist.
The vulva can have a slight odor, thanks to pheromones! This is a good thing! Don’t try to mask this smell at all costs. If it bothers you, talk to your midwife or doctor. Intimate hygiene soaps are just marketing! You can wash with whatever you like, as long as you only wash the area where, in theory, there is hair. Rinse with clean water and dry gently.
Feel good about yourself, feel good about your life!
The vagina
It’s a mucous and muscular duct averaging 9.6 cm in length. It is capable of stretching under the action of arousal. To be comfortable, it must always be well moistened. It shelters our army of defenses: the Lactobacilli that make up Döderlein’s Flora. The secretions produced by the vaginal walls serve the vagina’s self-cleaning system! So there’s no need to wash the inside of the vagina when cleansing.
Secreting vagina, competent vagina!
The perineum
It’s a large muscle that closes the lower part of our abdomen. It is composed of several layers. It works like a trampoline, contracting as it rises and relaxing as it falls. It should be familiar to everyone! It’s there to hold you in place, of course, but most of the time it needs to be supple and relaxed, otherwise it can be the cause of pain such as difficulty inserting a tampon, pain during penetrative intercourse…
Normal vaginal secretions
- Transudation fluid: Passage of serum through the vaginal mucosa following local hemodynamic changes: the vagina sweats, a sign of good function.
- Cervical mucus: secreted by the inside of the cervix, translucent, with the appearance and consistency of raw egg white; variable abundance, maximum at ovulation under the influence of estrogens; mechanical action by outward flow: plug/flush effect; chemical action: antibacterial barrier.
- Secretions are naturally acidic, which explains the discoloration of underwear. Systematic use of panty liners is not recommended.
- If secretions become thick, white or malodorous, or are accompanied by discomfort, pain or scratching, consult a health professional.
- Wash the vulva once a day with water or a normal or physiological pH soap (i.e. acid < 5), dry gently and don’t hesitate to apply sweet almond oil to the vulva if it’s sensitive. There’s no need for wipes or vulval deodorant… You need to feel comfortable in your vulva. Vulvar mantra: happy vulva, silky vulva!
Happy vulva, silky vulva!
The importance of urogenital microbiota
“The microbiota corresponds to a community of micro-organisms living in a given environment. The urogenital microbiota is in fact made up of several microbiota, all interconnected. The vaginal microbiota, the best known, consists mainly of lactobacilli in healthy, non-menopausal women. The urogenital microbiota also includes the urinary microbiota, the endometrial microbiota and the perineal and vulval microbiota. All are connected to the intestinal microbiota and interact with the microbiota of the sexual partner. In the case of recurrent urogenital pathology, a comprehensive approach is required.
A balanced urogenital microbiota is dominated by estrogen-dependent lactobacilli. It is estimated that there are around 40% of potentially pathogenic agents within the microbiota, which can develop when changes disrupt its balance. They can cause infections, vaginal dryness, dyspareunia and endometrial changes, as well as prematurity, miscarriage, IVF failure and possibly cancer.
There are many causes of imbalance: courses of antibiotics, smoking, reduced estrogen levels during the menopause or post-partum period, frequent changes of partner, diabetes, overweight, obesity, chronic stress, immunodepression, not to mention poor hygiene practices…
In what situations should we adopt the probiotic reflex?
In all situations where there is a risk of imbalance in the urogenital microbiota, specific strains of the vaginal microbiota, mainly lactobacilli, should be used. If a woman at risk of candidiasis is taking antibiotics, probiotics should be recommended rather than systematically prescribing antifungal ova as a preventive measure. Antibiotics can not only cause mycosis, but also bacterial vaginosis, for which antifungal agents will have no effect. Vagina-specific probiotics can be given orally during and at least one week after the end of antibiotic treatment.
Recent studies have shown that Saccharomyces yeasts, well known for their efficacy on the intestinal microbiota, can also be active at vaginal level.
In the event of recurrent infections, daily or divided intake of probiotics for at least three months, with gradual cessation, may be advisable, provided that other risk factors such as smoking, lack of physical exercise, stress, etc. are eliminated or reduced.
In the event of recurrent infections, daily or divided intake of probiotics for at least three months, with gradual discontinuation, may be recommended, provided that other risk factors such as smoking, lack of exercise, stress, etc. are eliminated or reduced.
Probiotics are not magic. They should not become automatic, but rather be given for specific indications. For example, formulas combining probiotics and phytotherapy can be useful in cases of frequent urinary tract infections, while also treating other causes such as constipation, digestive problems and poor or inappropriate hygiene. The result is a personalized approach for each patient.
As estrogen levels fall during the menopause, changes in the urogenital microbiota manifest themselves in vaginal dryness and pain during intercourse… Probiotic-based preparations, given as cures 2 or 3 times a year, in the pre-menopausal period, around the age of 45-47, give good results. A woman who has sufficient vaginal lactobacilli from the start of menopause will experience 10 times less dryness and 4 times less pain than a menopausal woman without lactobacilli. So you can prepare for menopause with probiotics and plant oils such as evening primrose or borage!
Vaginal and vulvar dryness
Vaginal and vulvar dryness is a frequent and taboo subject. Yet it affects more than one in six women at different times in their lives. More common during the menopause, it increases vulnerability to gynecological infections and can disrupt a couple’s sexual harmony. Solutions to intimate dryness do exist, so take action!
Intimate dryness: What is it?
Intimate dryness (vaginal or vulvar dryness) occurs when the vagina or vulva is not properly hydrated. Vaginal dryness can upset the balance of the vaginal flora. The physical and psychological effects are not insignificant. Vaginal lubrication comes from vaginal transudate and cervical mucus, depending on the cycle. Vulvar lubrication comes from cyprin secreted by Skene’s and Bartholin’s glands. It is therefore possible to suffer from vulvar or vaginal dryness, or both.
Pain during intercourse is present for 85% of dryness patients, as is reduced sexual activity (83%). As a result, 57% of women feel that this condition has been or is the cause of serious problems in their relationship. Here again, patients over 40 are more concerned. Over 5% of untreated women have stopped having sex. Vaginal dryness is very common, affecting 25% of women before the menopause and 30% to 55% afterwards, at some point in their lives. Yet vaginal and vulvar dryness remains a largely taboo subject, often hidden from doctors, gynecologists and midwives. This is a pity, as the condition is very treatable.
Vaginal secretions come from glands at the entrance to the vulva and from vaginal transudate. The glands secrete a somewhat “viscous” liquid every day, which serves to rid the vagina of dead cells and other impurities or germs. Vaginal secretions form, so to speak, a self-cleaning system for the uterus and vagina (dead cells…). In the vulva, more precisely in the muscle that helps the vulva contract, Bartholin’s glands produce a colorless, stringy liquid that helps moisturize the vagina and labia minora. Excitement and pleasure cause the vagina to lubricate in preparation for the sexual act.
How is dryness diagnosed?
To diagnose intimate dryness, the doctor or midwife will try to find out more about the patient by carrying out a medical examination: the symptoms described by the patient and her feelings (absence of natural lubrication, sensation of dryness, daily discomfort, rubbing of clothes…).
Then a clinical and gynecological examination (absence of vaginal and vulvar secretions and moisture). They can also take a vaginal swab to ensure the quality of the vaginal flora.
What are the symptoms and functional signs of dryness?
- Burns
- Irritation or local inflammation
- Itching: more of a vulvar symptom, vaginal itching is rare. There aren’t many itch receptors in the vagina. If a woman feels like scratching, the problem comes from the vulva. And the vulva is skin. It can therefore suffer from dehydration, defatting, irritation caused by unsuitable soaps and dry eczema.
- Redness around the external genitalia
- Appearance of small cracks
- Intimate dryness can lead to greater susceptibility to infection, and can have repercussions for couples, since it can cause pain during intercourse (dyspareunia), or even a reduction in libido, affecting their quality of life.
During certain periods of life, the vaginal mucosa changes and becomes more fragile. It can lose its elasticity, moisturizing and acidifying qualities, as well as its capacity for self-cleansing.
Factors contributing to intimate dryness
- Hormonal causes: menopause, hormonal changes and pregnancy.
The main culprits are psychological factors, vaginal infections, stress and medical treatment, as well as contraception. However, there are other causes: for example, smoking, alcohol or inappropriate intimate hygiene can affect lubrication.
- The menopause is defined by the cessation of ovarian function, resulting in an estrogen deficiency responsible for the well-known clinical signs. For hormonal reasons, menopausal women are the first to be affected by vaginal and vulvar dryness. What’s more, 40% of women taking hormone replacement therapy (HRT) suffer from vaginal dryness.
- Dry syndrome: occurs when secretions from the body’s mucous membranes are less than optimal. It leads to a range of symptoms: dry eyes, lack of saliva, dry bronchi or skin… Vulvar dryness can also be observed.
- It is sometimes caused by medication (low-dose estrogen contraceptive pills, antidepressants, anti-allergy drugs, acne treatments, diuretics, etc.) or certain autoimmune diseases, such as Gougerot-Sjögren syndrome (antibodies attack the body’s glands).
- Skin diseases: lichen, eczema, psoriasis can affect various areas of the body, including the vulva.
- Vulvodynia, or burning sensations in the vulva, leading to reflex muscle hypertonia.
- Intimate laser hair removal aggravates vulvar irritation and vaginal dryness. Not only does laser hair removal in the genital area burn the hair bulb, it also destroys the sebaceous glands. It is these glands that produce the hydrolipidic film that moisturizes and protects the skin of the vulva. On the one hand, intimate laser hair removal alters this film, and on the other, it removes the little “cushion” of hair that protects the vulva from friction, a source of irritation.
- Any medication or substance that dries out the mouth and tongue is likely to dry out the vaginal mucosa, such as anti-hypertensive or anti-acne medication (like Roaccutane).
Differential diagnosis
Herpes crisis, eczema, psoriasis, vaginal mycosis (note that a major difference is the presence of abundant discharge in the case of mycosis, which is not the case for vulvar dryness).
Treatments for intimate dryness
- The very first thing to do is talk about it. Talking about it will first help to relieve the stress this discomfort causes.
- If the discomfort occurs only during intercourse, an intimate lubricant will suffice to relieve it, such as a hyaluronic acid-based lubricant.
- If the discomfort continues throughout the day, a simple lubricant won’t be enough. The best thing to do is to make an appointment with your gynaecologist or midwife, who will prescribe a suitable treatment. In the meantime, or if the discomfort is bearable, regularly apply a cream for the intimate area ([MY] Gel Intime Hydratant Rééquilibrant) or a vegetable oil (sweet almond, jojoba, evening primrose, borage). These are often enriched with soothing herbs. You can reinforce their effect by buying lubricating ovules, often herbal, or evening primrose oil capsules, which you can administer intra-vaginally. And don’t forget to consider oral probiotics specifically formulated for intimate areas.
- Good hygiene: washing your vulva once a day in the shower is sufficient. It’s not advisable to use soaps internally, as they will dry out fragile mucous membranes. Instead, opt for a mild cleansing solution or a simple wash with clear water, taking care to dry the area thoroughly (by patting rather than wiping too vigorously!). No douching!
- A corticoid-based cream for eczema or psoriasis.
- A cream containing female hormones (especially for post-menopausal women).
- To treat intimate dryness, you need to avoid certain risk factors that can cause it. In most cases, this will bring the state of hydration back to normal.
- Laser treatment: Some cancer treatments have a very deleterious impact on the vaginal mucosa. To the point of causing intolerable pain. For women who can’t take hormones and are not sufficiently relieved by other methods, it has recently become possible to stimulate the mucosa with a vaginal laser (Mona Lisa laser). Sessions are expensive (€300 or more), but their effectiveness is remarkable if the indication is well defined.
Plants to soothe irritation:
Aloe vera, anti-inflammatory and moisturizing, is found in many preparations.
St. John’s wort oil can be applied topically, morning and night. “It is nourishing, healing, anti-inflammatory, analgesic, antibacterial, antimycotic and antiviral.
Hyaluronic acid: This molecule exists naturally in the dermis and epidermis. It absorbs water and protects tissues from drying out. Creams and ointments containing hyaluronic acid are sufficient for minor vaginal dryness. They plump up the mucosa and restore its suppleness. “Some studies show that, over time, hyaluronic acid leads to a re-epithelization of the mucosa. In other words, the simple act of moisturizing encourages a small amount of mucosal regrowth.
Prevention and advice
To prevent vaginal dryness, it’s important to maintain good local hygiene, but not too frequent, and to avoid using overly aggressive molecules. Alcohol, tobacco and other substances should be avoided, and non-aggressive undergarments such as cotton should be worn. It’s also important to maintain a healthy lifestyle in order to eliminate stress from your daily routine. Sexual intercourse should also take place after the vagina has been properly lubricated, either naturally or with lubricants.
INTIME hygiene tips
What are the best tips for good hygiene?
First and foremost, the vagina is self-cleaning and doesn’t need to be cleaned from the inside. Vaginal douching is therefore forbidden, but is fortunately becoming less common. External cleansing remains essential, however, and has a major influence on the balance of the urogenital microbiota. In fact, the rectum is the reservoir of lactobacilli, which ensure the vagina’s good health. If vaginal lactobacilli are depleted, they move from the rectum to the vagina via the skin of the perineum. If antiseptics are used on a daily basis, or during infectious episodes, there is a high risk of reducing physiological vaginal colonization, with a consequent risk of perpetuating infections. What’s more, the movement of lactobacilli is facilitated by the hydrolipidic film on the surface of the integuments. Washing too frequently with water, or with soaps and shower gels that are “too abrasive”, damages this endogenous hydrolipidic film, leading to dry mucous membranes.
When do we talk about poor hygiene?
One a day is enough, provided you rinse and dry the area thoroughly. Women who wash after each micturition or bowel movement should be warned that too many washes can have a deleterious effect over time. For optimum hygiene, avoid cleansing with unsuitable products such as shower gels or conventional soaps like Marseille soap, which are too stripping and drying. Remember that this area is specific, sensitive and fragile. Intimate hygiene products must therefore respect both the natural hydration and the local microbiota. Moisturizing and superfatting products are particularly well suited to this anatomical zone. Good hygiene can be learned from an early age, when little girls can imitate their mothers by using the same products.
Author :
Article written by Camille Tallet, midwife and osteopath, specialized in gynecological pain. She is president of the “Périnée Bien-aimé” association, which brings together health professionals to raise awareness of vulvar pain and its treatment.
