Vaginal Diseases

Introduction
Vaginal Atrophy
Vaginal Cancer
Vaginal Dryness
Vaginitis
Vulvar Cancer
Vulvodynia

Symptoms such as vaginal itching, burning, pain and discharge are some of the most common reasons that women seek medical care.Often, the problem is vaginitis, an inflammation of the vagina. In women of childbearing age, the most common cause is a bacterial infection. The main symptom is a smelly vaginal discharge, but some women have no symptoms. The treatment is antibiotics.

Other infections that can cause vaginitis include trichomoniasis and yeast infections.Some other causes of vaginal symptoms include sexually transmitted diseases, vaginal cancer and vulvar cancer.

Vaginal atrophy (atrophic vaginitis) is thinning and inflammation of the vaginal walls due to a decline in estrogen. Vaginal atrophy occurs most often after menopause, but it can also develop during breast-feeding or at any other time your body's estrogen production declines.

By some estimates, more than half of menopausal women experience vaginal atrophy, although very few seek treatment. The rest may resign themselves to the symptoms or be embarrassed to broach the topic with their doctors.

That's unfortunate, because the condition isn't trivial. For many women, vaginal atrophy makes intercourse painful. If intercourse hurts, your interest in sex will naturally wane - taking away an important source of joy in your relationship.

What's more, healthy genital function is closely intertwined with healthy urinary system function. When atrophic changes affect your urinary system as well as your vagina (genitourinary atrophy), you might also experience increased frequency or urgency of urination or burning with urination. Some women experience more urinary tract infections or incontinence.

The good news is that simple, effective treatments for vaginal atrophy are available. Reduced estrogen levels do result in changes to your body, but it doesn't mean you have to live with vaginal discomfort and associated urinary problems.

It's possible to have vaginal atrophy without any signs or troublesome symptoms. But with moderate to severe vaginal atrophy, you may experience:

• Vaginal dryness
• Vaginal burning
• Watery vaginal discharge
• Burning with urination
• Urgency with urination
• More urinary tract infections
• Urinary incontinence
• Light bleeding after intercourse
• Discomfort with intercourse

You might feel as if your vagina is smaller, and that could, quite literally, be the case. Vaginal atrophy can result in a vaginal canal that's shorter and narrower.

It's possible to have vaginal atrophy without any signs or troublesome symptoms. But with moderate to severe vaginal atrophy, you may experience:

• Vaginal dryness
• Vaginal burning
• Watery vaginal discharge
• Burning with urination
• Urgency with urination
• More urinary tract infections
• Urinary incontinence
• Light bleeding after intercourse
• Discomfort with intercourse

You might feel as if your vagina is smaller, and that could, quite literally, be the case. Vaginal atrophy can result in a vaginal canal that's shorter and narrower.

It's possible to have vaginal atrophy without any signs or troublesome symptoms. But with moderate to severe vaginal atrophy, you may experience:

• Vaginal dryness
• Vaginal burning
• Watery vaginal discharge
• Burning with urination
• Urgency with urination
• More urinary tract infections
• Urinary incontinence
• Light bleeding after intercourse
• Discomfort with intercourse

You might feel as if your vagina is smaller, and that could, quite literally, be the case. Vaginal atrophy can result in a vaginal canal that's shorter and narrower.

It's possible to have vaginal atrophy without any signs or troublesome symptoms. But with moderate to severe vaginal atrophy, you may experience:

• Vaginal dryness
• Vaginal burning
• Watery vaginal discharge
• Burning with urination
• Urgency with urination
• More urinary tract infections
• Urinary incontinence
• Light bleeding after intercourse
• Discomfort with intercourse

You might feel as if your vagina is smaller, and that could, quite literally, be the case. Vaginal atrophy can result in a vaginal canal that's shorter and narrower.

Vaginal atrophy is caused by a loss of estrogen. Less circulating estrogen makes your vaginal tissues thinner, drier, less elastic and more fragile. Menopause is the most common cause of reduced estrogen levels that result in vaginal atrophy.

In premenopausal women, estrogen levels are generally high enough to maintain the normal elasticity and thickness of vaginal tissue. But a drop in estrogen levels and vaginal atrophy may occur in other circumstances, including.

• During breast-feeding
• After surgical removal of both ovaries (surgical menopause)
• After pelvic radiation therapy for cancer
• After chemotherapy for cancer
• As a side effect of breast cancer hormonal treatment

Vaginal atrophy due to menopause may begin to bother you during the years leading up to menopause (perimenopause), or it may not become a problem until several years into menopause. Although the condition is common, not all menopausal women develop vaginal atrophy. Regular sexual activity helps you maintain healthy vaginal tissues.

Certain factors may contribute to vaginal atrophy. Among these are:

• Smoking. Cigarette smoking impairs blood circulation, depriving the vagina and other tissues of oxygen. Decreased blood flow to your vagina contributes to atrophic changes. Smoking also reduces the effects of naturally occurring estrogens in the body. In addition, women who smoke have an earlier menopause and are less responsive to estrogen therapy in pill form.
• Decreasing levels of hormones other than estrogen. After removal of the ovaries, lower levels of androgens such as testosterone may lead to vaginal atrophy. Women who have had their ovaries removed and experience symptoms of vaginal atrophy despite adequate estrogen therapy may benefit from testosterone replacement.
• Never giving birth vaginally. Researchers have observed that women who have never given birth vaginally are more prone to vaginal atrophy than are women who have had vaginal deliveries.

Your doctor will ask questions about the symptoms you're experiencing and assess your hormonal status. Expect to have a complete pelvic exam. During the pelvic exam, your doctor checks for signs of vaginal atrophy and pelvic organ prolapse, indicated by bulges in your vaginal walls from pelvic organs such as your uterus or bladder.

Your doctor may take a sampling of cells from your vagina to be studied under a microscope. He or she also may also place a paper indicator strip in your vagina to test its acidity.

If you don't have vaginal discomfort, you might not need treatment for vaginal atrophy. However, if you have vaginal atrophy and you're bothered by vaginal dryness, vaginal irritation, discomfort with intercourse, urinary frequency or urinary urgency, effective treatments are available.

The most effective treatment is estrogen applied topically to the vaginal area, usually in the form of a cream. Slow-releasing vaginal suppositories or rings are another option. A vaginal ring remains in place for up to three months to provide longer term relief. These treatments are referred to as local estrogen therapy.

With local estrogen therapy, the estrogen stays primarily in the vaginal tissues. Early in the course of treatment, you may absorb some estrogen into your bloodstream. But as your vaginal tissues become healthy again, estrogen absorption into your bloodstream is minimal. Doses are kept low to avoid unintended systemic effects. However, it's important not to exceed the dosage of estrogen your doctor recommends. Properly prescribed and used, local estrogen therapy isn't thought to carry the long-term risks associated with systemic estrogen therapy.

Systemic estrogen treatment - by pill, patch or gel - may be the best choice if other problems associated with estrogen deprivation, such as hot flashes or sleep deprivation, are troublesome. Systemic estrogen can sometimes provide adequate relief for vaginal atrophy, but often local estrogen therapy is needed in addition. If you have your uterus, systemic estrogen treatment requires treatment with a progestin as well to avoid overgrowth of your uterine lining.

Unlike estrogen therapy in pill or patch form (systemic), topically applied estrogen doesn't usually affect the uterine lining, so concurrent progestin treatment is rarely necessary.

You should experience noticeable improvements after a few weeks of estrogen therapy. Some symptoms of severe atrophy may take longer to resolve.

Regular sexual activity, either with or without a partner, can decrease problems with vaginal atrophy. Sexual activity enhances blood flow to your vagina, which helps keep vaginal tissues healthy.

Vaginal cancer is a rare cancer that occurs in the vagina - the muscular tube that connects the uterus with the outer genitals. Vaginal cancer most commonly occurs in the cells that line the surface of the vagina, which is sometimes called the birth canal.

Vaginal cancer most commonly affects women older than 60. However, vaginal cancer can occur at any age.

While several cancers can spread to the vagina from other places in the body, cancer that begins in the vagina (primary vaginal cancer) is rare. Vaginal cancer comprises only 1 percent to 3 percent of gynecologic cancers. About 2,400 women are diagnosed with vaginal cancer each year in the United States, according to the American Cancer Society.

Women with early-stage vaginal cancer have the best chance for a cure. Vaginal cancer that spreads beyond the vagina is much more difficult to treat.

Early vaginal cancer may not have any signs and symptoms. As it progresses, vaginal cancer may cause signs and symptoms such as:

• Unusual vaginal bleeding, such as after intercourse or after menopause
• Watery vaginal discharge that may be bloody and foul-smelling
• Lump or mass in the vagina
• Frequent urination
• Blood in urine
• Constipation
• Pelvic pain

In general, cancer begins when healthy cells acquire a genetic mutation that turns normal cells into abnormal cells. Healthy cells grow and multiply at a set rate, eventually dying at a set time. Cancer cells grow and multiply out of control, and they don't die. The accumulating abnormal cells form a mass (tumor). Cancer cells invade nearby tissues and can break off from an initial tumor to spread elsewhere in the body (metastasize).

It isn't clear what causes the genetic mutation that leads to vaginal cancer. Researchers have identified factors that may increase your risk of vaginal cancer.

The majority of vaginal cancers begin in the squamous cells. These thin, flat cells line the surface of the vagina. Other less common types of vaginal cancer include:

• Vaginal adenocarcinoma, which begins in the glandular cells on the surface of the vagina
• Vaginal melanoma, which develops in the pigment-producing cells (melanocytes) of the vagina
• Vaginal sarcoma, which develops in the connective tissue cells or smooth muscles cells in the walls of the vagina

Certain factors may raise your risk of vaginal cancer, including:

• Atypical cells in the vagina. Women with vaginal intraepithelial neoplasia (VAIN) have an increased risk of vaginal cancer. In women with VAIN, cells in the vagina appear different from normal cells, but not different enough to be considered cancer. A small number of women with VAIN will eventually develop vaginal cancer, though doctors aren't sure what causes some cases to develop into cancer and other cases to remain benign.
• Exposure to miscarriage prevention drug. Women whose mothers took a drug called diethylstilbestrol (DES) while pregnant may have an increased risk of a certain type of vaginal cancer called clear cell adenocarcinoma. DES was used in the 1950s to prevent miscarriage in early pregnancy.
• Human papillomavirus (HPV). HPV is a sexually transmitted virus that can increase the risk of vaginal cancer and other cancers. HPV causes the majority of cervical cancers and precancerous changes in the cervix. Even if you've had your uterus and ovaries removed (hysterectomy), you may still have an increased risk of vaginal cancer if you have HPV. The Food and Drug Administration (FDA) approved a vaccine to prevent HPV in 2006.
• Previous gynecologic cancer. Women who've been treated for a different gynecologic cancer, especially cervical cancer, may have an increased risk of vaginal cancer.

Other risk factors that have been linked to an increased risk of vaginal cancer include:

• Multiple sexual partners
• Early age at first intercourse
• Smoking

Screening
While there is no general screening test for vaginal cancer, it is sometimes detected during a routine pelvic exam before any signs and symptoms become evident. During a pelvic exam, your doctor carefully inspects the outer part of your vagina, and then inserts two fingers of one hand into your vagina and simultaneously presses the other hand on your abdomen to feel your uterus and ovaries. He or she also inserts a device called a speculum into your vagina. The speculum widens your vagina so that your doctor can check your vagina and cervix for abnormalities.

Your doctor usually also conducts a pap test to screen for cervical cancer, but sometimes vaginal cancer cells can be detected on a pap test. Pap tests and pelvic exams are generally recommended every three years. How often you undergo these screenings depends on your risk factors for cancer and whether you've had abnormal pap tests in the past. Talk to your doctor about whether you should have this health screening.

Diagnosis
Based on any signs and symptoms you have, your doctor may conduct a pelvic exam and pap test to check for abnormalities that may indicate vaginal cancer. Based on those findings, your doctor may conduct other procedures to determine whether you have vaginal cancer, such as:

• Colposcopy. Colposcopy is an examination of your vagina with a special lighted microscope called a colposcope. Colposcopy allows your doctor to magnify the surface of your vagina to see any areas of abnormal cells.
• Biopsy. Biopsy is a procedure to remove a sample of suspicious tissue to test for cancer cells. Your doctor may take a biopsy of tissue during a colposcopy exam. Your doctor sends the tissue sample to a laboratory for testing.

Staging
Once your doctor diagnoses vaginal cancer, he or she takes steps to determine the extent of the cancer - a process called staging. The stage of your cancer helps your doctor decide what treatments are appropriate for you. In order to determine the stage of your cancer, your doctor may use:

• Biopsy. Tissue samples from your cervix or vulva may show whether cancer has spread to those areas.
• Imaging tests. Your doctor may order imaging tests to determine whether cancer has spread. Imaging tests may include X-rays, computerized tomography (CT) scans or magnetic resonance imaging (MRI).
• Tiny cameras to see inside your body. Procedures that use tiny cameras to see inside your body may help your doctor determine if cancer has spread to certain areas. Cameras help your doctor see inside your bladder (cystoscopy) and your rectum (proctoscopy).

Once your doctor determines the extent of your cancer, he or she assigns your cancer a stage. The stages of vaginal cancer are:

• Stage I. Cancer is limited to the vaginal wall.
• Stage II. Cancer has spread to tissue next to the vagina.
• Stage III. Cancer has spread to nearby lymph nodes, or to the pelvic wall or both.
• Stage IVA. Cancer has spread to nearby lymph nodes, and has also spread to bladder, rectum or pelvis.
• Stage IVB. Cancer has spread to areas away from the vagina, such as the lungs.

Your treatment options for vaginal cancer depend on several factors, including the type of vaginal cancer you have and its stage. Because vaginal cancer is rare, no standard treatment guidelines have been developed. You and your doctor work together to determine what treatments are best for you based on your goals of treatment and the side effects you're willing to endure. Treatment for vaginal cancer typically includes surgery and radiation.

Surgery
Surgery to remove the cancer from your body is primarily used for early-stage vaginal cancer that's limited to the vagina or, in selected cases, nearby tissue. Because many important organs are located in your pelvis, surgery to remove larger tumors would require removal of these organs. For this reason, your doctor may attempt to control your cancer through other treatment methods first. Types of surgery that may be used in women with vaginal cancer include:

• Removal of small tumors or lesions. Cancer limited to the surface of the vagina may be cut away using a scalpel or a laser. Your surgeon may also remove a small amount of healthy tissue to ensure that all of the cancer cells have been removed.
• Removal of the vagina (vaginectomy). Removing part of the vagina (partial vaginectomy) or the entire vagina (radical vaginectomy) may be necessary to remove all of the cancer. Depending on the extent of your cancer, your surgeon may recommend surgery to remove your uterus and ovaries (hysterectomy) and nearby lymph nodes (lymphadenectomy) at the same time as your vaginectomy.
• Removal of the majority of the pelvic organs (pelvic exenteration). This extensive surgery may be an option if cancer has spread throughout your pelvic area or if your vaginal cancer has recurred. During pelvic exenteration, the surgeon removes many of the organs in the pelvic area, including the bladder, ovaries, uterus, vagina, rectum and the lower portion of the colon. Openings are created in your abdomen to allow urine (urostomy) and waste (colostomy) to exit your body and collect in ostomy bags.

If your vagina is completely removed, you may choose to undergo surgery to construct a new vagina. Surgeons use pieces of skin, sections of intestine or flaps of muscle from other areas of your body to form a new vagina. With some adjustments, a reconstructed vagina allows you to have vaginal intercourse. However, a reconstructed vagina won't be the same as your own vagina. For instance, a reconstructed vagina lacks natural lubrication and creates a different sensation when touched due to changes in surrounding nerves.

Radiation therapy
Radiation therapy is the most common treatment for vaginal cancers. Radiation therapy uses high-powered energy beams to kill cancer cells. Radiation can be delivered two ways:

• External radiation. External beam radiation is directed at your entire abdomen or just your pelvis, depending on the extent of your cancer. During external beam radiation, you're positioned on a table and a large radiation machine is maneuvered around you in order to target the treatment area. Nearly everyone with vaginal cancer receives external beam radiation.
• Internal radiation. During internal radiation (brachytherapy), devices containing radiation - radioactive seeds, wires, cylinders or other materials - are placed in your vagina or the surrounding tissue. After a set number of days, the devices are removed. Women with very early stage vaginal cancer may receive internal radiation only. Other women may receive internal radiation after undergoing external radiation.

Radiation therapy kills quickly growing cancer cells, but it may also damage nearby healthy cells, causing side effects. Side effects of radiation depend on the radiation's intensity and where it's aimed. Complications include bladder irritation, inflammation of the lining of the rectum, narrowing of the vagina, thinning of the lining of the vagina, premature menopause and infertility.

Other options
If surgery and radiation can't control your cancer, you may be offered other treatments, including:

• Chemotherapy. Chemotherapy uses chemicals to kill cancer cells. It isn't clear whether chemotherapy is useful in women with vaginal cancer. Some small studies have had mixed results. Chemotherapy may be used during radiation therapy to enhance the effectiveness of radiation.
• Clinical trials. Clinical trials are experiments to test new treatment methods. While a clinical trial gives you a chance to try the latest treatment advances, a cure isn't guaranteed. Discuss available clinical trials with your doctor to better understand your options.

No sure way to prevent vaginal cancer exists. However, you can increase the chance that vaginal cancer is discovered early by having routine pelvic exams and pap tests. When discovered in its earliest stages, vaginal cancer is more likely to be cured. Doctors recommend women receive pelvic exams and pap tests soon after they've begun having sexual intercourse or by age 21. Ask your doctor how often you need to have pelvic exams and pap tests.

When your vagina isn't properly lubricated, it can feel itchy and irritated. Vaginal dryness may make some daily activities uncomfortable, and it can make sexual intercourse less pleasurable. In fact, during menopause, vaginal dryness is a common cause of discomfort or pain during sex (dyspareunia).

Vaginal dryness is a common condition. It can affect women of all ages, though vaginal dryness most often occurs during and after the menopausal transition. An estimated 10 percent to 40 percent of women who've reached menopause have signs and symptoms related to vaginal dryness.

A number of self-care measures and medical treatments can help you reduce vaginal dryness.

Aside from dryness, some of the signs and symptoms include:

• Itching
• Burning
• A feeling of pressure
• Pain or light bleeding with sex
• Urinary frequency or urgency

A variety of conditions can cause vaginal dryness. Determining the cause is key to helping you find an appropriate solution. Potential causes include:

Decreased estrogen levels
Reduced estrogen levels are the main cause of vaginal dryness. Estrogen, a female hormone, helps keep vaginal tissue healthy by maintaining normal vaginal lubrication, tissue elasticity and acidity. These factors create a natural defense against vaginal and urinary tract infections. But when your estrogen levels decrease, so does this natural defense, leading to a thinner, less elastic and more fragile vaginal lining.

Estrogen levels can fall for a number of reasons:

• Menopause or perimenopause
• Childbirth
• Breast-feeding
• Effects on your ovaries from cancer therapy, including radiation therapy, hormone therapy and chemotherapy
• Surgical removal of your ovaries
• Immune disorders
• Cigarette smoking

Medications
Allergy and cold medications, as well as some antidepressants, can lead to dryness of mucous membranes, including those of your vagina.

Sjogren's syndrome
In this autoimmune disease, your immune system attacks healthy tissue. In addition to causing symptoms of dry eyes and dry mouth, Sjogren's syndrome can also cause vaginal dryness.

Douching
The process of cleansing your vagina with a liquid preparation (douching) disrupts the normal chemical balance in your vagina and can cause inflammation (vaginitis). This may cause your vagina to feel dry or irritated.

A pelvic exam is one way your doctor evaluates and diagnoses vaginal dryness. He or she may take a sample of cervical cells or vaginal secretions for examination under the microscope or to send to the laboratory for other testing. You may also be asked for a urine sample for testing if you have associated urinary symptoms.

Vaginal estrogen therapy
If vaginal dryness is due to a lack of adequate estrogen and if self-care measures don't correct the problem, vaginal estrogen therapy may be helpful. Vaginal estrogen therapy comes in several forms:

• Vaginal estrogen cream (Estrace, Premarin, others). You insert this cream directly into your vagina with an applicator, usually at bedtime. Your doctor will let you know how much cream to use and how often to insert it, generally two or three times a week.
• Vaginal estrogen ring (Estring). A soft, flexible ring is inserted into the upper part of the vagina by you or your doctor. The ring releases a consistent dose of estrogen while in place, and needs to be replaced about every three months.
• Vaginal estrogen tablet (Vagifem).You use a disposable applicator to place a vaginal estrogen tablet in your vagina. Your doctor will let you know how often to insert the tablet, usually twice a week.

If vaginal dryness is associated with other symptoms of menopause, such as moderate or severe hot flashes, your doctor may suggest estrogen pills, patches, gel or a higher dose estrogen ring. Talk to your doctor to decide if estrogen treatment is an option and, if so, which type is best for you.

Vaginitis is an inflammation of the vagina that can result in discharge, itching and pain. The cause is usually a change in the normal balance of vaginal bacteria or an infection. Vaginitis can also result from reduced estrogen levels after menopause.

The most common types of vaginitis are:

• Bacterial vaginosis. This type of vaginitis results from overgrowth of one of several organisms normally present in your vagina, upsetting the natural balance of vaginal bacteria. More than one in six pregnant women in the United States has bacterial vaginosis, though many aren't aware of it.
• Yeast infections. A naturally occurring fungus called Candida albicans usually causes this type of vaginitis. An estimated three out of four women will have a yeast infection in their lifetime.
• Trichomoniasis. This type is caused by a parasite and is commonly transmitted by sexual intercourse.
• Atrophic vaginitis. This type results from reduced estrogen levels after menopause. The vaginal tissues become thinner and drier, which may lead to itching, burning or pain.

Treatment depends on the type of vaginitis you have.

Vaginitis symptoms may include:

• Change in color, odor or amount of discharge from your vagina
• Vaginal itching or irritation
• Pain during intercourse
• Painful urination
• Light vaginal bleeding

Additionally, you may have these signs and symptoms depending on the type of vaginitis:

• Bacterial vaginosis. You may develop a grayish-white, foul-smelling discharge. The odor, often described as fish-like, may be more obvious after sexual intercourse.
• Yeast infections. The main symptom is itching, but you may have a white, thick discharge that resembles cottage cheese.
• Trichomoniasis. This infection can cause a greenish yellow, sometimes frothy discharge.

The cause depends on the type of vaginitis you have.

Bacterial vaginosis
Bacterial vaginosis results from an overgrowth of one of several organisms normally present in your vagina. Usually, "good" bacteria outnumber "bad" bacteria in your vagina. But if bad bacteria become too numerous, they upset the balance and bacterial vaginosis results. This type of vaginitis can spread during sexual intercourse, but it also occurs in people who aren't sexually active. Women with new or multiple sex partners, as well as women who douche or use an intrauterine device (IUD) for birth control, have a higher risk of bacterial vaginosis.

Yeast infections
Yeast infections occur when certain internal or external factors change the normal environment of your vagina and trigger an overgrowth of a microscopic fungus - the most common being C. albicans. A yeast infection isn't considered a sexually transmitted disease. Besides causing most vaginal yeast infections, C. albicans also causes infections in other moist areas of your body, such as in your mouth (thrush), skin folds and fingernail beds. The fungi can also cause diaper rash.

Factors that increase your risk of yeast infections include:

• Medications, such as antibiotics and steroids
• Uncontrolled diabetes
• Hormonal changes, such as those associated with pregnancy, birth control pills and menopause

Bubble baths, vaginal contraceptives, damp or tightfitting clothing and feminine hygiene products, such as sprays and deodorants, don't cause yeast infections, but they may increase your susceptibility to infection.

Trichomoniasis
Trichomoniasis is a common sexually transmitted disease caused by a microscopic, one-celled parasite called Trichomonas vaginalis. This organism spreads during sexual intercourse with someone who already has the infection. The organism usually infects the urinary tract in men, but often causes no symptoms in men. Trichomoniasis typically infects the vagina in women.

Noninfectious vaginitis
Vaginal sprays, douches, perfumed soaps, scented detergents and spermicidal products may cause an allergic reaction or irritate the delicate skin around your vagina. Vaginal itching and burning can also result from vaginal dryness caused by a drop in your hormone levels after menopause or surgical removal of your ovaries.

To diagnose your condition, your doctor may review your history of vaginal infections or sexually transmitted diseases and conduct a pelvic examination. Your doctor may take a sample of a cervical or vaginal discharge for laboratory analysis. This sample can confirm what kind of vaginitis you have.

The type of medication used for vaginitis treatment depends on which type you have:

• Bacterial vaginosis. For this type of vaginitis, your doctor may prescribe metronidazole (Flagyl, MetroGel) or clindamycin (Cleocin) as tablets or vaginal gels or creams.
• Yeast infections. Yeast infections usually are treated with an antifungal cream or suppository, such as miconazole (Monistat) and clotrimazole (Gyne-Lotrimin). Yeast infections may also be treated with an oral antifungal medication, such as fluconazole (Diflucan). The advantages of over-the-counter treatment for a yeast infection are convenience, cost and not having to wait to see your doctor. The catch is you may be treating something other than a yeast infection. It's possible to mistake a yeast infection for other types of vaginitis or other conditions that need different treatment. Using the wrong medicine may delay a proper diagnosis and the most appropriate treatment, and can lead to complications.
• Trichomoniasis. Your doctor may prescribe metronidazole (Flagyl) tablets.
• Atrophic vaginitis. Estrogen, in the form of vaginal creams, tablets or rings, can effectively treat atrophic vaginitis. This treatment is available by prescription from your doctor.
• Noninfectious vaginitis. To treat this type of vaginitis, you need to pinpoint the source of the irritation and avoid it. Possible sources include new soap, laundry detergent, sanitary napkins or tampons.

Good hygiene may prevent some types of vaginitis from recurring and may relieve some symptoms:

• Avoid baths, hot tubs and whirlpool spas. Rinse soap from your outer genital area after a shower, and dry the area well to prevent irritation. Don't use scented or harsh soaps, such as those with deodorant or antibacterial action.
• Avoid irritants. These include scented tampons and pads.
• Wipe from front to back after using the toilet. Doing so avoids spreading fecal bacteria to your vagina.

Other things that may help prevent vaginitis include:

• Don't douche. Your vagina doesn't require cleansing other than normal bathing. Repetitive douching disrupts the normal organisms that live in the vagina and can actually increase your risk of vaginal infection. Douching won't clear up a vaginal infection.
• Use a male latex condom. This helps avoid infections spread by sexual contact.
• Wear cotton underwear and pantyhose with a cotton crotch. Don't wear underwear to bed. Yeast thrives in moist environments.
• Eat yogurt that contains active lactobacillus cultures. This sometimes may help reduce recurrent vaginal yeast infections. Lactobacillus is a type of "good" bacteria that's common in your vagina.

Cancer of the vulva, the outer part of the female genitalia, is rare. Vulvar cancer most often occurs in women between the ages of 55 and 85, although it can also occur in women who are younger than 40.

More than 90 percent of vulvar cancers are squamous cell carcinomas - a type of skin cancer - that develop slowly over years and are preceded by precancerous changes in the surface of your skin. A small percentage of vulvar cancers begin as melanoma. Rarely, vulvar cancers may develop in the mucus-producing glands located on the sides of the vaginal opening. The exact cause isn't known. Human papillomavirus (HPV), a sexually transmitted infection, may play a role.

Getting regular gynecologic exams may increase your chance of early detection of vulvar cancer, which means a better chance of successful treatment. You may also be able to prevent vulvar cancer by engaging in safe sexual practices to reduce your risk of contracting HPV infection, and you may be able to control other risk factors as well.

Recognizing possible signs and symptoms of vulvar cancer may help you detect the disease early, before it reaches an advanced stage. This may give you a better chance for successful treatment and long-term recovery. If you experience any of the following vulvar signs or symptoms, see your doctor:

• Itching that doesn't improve
• Burning, pain and tenderness
• Bleeding that isn't from menstruation
• Skin changes, such as color changes or thickening
• A lump or open sore (ulcer)

The exact cause of vulvar cancer isn't known. Most vulvar cancers occur in women between the ages of 55 and 85 who have a mutation or defect in the p53 tumor suppressor gene - a gene that plays a role in keeping cells from becoming cancerous. These women also often have lichen sclerosus - a condition that causes the vulvar skin to become thin and itchy.

The remaining 30 percent to 50 percent of vulvar cancers occur in younger women who have the sexually transmitted infection HPV, which appears to play a key role. It may take years or decades for vulvar cancer to develop after infection with HPV. Many times these women have a precancerous skin condition called vulvar intraepithelial neoplasia in multiple areas of the vulva, and they typically are smokers.

Although the exact cause of vulvar cancer isn't known, certain factors appear to increase your risk of the disease. These factors include:

• Age. The majority of women with vulvar cancers, 85 percent, are older than 50 years of age. And half of women with vulvar cancers are older than 70 when first diagnosed with the cancer. However, 15 percent of new diagnoses are in women younger than 40.
• HPV infection. This sexually transmitted disease is present in most younger women who have vulvar cancer. Having HPV, or using unsafe sex practices that put you at greater risk of HPV infection, increases your risk of vulvar cancer.
• Smoking. Smoking exposes you to cancer-causing chemicals that may increase your risk of vulvar cancer. Women with a history of genital warts or HPV have an even further increased risk of vulvar cancer if they smoke.
• Human immunodeficiency virus (HIV). This virus, which affects the body's immune system, may make you more susceptible to HPV infections, thereby increasing your risk of vulvar cancer.
• Vulvar intraepithelial neoplasia. Though most cases of this precancerous condition don't develop into vulvar cancer, the condition does increase your risk of vulvar cancer and should be monitored by your doctor.
• Lichen sclerosus. About 4 percent of women with this condition, which causes the vulva to become thin and itchy, later develop vulvar cancer.
• Melanoma. If you have a family or personal history of this serious type of skin cancer anywhere on your body, you're at increased risk of a vulvar melanoma.
• Immunosuppression. Medications that suppress your immune system may also increase your risk of vulvar cancer if you have an established HPV infection. Some women may not even realize they are infected with HPV until they use these medications. Immunosuppression with drugs such as steroids is commonly used in people with organ transplants.

To check for vulvar cancer, your doctor will first conduct a physical examination, including a pelvic exam. If your doctor finds any irregularities, you'll likely need further testing.

Biopsy
Because signs and symptoms of vulvar cancer can also suggest a noncancerous condition, your doctor will need to confirm a diagnosis by removing a small sample of tissue (biopsy) from the irregular area for analysis under a microscope.

To select the best tissue to sample, your doctor may swab a blue dye across your vulva. This dye will react with certain diseased areas, including those affected by a precancerous condition or by vulvar cancer, causing them to turn blue.

Your doctor might also use a special lighted microscope called a colposcope. The colposcope magnifies the surface, helping your doctor identify areas of abnormal cell growth that can't be seen by the naked eye. Your doctor may also swab the area with a weak acetic acid solution (similar to vinegar), which can cause areas affected by a precancerous condition or by vulvar cancer to turn white, making them even more visible.

Once your doctor determines which area to biopsy, he or she may choose one of two types of biopsies:

• Excisional biopsy. If the abnormal area is small, your doctor may use a scalpel to make an incision through your skin and remove the entire tumor. Your doctor will use a local anesthetic to numb the area and may use stitches to sew up the area depending on how much tissue is removed.
• Punch biopsy. If the irregular area is larger, your doctor may remove a portion of it with a small incision or punch biopsy technique. This technique uses a small cookie-cutter-like device to remove a cylindrical piece of skin about 4 millimeters across.

Staging tests
Staging tests help determine the size and location of your cancer and whether it has spread. They also help your doctor determine the best treatment for you. To gather this information, your doctor may use the following tests:

• Cytoscopy. Using a lighted tube, your doctor examines the inside surface of your bladder. More advanced stages of vulvar cancer may spread to this area. If your doctor finds irregularities, he or she will remove a sample for biopsy. You may need local or general anesthesia depending on how large a sample is needed.
• Proctoscopy. In this test, your doctor uses a lighted tube to inspect your rectum and removes tissue samples from any abnormal-looking areas for microscopic analysis.
• Pelvic examination under anesthesia. With anesthesia, your doctor can do a more thorough examination of your pelvis for potential spread of the cancer.

Imaging tests also can help determine if your cancer has spread. These tests may include:

• Chest X-ray. This X-ray of your chest will determine whether the cancer has spread to your lungs.
• Computerized tomography. Computerized tomography - also called CT, CT scan and CAT scan - is an X-ray technique that produces more detailed images of your internal organs than do conventional X-ray exams. Conventional X-ray exams produce two-dimensional images. But CT uses an X-ray-sensing unit that rotates around your body, and a large computer to create cross-sectional images (like slices) of the inside of your body. A CT scan can help your doctor see if cancer has spread to your liver or other organs. Some CT scans require you to ingest a contrast medium before the scan. A contrast medium blocks X-rays and appears white on images, which can help emphasize structures in your body.
• Magnetic resonance imaging (MRI). This test uses a magnetic field and radio waves to create cross-sectional images. Most MRI machines are large, cylindrical-shaped magnets. The strong magnetic field is produced by passing an electric current through wire loops or coils, which are located inside a protective housing. Other coils in the housing send and receive radio waves. When you're in the machine, your body produces very faint signals in response to the radio waves. These signals are detected by coils within the machine, or by additional coils designed to surround a specific body part needing examination. A computer then processes the signals and generates an image. The collected signals create a composite, three-dimensional representation of your body.
• Positron emission tomography (PET). Unlike other scanning techniques, a PET scan doesn't produce clear structural images of organs. Instead, it shows images containing areas of more or less intense color to provide information about chemical activity within certain organs and tissues. Tumors often use more energy than healthy tissues do and may absorb more of a radioactive tracer, which allows the tumors to appear on the scan. This test is helpful in determining whether your cancer has spread to your lymph nodes or elsewhere in your body.

Treatment options for vulvar cancer depend on the type and stage of cancer and include surgical removal of the tumor, radiation therapy, chemotherapy or a combination of these.

Surgery
The more advanced a vulvar cancer is, the more tissue that may need to be surgically removed. Options include:

• Laser surgery. If the cancer is in the early stages, laser surgery is an option. Your doctor aims a laser beam at the layer of your vulva that contains cancer, killing the cancer cells.
• Excision. This procedure, which may also be called a wide local excision or radical excision, involves cutting out the cancer and about a half-inch of the normal tissue all the way around it.

• Vulvectomy. Several types of vulvectomy exist. A skinning vulvectomy removes only the top layer of skin where the cancer is. Your doctor may graft skin from another part of your body to cover this area. A simple vulvectomy involves removing the entire vulva. These types of vulvectomies are performed in people with noninvasive vulvar cancer. In a radical vulvectomy, your doctor removes either the cancer and the deep surrounding tissue (partial vulvectomy) or the cancer and the entire vulva, clitoris and nearby tissue (complete radical vulvectomy).

  Removing large areas of skin and tissue in the vulva may create problems with healing, infection, and the ability of the skin grafts to take. The risk of such complications rises with greater tissue removal.

• Pelvic exenteration. If the cancer spread is extensive, your doctor may remove any or all of these organs: the lower colon, rectum, bladder, cervix, uterus, vagina, ovaries and nearby lymph nodes. If your bladder, rectum or colon is removed, your doctor will create an artificial opening in your body (stoma) for your waste to be removed in a bag (ostomy).

• Lymph node removal. Vulvar cancer often spreads to the lymph nodes in the groin, so your doctor may remove these lymph nodes. Your doctor may also tie off a major vein, the saphenous vein. Some doctors will try to avoid closing this vein to prevent additional risk of leg swelling that can occur with this procedure. After the procedure, you'll need a suction drain in the incision for several weeks.

  Removing lymph nodes can cause problems with fluid retention, leg swelling and an increased risk of infection of the lymph vessels (lymphangitis), a condition called lymphedema. If you develop this complication, your doctor may give you compression devices or support stockings to help ease the symptoms. You'll also need to avoid scratches, sunburn and other injury to your legs.

Other complications from vulvar cancer surgery may include the development of cysts near the wounds (lymphoceles), blood clots, urinary infections, loss of sexual desire or pleasure, and painful irritation.

Radiation therapy
Radiation therapy uses high-energy X-rays to kill cancer cells. The radiation is given outside the body and is usually used only to treat the lymph nodes in the groin and pelvis, not the vulva itself. Sometimes it's used to shrink a large tumor so that it can later be removed with less extensive surgery. The skin in the treated areas may look and feel sunburned for six to 12 months. Also, if radiation is used on the pelvis area, you may experience problems with premature menopause and urination.

Chemotherapy
Chemotherapy uses drugs to destroy cancer cells. You may take these drugs through a vein, by mouth or through your skin (topically). Vulvar cancers that have spread tend to be resistant to chemotherapy.

The side effects of chemotherapy may include hair loss, nausea, vomiting and fatigue. These occur because chemotherapy affects healthy cells - especially fast-growing cells in your digestive tract, hair and bone marrow - as well as cancerous ones. Not everyone has side effects, however, and there are now better ways to control some of them.

Reconstructive surgery
Treatment of vulvar cancer often involves removal of some skin from your vulva. The wound or area left behind can usually be closed without grafting skin from another area of your body. However, depending on how widespread the cancer is and how much tissue your doctor needs to remove, your doctor may perform reconstructive surgery - grafting skin from another part of your body to cover this area.

You can help prevent vulvar cancer by avoiding sexual behaviors that put you at risk of sexually transmitted diseases such as HPV and HIV, both conditions that increase your risk of vulvar cancer. Not smoking may also reduce your risk of vulvar cancer.

You can help prevent invasive vulvar cancer by being aware of the signs and symptoms of vulvar cancer and having regular gynecologic exams to monitor for precancerous changes that may lead to vulvar cancer. When vulvar cancer is detected early, it's highly curable. According to the American Cancer Society, the overall five-year survival rate is 90 percent when the lymph nodes aren't involved. The overall five-year survival rate drops to 50 percent to 70 percent if cancer has spread to the lymph nodes.

In addition, a new vaccine against HPV, which was approved by the Food and Drug Administration in 2006, is effective in preventing vulvar cancer as well as cervical cancer.

The pain has lasted for months. You're so uncomfortable you can hardly sit. Having sex is unthinkable. Nothing alleviates the pain, burning and irritation, at least not for long.

These descriptions may be characteristics of a lasting pain in the area around the opening of your vagina (vulva) called vulvodynia (vul-vo-DIN-ee-uh) or chronic vulvar pain. Experts believe vulvodynia is greatly underrecognized. There are several reasons vulvodynia may be underreported. It may be partly due to the absence of visible signs of vulvodynia. Or it could be the reluctance of many women to talk about their symptoms.

If you or someone you know is living with vulvodynia, don't hesitate to get help. Treatment options are available to lessen the pain and discomfort of vulvodynia.

The word "vulvodynia" means "painful vulva." Your vulva consists of the pad of fatty tissue at the base of your abdomen (mons pubis), the labia, the clitoris and the opening of your vagina.

The main symptom of vulvodynia is pain in your genital area, which can be characterized by:

• Burning
• Soreness
• Itching
• Stinging
• Rawness
• Painful intercourse (dyspareunia)
• Throbbing

The pain you experience may be constant or intermittent and can last for months or even years but can vanish as suddenly or mysteriously as it started. A similar condition, vulvar vestibulitis, may cause pain only when pressure is applied to the area surrounding the entrance to your vagina.

Vulvar tissue may look minimally inflamed or swollen. More often, your vulva appears normal.

Doctors don't know what causes vulvodynia, but contributing factors may include:

• Injury to or irritation of the nerves surrounding your vulvar region
• Past vaginal infections
• Allergies or a localized hypersensitivity of the skin
• Muscle spasms

Many women with vulvodynia have a history of treatment for recurrent vaginitis or vaginal yeast infections. Some women with the condition have a history of sexual abuse. Vulvodynia isn't sexually transmitted or a sign of cancer.

Treatments for vulvodynia focus on relieving symptoms. No one treatment works for every woman, and you may find that a combination of treatments works best for you. Available options may include:

• Medications. Tricyclic antidepressants such as amitriptyline can help lessen chronic pain. This type of antidepressant may work better than some of the other types of antidepressants, such as fluoxetine (Prozac, Sarafem) or sertraline (Zoloft), for this condition. Anticonvulsants such as carbamazepine (Tegretol) and gabapentin (Neurontin) also may lessen the pain of vulvodynia. Antihistamines such as hydroxyzine can reduce itching.
• Biofeedback therapy. This therapy can help reduce pain by teaching you how to control specific body responses. The goal of biofeedback is to help you enter a relaxed state in order to decrease pain sensation. To cope with vulvodynia, biofeedback can teach you to relax your pelvic muscles, which can sometimes contract in anticipation of pain and actually cause chronic pain itself.
• Local anesthetics. Using medications such as lidocaine can provide temporary relief from the pain.
• Topical creams. Creams that contain estrogen or cortisone can help alleviate the pain.
• Sitz baths. Bathing the area around your external genitals and buttocks in a saline solution can sometimes help make you feel better, but it also has the potential to aggravate your discomfort.