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Intimate and embarrassing women's health problems answered by doctors - from lumps and itches to the red-flag signs of cancer you must not ignore
From rashes to lumps, odours to dryness, redness, itching and more, there are many intimate health complaints that can affect women, and often the symptoms can be easy to confuse.
Here’s our definitive expert guide to getting the right diagnosis and treatment for these problems, and what you can do to prevent them coming back.
THICK DISCHARGE AND VAGINAL ITCHING
IT COULD BE: Thrush
This is a fungal overgrowth that can affect the vagina and the surrounding skin. It’s extremely common, and an estimated 75 per cent of women will have thrush at least once.
Thrush can be caused by an overgrowth of Candida albicans, a fungal yeast which is found naturally in the vagina
Symptoms include a thick, odourless, white, cottage-cheese-like discharge; a burning or itching sensation around the vulva; and a sore and irritated vagina, particularly after sex, says Dr Sachchidananda Maiti, a consultant gynaecologist and obstetrician at Manchester University NHS Foundation Trust and the private Pall Mall Medical clinics.
‘It also causes painful sex or stinging when you pass urine,’ he says.
It’s not a sexually transmitted disease, although it can be passed to a partner (in men, it can affect the penis).
WHAT CAUSES IT? The main culprit is an overgrowth of Candida albicans, a fungal yeast which is found naturally in the vagina. An imbalance can be caused by taking antibiotics or the contraceptive pill, as well as stress and sex.
Fluctuating levels of oestrogen can also alter the vaginal pH, leading to vaginal thrush around the time of periods.
HOW IT’S TREATED: ‘Thrush is treated with antifungals,’ says Dr Maiti. ‘These include pessary tablets that you insert into the vagina.’
Antifungal treatments can be bought from pharmacies without a prescription.
These include Canesten Thrush Treatment (£10 from most pharmacies) and fluconazole (£2.49 for two capsules, chemist-4-u.com).
Your sexual partner doesn’t need treatment unless they have symptoms, but it’s a good idea for them to ‘use a condom until you are clear of thrush, so you don’t keep passing it back and forth between you,’ says Dr Maiti.
The infection will usually clear up within a few days, but if symptoms persist you should consult your doctor. They may also swab for a bacterial or viral infection.
Guidelines from the National Institute for Health and Care Excellence (NICE) recommend recurrent thrush be treated with three doses of 150mg oral fluconazole, an antifungal drug, followed by a maintenance dose of 150mg once a week for six months.
MALODOROUS DISCHARGE
IT COULD BE: Bacterial vaginosis (BV)
This is an infection caused by an imbalance in the community of bacteria that is naturally found in the vagina - according to the World Health Organisation, BV affects between 23 to 29 per cent of women of reproductive age at some point.
Symptoms include a grey or white watery discharge, with a strong fishy odour.
WHAT CAUSES IT? Although it mainly affects sexually active women, it is not a sexually transmitted infection, says Dr Rhiannon Bray, a consultant urogynaecologist at Kingston Hospital NHS Foundation Trust and the private New Victoria Hospital in London.
‘In the vagina there is a community of yeast and bacteria, collectively known as the vaginal microbiome - just as the gut has its own microbiome the vagina does, too.
‘When a woman has BV it’s often because she has too many bacteria in the mix and less yeast.
‘It can happen when we wash away the good microbes, with soap or using bubble bath, shampoo or shower gel in the bath, and feminine hygiene products which can allow the bad bacteria to take hold.’
BV can also occur when there’s an overgrowth of pathogens and less of the ‘friendly’ lactobacillus bacteria, which can occur as a result of sex, using strong detergents to wash your underwear and smoking.
‘Women will get BV and worry about the fishy smell and wrongly believe they’re not clean enough,’ says Dr Bray.
‘Then they start over-washing the vagina - but this can wash away all the good bacteria and make things worse. The vagina is self-cleansing and doesn’t need washing or wiping with cleansing wipes.’
BV is diagnosed by taking a history of symptoms and a swab to rule out other causes, including sexually transmitted infections such as chlamydia.
HOW IT’S TREATED: ‘BV is mainly treated with antibiotics such as metronidazole, which comes as a tablet or vaginal gel; or clindamycin, which comes as a pill, suppository or cream that is inserted into the vagina,’ says Dr Bray.
If you have a same-sex partner, she will also need to be treated (it doesn’t spread to male partners).
To reduce the chance of a recurrent infection, stop using fragranced bubble baths and shower gels - and take showers instead of baths, says Dr Ann Nainan, a London GP with a special interest in sexual medicine.
‘Also wear cotton underwear and breathable fabrics, especially in sports wear, if you are doing activities where you get very hot, such as running or hot yoga, because warmth and moisture increase bacterial and fungal growth,’ she adds.
‘And change out of your gym gear right away. Don’t sit around all day in your yoga pants, as this provides the ideal environment for pathogens to grow.’
There are vaginal probiotics (i.e. supplements of ‘good’ bacteria) now available, said to help balance the vaginal microbiome, although Dr Nainan says ‘more research is needed’ on these and they don’t treat BV.
However, she adds that if you have recurrent infections and conventional treatments haven’t worked for you, ‘specific Lactobacillus supplements taken orally may be worth trying to help restore and maintain the vaginal microbiome’.
Tight clothing, soaps and perfumed bubble baths can cause irritation and lead to itchiness
RED, ITCHY VULVA
IT COULD BE: Vulvar dermatitis, otherwise known as female genital eczema
Dermatitis and eczema can lead to dry, itchy, inflamed skin anywhere, including on the vulva (the external area around your vagina). When it strikes here the vulva and the surrounding folds of skin may become red, painful, itchy and can bleed if scratched.
WHAT CAUSES IT? Tight clothing, soaps and perfumed bubble baths, feminine wipes and incontinence can be implicated, as they can cause irritation.
HOW IT’S TREATED: The National Eczema Society recommends seeing a doctor to treat skin problems in this area rather than trying to self-medicate.
‘Emollients - i.e. soothing moisturisers that hydrate the skin - and steroid creams and ointments can be prescribed for these types of skin complaints,’ says Dr Jo Bailey, a consultant gynaecologist at the private Nuffield Health Bristol Hospital.
DRYNESS AND PAIN DURING SEX
IT COULD BE: Vaginal atrophy
Sometimes known as genitourinary syndrome of menopause (GSM), vaginal atrophy occurs due to a thinning and dryness of the vaginal walls.
‘Up to 80 per cent of women experience vaginal dryness at some point, but most don’t come forward for help - maybe because they are too embarrassed or just accept it as a normal part of ageing,’ says Dr Tania Adib, a consultant gynaecologist at the private HCA Lister Hospital in London.
As well as making sex painful, it can also lead to itching and a burning feeling around the vagina. There may also be urinary symptoms such as mild incontinence and, confusingly, some women develop vaginal discharge, too.
WHAT CAUSES IT? It’s caused by a drop in the level of oestrogen, mostly associated with menopause.
‘Oestrogen supports the skin integrity, the collagen [the scaffolding of skin] and blood flow to the tissue - so as oestrogen levels decline, the collagen degrades and becomes thinner and the skin becomes more fragile in the vaginal and vulval area,’ says Dr Adib.
The oestrogen link means it mostly affects post-menopausal women (levels plummet at menopause), but also some younger women who are breastfeeding (which causes oestrogen levels to drop), and those in the perimenopause - the years running up to the menopause.
Vaginal dryness can start ten years before the menopause as oestrogen levels start to decline, according to a study published earlier this year in the journal Cureus.
‘So vaginal dryness can affect women in their late 30s and early 40s while they are still having periods - and because they’re still having periods, they don’t necessarily associate it with declining hormone levels and think they have thrush or BV instead and treat it with over-the-counter creams,’ says Dr Adib. ‘This may give some temporary relief but won’t solve the underlying hormonal imbalance.’
HOW IT’S TREATED: ‘The good news is that there are lots of effective treatments for GSM, including moisturisers you can buy over-the-counter in pharmacies [that can be inserted into the vagina with an applicator],’ says Dr Adib.
‘Then there is topical oestrogen which can be inserted into the vagina via a pessary or a cream. This is available over the counter [Gina 10mcg Vaginal tablets, £29.99 for 24, superdrug.co.uk] and on prescription [estradiol; brand names include Vagifem]. It contains a tiny amount of oestrogen which is just enough to be effective locally in the vagina.
‘Because it’s only a tiny dose it doesn’t affect the rest of the body,’ says Dr Adib.
Lubricants (gels for sex) are also available on NHS prescription, including brands such as Sylk and moisturisers such as Yes. They can also be bought from pharmacies.
‘Once you are perimenopausal or menopausal, systemic HRT (such as patches, gels or pills that affect the whole body and are used for menopausal symptoms rather than just vaginal dryness) can help and are also available on prescription.
‘If you have a dry vulva or vaginal entrance and vaginal oestrogen is not helping, a pessary containing a bioidentical hormone (made from plant sources) called DHEA [brands include Intrarosa] may be given,’ says Dr Adib.
‘DHEA converts into testosterone in the lower part of the vagina and the entrance to the vagina where there are testosterone receptors [testosterone helps maintain moisture and lubrication], and oestrogen in the upper half of the vagina,’ she explains.
She adds that while GPs should be able to prescribe DHEA on the NHS, some can’t as it’s not on their practice formulary - a list of medications they are allowed to prescribe, which is decided locally.
Natural remedies such as sea buckthorn oil can make up to a 40 per cent improvement in dry vagina symptoms, says Dr Adib.
Laser treatments such as a fractional carbon dioxide laser, which emits jets of carbon dioxide a fifth of a millimetre into the skin at one-millimetre intervals, are also used to treat GSM.
‘It tricks the body into thinking there’s been an injury, so the body brings in new blood vessels and growth factors to rejuvenate the collagen in the skin and this improves lubrication,’ says Dr Adib, who offers laser treatment at her clinic.
However, vaginal laser treatments cost around £1,800 for an initial course of three sessions, and then £650 for a top-up. NICE says the evidence for its effectiveness long-term is inadequate and it’s not available on the NHS for urogenital atrophy.
SHINY, WHITE, ITCHY PATCHES
IT COULD BE: Lichen sclerosus
This inflammatory skin condition can affect the vulva, causing itchy, shiny, white patches (which can affect a man’s penis, too) and intense itching.
‘Initially most women who get this think they have got thrush and treat it as though it's thrush, and it doesn’t respond,’ says Dr Adib.
‘You really need to be examined by a doctor to identify what is causing the itch. It’s usually obvious on examination because of the shiny, white patches.’
WHAT CAUSES IT? The exact cause is unknown as the inflammatory skin response is an autoimmune condition (in other words, it's caused by an attack by the body’s own immune system), but ‘it’s likely to be a combination of an overactive immune system, genes and previous skin damage or irritation’, says Dr Adib.
HOW IT’S TREATED: ‘There’s no cure for lichen sclerosus, but steroid creams can ease the symptoms and vaginal lubricant may help if sex is uncomfortable,’ says Dr Adib.
‘In pre-menopausal women it can clear up spontaneously, but this doesn’t happen generally in older women.’
Self-help tips include wearing cotton or silk underwear, as these can be less irritating than other materials.
SORE, RED PATCHES
IT COULD BE: Lichen planus
This is a rash that causes sore, red patches on the vulva and less commonly the vagina, which can be itchy.
‘Often the skin on the vulva looks redder and more inflamed than lichen sclerosus and it can affect the vagina as well as the vulva,’ says Dr Adib.
A more severe form, called erosive lichen planus, can lead to painful ulcers developing on the genitals, but this is rare.
WHAT CAUSES IT? Lichen planus is believed to be an autoimmune condition. It’s not sexually transmitted, you can’t pass it on to others, and it typically only affects older women.
HOW IT’S TREATED: Lichen planus can occur anywhere on the skin - and in the mouth - and usually goes away on its own within nine to 18 months, but if it’s on the genitals it can be more persistent.
‘A steroid foam which can be inserted into the vagina to reduce inflammation can help,’ says Dr Adib.
Self-care measures include having showers rather than baths, as your skin is in contact with chemicals from toiletries more when you're in a bath.
Applying a frozen bag of peas wrapped in a tea towel may cool inflamed areas.
Sexual health clinics can provide prescription-only creams to help treat certain embarrassing ailments
CAULIFLOWER GROWTHS
IT COULD BE: Vaginal warts
These can develop as a result of infection with some strains of the sexually transmitted human papillomavirus (HPV).
These appear as small, rough lumps on the skin that can be isolated, or in groups of warts that may look like cauliflowers.
They can be red, white, skin-coloured or darker than surrounding skin and appear on the vulva, in the vagina and on the skin between the vagina and the anus.
They can cause pain and discomfort during intercourse, and symptoms when peeing (such as soreness or finding it hard to pee).
WHAT CAUSES IT? ‘There are many subtypes of HPV and we know that some of them are more likely to cause warts. You can get warts affecting the outside skin of the vulva, as well as the vagina and cervix,’ says Dr Bailey.
HOW IT’S TREATED: ‘Vulval warts can be treated with prescription-only creams and liquids which work by stopping the growth of the wart. They're available from sexual health clinics,’ says Dr Bailey.
‘But it can be difficult to apply these inside the vagina, so for those cases we can use surgery under both local or general anaesthetic, or freezing (cryotherapy) - but they can sometimes come back regardless of the treatment approach.’
SWOLLEN LUMPS
IT COULD BE: Bartholin's cysts
The Bartholin’s glands are found on either side of the vaginal opening: these pea-sized glands produce fluid that helps lubrication during sex. If the opening of the gland becomes blocked, fluid builds up inside to produce a cyst that may be up to 4cm in diameter.
Around one in 50 women will have a Bartholin’s cyst at some point, most commonly between the ages of 20 to 30. They are less likely after menopause, when the vaginal tissues tend to shrink.
‘They do not tend to cause symptoms unless they are large, or become infected, causing an abscess,’ says Dr Deborah Lee, a sexual and reproductive health expert with the online pharmacy doctorfox.co.uk.
A Bartholin’s abscess can cause fever, and severe pain in the vagina which may be felt when you sit down.
If you suspect you have a Bartholin's abscess, seek medical advice as it can lead to sepsis if left untreated and may require intravenous antibiotics, and drainage of the cyst.
WHAT CAUSES IT? The cysts occur due to blockage of the Bartholin’s glands. It’s not known how they become blocked but is sometimes associated with sexually transmitted infections or bacterial infections such as E.coli.
HOW IT’S TREATED: ‘The majority of Bartholin’s cysts will naturally disappear by themselves,’ says Dr Lee.
‘Sitting in a warm bath can encourage the cyst to drain as the warm water can help the end of the blocked duct to relax and encourage the fluid inside to naturally drain.’
Gynaecologists recommend a sitz bath (a special type of shallow bath designed for soaking the genital regions), says Dr Lee. These come in foldable designs to fit over a loo seat and can be bought online for £12 to £15.