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CHAPTER 1

External female genital anatomy

Doctor, while you’re down there, can you just tell me if my vagina looks normal?

This is one of the questions I am most frequently asked by my patients, but it is also one of the most inaccurately phrased. What women actually mean is: ‘Does my vulva look normal?’

Many people don’t know the difference between the vulva and vagina, and I think this is a major reason why women so often feel embarrassed to go and see a doctor when they’re concerned that something is not right: because they don’t even know what to call the area they are worried about. What’s more, women’s perceptions of a ‘normal vulva’ are usually inaccurately shaped by the pornography industry, and as someone who looks at vulvas (and vaginas) for a living, I feel appropriately qualified to suggest that this area is becoming a target for body dysmorphia.

It’s very common for women to feel embarrassed or ashamed to take their clothes off and a lot of women apologise as I begin an examination, but it’s important to remember that, as awkward as it may make you feel as a patient, as healthcare professionals we’re totally relaxed and at home. So with that out of the way, let me take you on a brief tour of your anatomy.

The vulva

Vulva, a word that makes a lot of people giggle or blush, is the term used to refer to the external genital region containing the following structures:

 Mons pubis Also known as the Mound of Venus, this is the fatty tissue that covers the front of the pubic bone and is covered in hair. A lot of women apologise for not shaving or waxing this area, but there is no evidence to show that hair removal improves hygiene or reduces the risk of infections, so you don’t actually need to (see here for more on this). Pubic hair also plays a protective role in cushioning the sensitive underlying skin, as well as collecting pheromones, the chemicals that play a role in sexual attraction.

 Clitoris and clitoral hood Your clitoris is shaped like the wishbone of a chicken. The clitoral head, about the size of a small pea, is the visible part of the clitoris, but is, in fact, just the tip of the iceberg, because extending down either side underneath the skin are two arms, each about 5–7cm long. The clitoris is made of the same kind of spongy tissue that is found in the centre of a penis, which fills with blood to produce an erection, and the same thing happens to the clitoris during arousal. The clitoral head has the same embryological origin as the head of the penis but contains about two to three times as many nerves, and might explain why it doesn’t need to be pressed like a doorbell with a dead battery, which many men don’t realise. The sensitive nature is also the reason that there is a fold of skin usually covering it, called the clitoral hood.

 Urethral opening The urethra is the tube that empties urine from the bladder. It’s much shorter in women, at only about 5cm, compared to 20cm in men, which is why women are more likely to get urinary tract infections (UTIs). This is also the reason why you should wipe front to back after using the toilet, and urinate after sex in order to avoid helping the spread of bacteria into the urethra and up into the bladder. Some women may be able to see their urethral opening, while others cannot, and that’s because it can be quite high up, sometimes even almost inside the vagina. I’ve seen many a medical student try to put a catheter into the clitoris, but it’s always the boys who blush the most when I politely redirect them to the urethra!

 Periurethral/Skene’s glands I’ve often been asked at parties by overexcited men about female ejaculation. Well, these are the glands that are responsible for this phenomenon, and they are the female version of the prostate gland. The fluid they make is thought to offer some protection against the bugs that cause UTIs. Infrequently, they can get blocked and swell up, causing a cyst, which can sometimes be confused with a vaginal-wall prolapse.

 Vagina This refers to the muscular tube inside that goes from your vaginal opening on the outside, up to the cervix. Your vagina cannot be seen from the outside (hence the inaccuracy of the question: ‘Does my vagina look normal?’), and at about 7–9cm long, it has an amazing degree of elasticity and can expand in all directions – enough to allow for the birth of a baby. Its expansive nature also means it can also accommodate many a foreign object.Possibly the most unusual thing I’ve ever removed from someone’s vagina was a disco ball. Not a massive one from the ceiling of a 70s club, but one that was golf-ball-sized and originally belonged on a key chain. It was 7 a.m., and the end of a particularly harrowing night shift in A&E, but having been told that the offending object was a key ring, I thought it would be a quick job. Then the triage nurse casually added: ‘Oh, by the way, Doc, the key ring itself has snapped off and it’s just the disco ball left inside now …’ Needless to say, it certainly was a challenge, largely due to the fact that your vagina can make a pretty impressive vacuum, but I got it out in the end. If the owner of said disco ball is reading this, I just want to say how much I still feel your pain and embarrassment to this very day.

 Labia majora These are the larger, skin-covered outer lips of the vulva. The skin here is usually darker than the rest of the surrounding skin and has a fatty layer underneath that plays a protective role.

 Labia minora These are the inner, more fleshy-looking lips, that are usually quite red or pink and probably what cause the most concern with regards to what’s ‘normal’. Most women’s labia minora will be visible below the labia majora and it’s common for them to be asymmetrical. The average size ranges from 2–10cm in length and 1–5cm in width1 and consequently the appearance of the labia minora varies significantly from one woman to the next. It’s kind of ironic how teenage boys (and let’s be honest, most immature men) boast about the size of their penis, yet women are expected to have neat, tucked-in labia that never see the light of day. Why is this? Because they originate from the same embryological structure. It is normal for them to seem to enlarge slightly with age due to loss of collagen and oestrogen, both of which support the structure of the tissue.

 Perineum This is the area between the back of the vaginal opening and the anus.

 Pelvic-floor muscles Your pelvic floor is underneath the skin of the perineum and is made up of several muscles and pieces of connective tissue that act as a sling to hold your insides in. Pelvic-floor weakness can lead to prolapse of the vaginal walls, bladder, urethra or the uterus. A lot of people think you can only get a prolapse if you’ve had a baby, or if you’ve had a vaginal delivery, during which these muscles may tear or be cut to facilitate delivery. However, this is not the case, and it can happen to anyone – regardless of whether they’ve only ever had C-sections, or even if they’ve never had a baby. The pelvic-floor muscles also help you to maintain control of your bladder and bowel.

THINGS YOU’VE ALWAYS WANTED TO KNOW, BUT WERE TOO AFRAID TO ASK

Is ‘down-there’ hair removal safe?

Generally speaking, yes. Minor cuts, burns and ingrown hairs may occur as a result, but they’re rarely severe enough to require medical attention. The most commonly reported reason given for removing pubic hair is for hygiene purposes,² however there isn’t actually any evidence to show that it improves hygiene or reduces the risk of infections. I think this belief is perpetuated by the myth that your vulva and vagina are dirty and teeming with germs. As doctors, we don’t judge or have a preference about the terrain down there, so don’t feel you have to schedule a waxing/shaving session before an appointment. I’ll take it as it comes, thank you!

Will having lots of sex make my vagina loose?

No. Regardless of what the teenage boys in the playground may have said, this is not true. Your vagina is very elastic and can expand enough to let a baby out (and other objects in) but it always shrinks back. While having a baby may change the shape of your vagina slightly, having sex will not because a penis is not large enough to do so. Having sex will also not change the size or shape of your labia minora.

Do I need a labiaplasty?

Absolutely not! Labiaplasty is surgery to trim the labia minora and/or clitoral hood. It is largely performed for cosmetic reasons. I think that the sudden interest in ‘neatening up’ one’s labia may be an undesirable offshoot of the current obsession with aesthetic ‘perfection’. There are numerous plastic surgeons around the world advertising labiaplasty as a quick and simple procedure to make your labia more symmetrical/neat and tidy, etc. But symmetry is overrated – no other body part is truly symmetrical: we’ve all got one foot that’s bigger than the other, eyebrows that don’t match. And it’s the same with labia. It’s also normal for your labia minora to be visible on the outside, although Barbie and the porn industry may tell you otherwise. There is minimal evidence to show that the surgery actually improves pain, sexual function or how women feel about their genitalia, plus there is a risk of pain after the surgery due to nerve damage or resulting scar tissue, so it’s really not a decision to take lightly. And it cannot be reversed in the same way that you could, for example, have breast implants removed. As a famous professor once pointed out: ‘If you think your labia are too long, stop shaving off your pubic hair and you’re unlikely to think so.’

When should I start doing pelvic-floor exercises?

Right about … now! Also called Kegel exercises (see here), everyone should be doing them, regardless of whether they are pregnant or have ever had a baby, because that’s not the only thing that weakens them. They generally weaken with age, so you want them to be as strong as possible from a young age. Doing pelvic-floor exercises in pregnancy, especially from an early stage, has also been shown to reduce the amount of time it takes to push your baby out, and the risk of leaking urine after the birth.^{3, 4} Many people think having a Caesarean section prevents pelvic-floor weakness, but that’s not the case. Carrying around several kilos of extra weight for nine months will put extra strain on the pelvic floor whether you push out that watermelon or it comes out the sunroof!

THE GYNAE GEEK’S KNOWLEDGE BOMBS

The female vulva can generate a great deal of anxiety, but I hope you now feel more comfortable with describing the different areas should you ever need to talk to a doctor about it.

The following are the key facts that I would like you to take away from this chapter:

 Your vulva is on the outside; your vagina is on the inside.

 Your vulva looks normal. Don’t let anyone tell you otherwise.

 Pubic hair removal is safe but doesn’t carry any health benefits, so don’t feel you have to do it.

 You do not need a labiaplasty if it’s purely for appearance reasons. It’s normal for your labia minora to hang below the labia majora and for one to be longer than the other. It’s Barbie who got that part wrong, not you.

 Your pelvic-floor muscles are the lifelong friends that you need to get to know. Kegel exercises (see here) are the most underrated workout that we should all be doing, not just in pregnancy.