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The labia minora are relatively prominent in childhood and as the hymen is thickened the vaginal orifice is difficult to see. The vestibule and introitus is normally bright red, and this often gives rise to the mistaken suspicion of abnormality. Due to reduced oestrogen levels, adhesions of the labia minora can be seen. These can mimic disorders of sexual differentiation and are sometimes mistaken for pre‐pubertal lichen sclerosus. A line of demarcation between the clitoral hood and the labia minora under the clitoris is seen with adhesions (see Chapter 51). Milia are sometimes seen on the labia majora in childhood.

Table 3.1 Normal changes in the vulva through life

	Labia majora	Labia minora	Vagina	Other
Neonate	Fat is increased Milia (blocked eccrine ducts) may appear	Prominent	Lined by stratified epithelium, rich in glycogen Lactobacilli present	May be white or slightly blood‐ stained discharge
Childhood	Fat reduces	May form adhesions	Lack of glycogenation makes vagina more alkaline
Puberty	Fat increases and also in the mons, which becomes more prominent Pubic hair appears	Become more covered by labia majora Increased pigmentation More rugose	Epithelium thickens Increased glycogenation of cells Lengthens Cervix glands active	Clitoris enlarges Urethral orifice more prominent Hymenal ring enlarges Bartholin’s glands become active
Reproductive years	May be increased parakeratosis mid‐cycle		pH increases during menses
Pregnancy	Increased blood flow giving a blue/purple appearance Varicose veins may appear Connective tissue relaxes Pigmentation	Look redder Rims may be more pigmented	Muscle fibres increase Thickening of vaginal mucosa and increased glycogen	Linea nigra Increased pigmentation Increased candida
Menopause	Loss of subcutaneous fat Reduced hair density and colour	Fordyce spots reduce in number and size	Reduced epithelial thickness Raised pH Pale Cervical and vaginal secretions reduce

Before puberty, there is little glycogen in the vaginal epithelium, which therefore restricts the action of lactobacilli and the consequent acidification of the vaginal environment. The resultant relative alkalinity of the vaginal secretions increases susceptibility to vulvovaginitis and urinary tract infections.