Vagina. Vagina. Vagina.

It’s time for the mystique and taboo shrouding the vagina to dissipate. Let’s get comfortable – not only in saying the word but by bringing all things related to the deep, dark ‘netherworld’ right out into the open and into the realm of normalcy. I wish women would raise their vaginal health concerns as unashamedly as they would a headache.

It is not surprising that so many women do not understand their own vaginas when the history of the vagina is steeped in centuries of myth and misperceptions created by, well, ancient men.

In the times of Ancient Greece, prominent medical researcher and physician Galen, delivered the idea that men and women actually shared the same genitalia – only that the vagina and uterus were basically an inverted form of the penis and testicles. Texts of the time were undeniably hierarchical, suggesting the female genitalia were not only an inverted version of a man’s but were somehow incomplete and less superior. Aristotle held that a woman was really just a ‘mutilated’ form of a man, never mind the ‘wandering womb’ theory of Aretaeus – this idea proposed that the uterus of a woman was like an ’animal within an animal’- able to move around freely, banging into other organs and causing a variety of symptoms and afflictions. Luckily for the physicians of the time, this dangerous womb animal could be lured back into place by offering the vagina pleasant scents as a cure. About as cute as it is accurate.

And this was just the beginning.

Fast-forward to the Renaissance years which saw physicians gaining permission for the first time to dissect cadavers and still, even after gleaning physical insights into the anatomy of the vagina, the misunderstandings continued or the published drawings were just as soon cloaked in scandal and prohibited by the church at the time.

Even the name ‘vagina’ has a hazy history.

The scientific term ‘vagina’ derived from the Latin word meaning ‘sheath’ or scabbard’ was only anatomically applied to the actual organ in the 1680s, prior to this many other terms were used. And even to this day, the word ‘vagina’ conjures up much taboo with many of us opting to use different names such as ‘cookie’, ‘down-there’ or ‘va-jay-jay’ not to mention the unmentionable colloquialisms. If the name itself still conjures a blush or raises feelings of embarrassment or shame, it is no small wonder that the actual organ itself and the subject of vaginal health is still somewhat opaque.

Our vaginas are actually the most incredible organs as they are able to self-regulate to perfection: self-clean, protect us against infection, bring life into the world (should we choose) and of course, transcend us into pleasure.

Our vaginal health is an integral part of feeling well and confident as women and it brightens (or dims) our sense of sensuality.

A legacy of poor (and male-dominated) understanding coupled with diversities in today’s modern society relating to cultural norms, beliefs and sexual practices have largely contributed to a great deal of vaginal ‘mystique.’ In other cases, women are just not completely informed or perhaps even, misinformed of what ‘normal’ vagina health is- be it regarding the aesthetics, smell or hygiene practices.

Misinformation about the vagina continues to be problematic even in today’s modern world- feminine hygiene industries which try to sell us products to make our vaginas smell better or ‘fresher.’ Ladies, if nature intended your vagina to smell like poppies of the forest then your vagina would smell like poppies of the forest.

The truth is, when it comes to the vagina, the range of ‘normal’ is extensively large with so much inter-individual variation in terms of smell, size and looks.

Our perception of our bits and why we view them or experience them in a certain way is a complex matter and influenced by a variety of cultural and psychological factors but when it comes down to pure anatomy and physiology – there are some basic fundamentals of vaginal health that are not up to interpretation or perception.

“A rose by any other name would smell just as sweet.”

Let’s start with understanding the correct names for all our parts.

The term ‘vagina’ has become a catch-all phrase for both our internal and external bits but medically speaking, refers only to the internal fibromuscular tube that connects the uterus to the vestibule- which is where the vagina opens up to the outside of the body.

The term ‘vulva’ refers to everything on the outside (where your clothes touch your skin) and includes:

• the mons pubis (mound of fatty tissue which covers the pubic bone and grows pubic hair)
• labia majora and minora
• the clitoris
• urethral opening (where you pee from)
• vestibule (vaginal opening)
• perineum (area between the vestibule and anus)

Your vagina is divinely designed for protection and pleasure.

The skin of the vulva and vagina is called the mucosa. A mucosa is a moist lining of an organ and can be found in other body parts such as the mouth and intestines. The cells making up the vulva and vagina form many layers much like the many tightly-packed bricks in a wall. The specialized bottom layer of cells, called basal cells, are able to produce new cells which grow upwards and eventually replace the top layer of cells (which can be sloughed off due to everyday wear and tear.) The vulval cells produce fatty substances and Keratin which form a protective layer.

Our perfectly normal daily vaginal discharge serves a very important protective function against bad bugs entering the body.

The top layer of cells in the vulva is replaced approximately every 30 days whilst vaginal cell turnover is even more impressive at approximately 96 hours explaining how the wondrous vagina can withstand the friction of foreplay and sex as well as childbirth.

The hair follicles of the vulva have glands to produce sweat (apocrine) and sebum (sebaceous glands) which is an oily substance that keeps the vulva moist and protected. Secretions from the vulval glands plus the oily substances produced the skin cells of the vulva make a film on the surface of the skin called the acid mantle – this keeps the pH of the vulva in the acidic region (3.8-4.5) and is an important part of protection against bugs, irritants and contaminants.

It also explains how something that lives so close to the anus and opening of the urethra (where urine comes out) is able to resist infection from the bugs found in the faeces and urine on a daily basis. Pretty darn smart.

Under the vaginal mucosa sits a layer of muscle (that is not under voluntary control) and a rich blood supply which also explains its ability to regenerate so quickly after injury.

I have had enough pleasure (said no one, ever…)

The clitoris is the only biological structure that exists for the sole purpose of pleasure and ladies, it was given to us!

Packed with nerves-ending, various kinds of stimulation whether it’s via tongue, finger, penis or toys can send us to a very zen or wild place. Scientists now understand that various parts of the vulva, including the clitoris, the labia minora, the spongy tissue around the urethral opening and the vagina are interconnected when it comes to pleasure and share a network of nerve signals. 

This means that stimulation and arousal of one part (like the cervix for example) may create arousal in another part. In fact, when other erogenous zones are stimulated, like the anus or nipples, there is invariably a clitoral response as well. This leaves a great deal of room for fun experimentation and exploration in the bedroom either solo or with your partner to figure out the full pleasure capabilities of your vulva and vagina.

Discharge & Odor

Vaginal discharge is made up of secretions from the glands at the vaginal opening (Skene’s and Bartholin’s) and the cervix mixed with a small amount of fluid that leaks through the vaginal wall from the blood stream. Vaginal discharge also contains sloughed-off dead skin cells and many harmless bacteria that naturally inhabit the area.

The vagina can produce between 1-4ml of discharge in a 24-hour period. The amount of discharge can vary during different times in your cycle (we make more around ovulation when hormones peak) and whether you are on hormonal treatments like the oral contraceptive pill. A normal vaginal discharge is clear, white or creamy in colour and texture can vary widely under hormonal influence and between different women. Gooey, sticky, watery, paste-like, thick and thin are all totally normal.

There seems to be a great deal of confusion about what a normal vagina smells like and whether we are intoxicated by this secret, mysterious scent or in fact, ashamed by it. Society has put forward both sentiments from Gwyneth Paltrow’s intriguing “This Smells like my Vagina” candle (I can’t stand the suspense anymore, I ordered it) to the female hygiene industry marketing loudly about vaginal ‘freshness and cleanliness.’

The range of normal vaginal odors has been described as ‘odor-less,’ ‘musty,’ ‘mildy sweaty, ‘tangy’ or ‘sour.’

In short, if your vaginal discharge does not smell foul (rotten) or fishy – which can be a sign of Bacterial Vaginosis – you are probably fine.

It is completely normal to smell a bit muskier down there after exercise or sex and during your period.

As Jen Gunter, MD says in her book The Vagina Bible “I smell vulvas and vaginas all day long. Healthy vulvas don’s smell more than any other body part. Some women are aware of groin odor from their apocrine sweat glands… this is the genital tract equivalent of armpit odor.” Enough said.

If your vaginal discharge changes in colour (grey, green, yellow or brown should set off alarm bells), smell or is accompanied by itching, irritation, pain, swelling or bleeding – it’s time to call your doctor.

Looks don’t matter (unless they matter to you)

Length

• The length of the vaginal canal can differ significantly between women and is not affected by body weight but rather by genetics. The back wall (closest to your rectum) can vary from 5-14cm and the front wall can vary from 4.5-8cm. Losing weight will not change the aesthetics of the vagina, except for the reduction in fat in the mons pubis (fat cushion over the pubic bone) but even so, the mons is usually one of the last places where fat is noticeably reduced.

Colour

• Melanin is a pigment which confers colour to the skin, hair, eyes and vulva. The vulva is rich in melanocyctes – the cells that produce melanin. It’s worth noting that skin colour does not always match the colour of the vulva. Some women with fair skin may have darker brown vulvas and similarly, women with darker skin may have lighter-coloured vulvas. Melanin production is influenced by age and hormonal factors, particularly estrogen so when estrogen level increase, like in pregnancy, this may cause colour and pigmentation changes on the vulva. Changes in colour are usually not cause for concern unless there is a distinct lesion or associated bleeding, pus or pain during sex in which case you should consult your doctor.

Shape

• The folds of the labia majora and minora play a role in sexual arousal and pleasure and serve to protect the vestibule (vaginal opening)
• The labia majora are filled with many different types of glands and bear pubic hair. The follicles inside the pubic hair contain sweat glands that become more active at puberty. The natural bacteria that colonize the vulva interact with the sweaty and pheromone-containing secretions creating odorous compounds which gives the vulva and vagina its normal smell.
• The labia minora contain erectile tissue and specialized nerve endings responsible for sexual pleasure and are very sensitive to touch.
• The width and length of a woman’s labia is highly variable and it can be normal for either the labia minora to protrude beyond the labia majora or not. In addition, the labia may be asymmetric.

Vaginal diversity should be accepted and celebrated. If you have personal aesthetic aspirations for your vulva there is a whole world of female rejuvenation options on offer. If you do pick this route, opt for a medical specialist/gynaecologist who is experienced in the field.

Your vagina has a particular pH and a micro-biome – don’t mess with that.

The vaginal microbiome is truly a wonder. Millions of beneficial bacteria naturally colonize the vagina and vulva to protect us from infection. The dominant strain of healthy vaginal bacteria are called Lactobacillus.

Lactobacilli produce lactic acid which, together with the acids found in vaginal discharge, keep the vaginal pH on the acidic side between 3.8-4.5. This acidic pH makes it harder for pathogenic (bad) bugs to thrive and cause infection. Lactobacilli also make proteins that directly kill harmful organisms.

Anything that causes a decline in the Lactobacillus community or a change in the normal vaginal pH can lead to overgrowth of bad organisms and infection. Two of the most common infections we encounter as doctors are vaginal thrush (caused by yeast overgrowth) and bacterial vaginosis (caused by anaerobic bacteria) It is important to treat both, especially BV, as it can pose serious risks to fertility and pregnancy.

During your menstrual cycle, the pH of the vagina can increase due to the presence of blood itself which has a pH of 7.35 which explains why women are more susceptible to infection during their periods.

It is good common sense to use a probiotic when taking antibiotics and to ditch the douching which can strip away all our beneficial bacteria.

Don’t let a dry vagina dry up your sex life.

After Menopause:

Vaginal dryness is a very common complaint for post-menopausal women. The lining of the vagina relies on the hormone Estradiol (estrogen) to remain plush and juicy. As estrogen levels decline after menopause the vaginal can atrophy (shrink) and become dry. This can lead to painful sex and sometimes even bleeding from intercourse. So many women begin to develop anxiety related to this painful experience of sex leading to a significant impact on intimacy and sexual fulfilment. Post-menopausal vaginal dryness is completely treatable. Systemic HRT options can be discussed with your doctor but local vaginal estrogen treatments are considered the “crème de la crème” when it comes to treating post-menopausal vaginal atrophy. Vaginal estrogens are incredibly effective at restoring vaginal moisture and sexual comfort. They are also considered incredibly safe as their absorption into the body (systemic absorption) is very limited. These vaginal estrogen creams can be utilized in the long term, for as long as a woman needs. In some cases, where a woman has survived breast cancer and standard HRT is not an option for her, vaginal dryness may be considered for treatment with vaginal estrogen creams under close medical supervision.

Before Menopause:

Pre-menopausal women can also experience vaginal dryness which can be the result of stress, certain anti-allergy and antidepressant medications as well as exposure to harsh chemicals in washing powders, swimming pools and soaps/ hygiene products. It is wise to review your hygiene practices and products (see guide below). Vaginal moisturizers containing hyaluronic acid (a natural chemical found in the body that moisturizes and prevents water loss) and lubricants can be used.

Maintaining Vaginal Health – the 101 on Vaginal Care

How to clean and care for your vagina:

• Your vagina (the inside tube) does NOT need to be cleaned. It is self-cleaning. Attempting to clean the vagina internally can be dangerous.
• Washing the vulva (all the outside bits) is fine. Medically- speaking, the vulva does not need to be cleaned all that regularly (unlike your teeth and hands) so the frequency is best determined by personal preference and lifestyle factors ( how much you sweat or if you have your period, for example)
• Where exactly, should you wash?
• The vaginal opening (vestibule) should be washed only with water as it has the same mucosa as the vagina which as mentioned, should not be washed. The rest of the vulva (mons, pubic hair, labia majora, clitoris) can be washed with product – a good rule is not to apply product between the labia minora.
• Soap or Cleanser?
  • There are 3 good reasons to opt for gentle vaginal cleanser instead of soap:
    1) Soap dries the skin and the vaginal mucosa by stripping away the natural oils, secretions and bacteria which we have learned are so important for vaginal health. Dryness can lead to irritation and trauma as well as infection. Loss of the good bugs can lead to overgrowth of the bad bugs and infection.
    2) Soap can increase the pH of the skin which increases propensity for infection.
    3) Cleansers are not soaps- they are able to remove dirt but leave the acid mantle of the vulva intact.
• Finish off with a gentle pat-dry, not a rub.

Leave out the Va-jazzle

Bath bombs, bubble bath and anything sparkly and glittery are not a glam idea. Fragrances are a common source of chemical irritation to the vulva and vagina causing allergy, inflammation and infection.

The Lowdown on Lube and vaginal moisturizers

Be the ingredient police…

Avoid:

• Applying face serums to the vulval area- chemicals found in face serums such as retinoic acid, salicylic acid and hydroxy acids have not been tested for vulval safety.
• Hydroquinone, a chemical used to skin lightening is not safe to use on the vulva.
• Phthalates and BPAS – these are endocrine-disrupting chemicals that can negatively impact female hormonal health
• Sodium Laural Sulphate (SLS) – a foaming agent commonly found in shampoos is a harsh surfactant chemical that can irritate the vulva and vagina.

Enjoy:

• Hyaluronic acid- this is a naturally occurring chemical in the body and is found in the skin and joints where it binds to and retains water- in this way it is an excellent skin hydrator and provides cushioning support for the joint. HA is a safe and well-studied ingredient in vaginal moisturizers. It can be considered as an alternative to vaginal-based estrogen therapies in post-menopausal women or can be used in younger women with dryness.

Ditch the douching:

• Many studies have shown the harms of douching. Douching strips away the healthy vaginal bacteria and irritates the sensitive vaginal mucosa predisposing the irritation and infection. Don’t do it.

Keep the Kegels:

• Weakness of the pelvic floor muscles can lead to urinary incontinence, prolapse of the uterus and vagina and a weaker orgasm. A weak pelvic floor is often caused by injury during natural childbirth or by age-related muscular weakness. Practising Pelvic Floor Muscle Exercises helps to strengthen the muscles involved, very much like lifting weights and doing reps would strengthen a bicep muscle. You can exercise your PFM by imagining you are trying to stop yourself from peeing (and contracting the muscle) or that you are trying to pick up a marble with your vagina.

The vagina is truly a wondrous thing.

But perhaps the most wondrous part of all, is that it is attached to the incredible women who own it.

We are upon a new era, ladies. It is time to celebrate and enjoy all of the luscious wonders of the female body and great strength of the feminine spirit.