Why Dr. Hall?

Dr. Hall is one of the few gynecologists in the Washington DC area who specialize in disorders of the vulva.  This has been an ongoing area of interest of hers for the past 20 years, leading to additional certifications and many years of experience.

Dr Hall is considered an expert diagnostician of vulva disorders, seeing many patients referred by other gynecologists and dermatologists who need assistance with the diagnosis and treatment of a variety of vulva problems. Dr. Hall is an active member of the International Society of Vulva and Vaginal Disorders (ISVVD).

We can help you-contact our office.

What are Vulva Vaginal Disorders?

Vulva -vaginal disorders are ongoing pain syndromes of the vulva and/or vagina that cause irritation, itching, burning, and pain during intercourse or sexual relations. The reason for these symptoms is often elusive and multifactorial, requiring an expert in vulva-vaginal disorders to make an accurate diagnosis and to plan a successful treatment.

A vulva-vaginal disorders specialist also is an expert is the diagnosis of vulva and vaginal cancers. Vulva cancers are like any skin cancer, but occur on the vulva. Any cancer can occur on the vulva, and include melanoma, basal cell cancer, squamous cell cancer, and even cancers that have spread from other areas of the body. Vaginal cancers occur, however are much less common than vulva cancers.

There are many benign abnormalities of the vulva and vagina that may cause severe symptoms such as itching, bleeding, and pain, however many  vulva disorders are totally without symptoms. 

Virtually any skin disorder that occurs in other areas of the body can occur on the vulva. This includes ulcers (like one gets in the mouth), infections of all types, eczema, contact dermatitis, folliculitis, polyps, and abscesses. psoriasis,  and autoimmune disorders.

Many STDs infect the vulva and vagina presenting as bumps, ulcers or sores such as genital herpes, warts or molluscum contagiosum.  HPV of the vulva and perianal area may lead to vulva or anal cancers if left undetected and untreated.

Vulvar Anatomy

The vulva is the external part of the female genitalia. It protects a woman’s sexual organs, urinary opening, vestibule and vagina and is the center of much of a woman’s sexual response. The outer and inner ‘lips’ of the vulva are called the labia majora and labia minora.  The vestibule surrounds the opening of the vagina, or introitus, and the opening of the urethra, or urethral meatus. The perineum is the area extending from beneath the vulva to the anus.

Diagram reproduced with permission from The Interstitial Cystitis Survival Guide by Robert Moldwin, MD, New Harbinger Publications, Inc. © 2000.

The pudendal nerve transmits pain messages and other sensations from the vulva. The pudendal nerve originates from the sacral spine, which is located directly below the low back area.

The nerve passes through the pelvis and enters the vulvar region near the ischial spine, which is part of the hip bone. From there, it branches off into the inferior rectal nerve, perineal nerve and dorsal nerve of the clitoris. The pudendal nerve is responsible for proper functioning and control of urination, defecation and orgasm in both males and females.

Lichen Sclerosis of the Vulva

Lichen sclerosis is an autoimmune skin disease of the vulva that is often misdiagnosed by medical practitioners.\It is characterized by thickened white tissue of the vulva, causing architectural changes in the vulva skin. Most notably, the clitoris may scar over in lichen sclerosis, making sexual response more difficult due to a lack of sensation. The labia minora and majora may fuse together and the vaginal diameter may decrease and become stiff, making intercourse painful or impossible.

Lichen Sclerosis is more common in women after menopause, but occurs in women of all ages. The cause of lichen sclerosis is not completely understood, but occurs when the immune system becomes overactive causing the tissue on the vulva to thicken and scar. Lichen sclerosis can be associated with other autoimmune disorders, or in families with autoimmune disorders,

The presenting symptoms of lichen sclerosis are most commonly itching and/or burning of the vulva, discoloration of the vulva skin, cracking, or fissures in the vulva or skin around the anus. She may complain of a pulling sensation around the clitoris, and a decrease in sensation around the clitoris.

Patients are often misdiagnosed, or the diagnosis is missed by a practitioner not familiar with this disease. allowing the patient may have active, advancing lichen sclerosis for years before the diagnosis is made.

The disease may be completely asymptomatic  and the diagnosis is made after scarring of the clitoris and narrowing of the vaginal opening has already occurred. While treatment is available, it cannot undo the damage already done by progression of this disease. Untreated lichen sclerosis is also associated with an increased incidence of cancer of the vulva.

Dr. Hall has a special interest in lichen sclerosis. Contact us.

Lichen Simplex Chronicus

Lichen simplex chronicus (LSC), or eczema, is a common skin condition that is very itchy. Although not dangerous, both the itching, and the pain from rubbing and scratching, can be miserable. Eczema/LSC of the genital area most often affects the, the vulva or skin around the anus.  

Some people with LSC have had sensitive skin or eczema/LSC on other areas of the skin at some point, and many have a tendency towards allergies, especially hay fever or asthma. LSC is also seen more often in women with diabetes or pre-diabetes, obesity, and in women with PCOS (polycystic ovarian disease).

The skin usually appears thickened with a white color or dark red with excoriations (sores)  from rubbing and scratching. The patient often is treated with various topical treatments with continued scratching of the area. This causes the tissue to thicken more and itch more. Although rubbing and scratching often feel good at first, rubbing irritates the skin and ultimately makes itching even worse, so that there is more scratching, then more itching, then more scratching. This is called the “itch-scratch cycle.”

The cause of LSC is not entirely clear, however, LSC starts with irritation that triggers itching. Often, at the office visit with the vulva specialist, the original infection or other initial cause of irritation is no longer present. Common triggers include a yeast or fungus infection, vulva topical medications, moisturizers or lubricants, panty liners, an irritating condom, or any other activity or substance that can irritate the skin and start the itching.  

If you have ongoing vulva itching, contact us. We can help.

Vulva Cancer

A wide spectrum of benign, premalignant, and malignant lesions may involve the vulva. The challenge to the clinician is to differentiate between normal variants, benign findings, and potentially serious disease. Vulva cancers can be serious, even deadly.

Melanomas, basal cell carcinomas and squamous cell carcinomas may occur on the vulva, vaginal opening, anus or buttocks and these areas require systematic exams to complete a total body skin check.

Many dermatologists are hesitant to thoroughly examine the genital area when performing routine skin checks in high risk patients. Dr. Hall offers screening of these hard to see areas with the aid of a colposcope and the use of biopsies when indicated.

Contact us for a vulva skin check.

I had terrible itching and burning of my vulva for 5 years and I had been misdiagnosed by 2 previous OB/GYNs. Dr. Hall knew immediately what the problem was and has successfully treated it for 2 years. I can’t thank her enough. – LH

Contact our office to learn more about our Vulva Dermatology and Vaginal Disorders services or to make an appointment.

What Is Vulvodynia?

Vulvodynia, simply put, is chronic vulvar pain without an identifiable cause. The location, constancy and severity of the pain vary among sufferers. Some women experience pain in only one area of the vulva, while others experience pain in multiple areas. The most commonly reported symptom is burning, but women’s descriptions of the pain vary. One woman reported her pain felt like “acid being poured on my skin,” while another described it as “constant knife-like pain.”

Most women have pain at only one vulvar site. If the pain is in the vestibule, the tissue surrounding the vaginal opening, the diagnosis is vestibulodynia (formerly known as vulvar vestibulitis syndrome (VVS)). The red dots represent the painful areas in vestibulitis

The majority of women with localized vulvodynia have Provoked Vestibulodynia (PVD), in which pain occurs during or after pressure is applied to the vestibule, e.g., with:

  • sexual intercourse,
  • tampon insertion,
  • a gynecologic examination,
  • prolonged sitting, and/or
  • wearing fitted pants.

A less common form of localized vulvodynia, known as clitorodynia (pain in the clitoris), can be very painful.

PVD is further classified as primary or secondary.

Women with primary PVD have experienced vestibular pain since the first attempt at vaginal penetration.

Women with secondary PVD have experienced pain-free sexual intercourse prior to the development of vulvar pain.

For women with generalized vulvodynia (GV), pain occurs spontaneously and is relatively constant, but there can be some periods of symptom relief. 

Activities that apply pressure to the vulva, such as prolonged sitting or sexual intercourse, typically exacerbate symptoms.

The above diagram shows the Q-tip test, done by Dr. Hall to accurately diagnose the area of pain. During the test, gentle pressure is applied to various vulvar sites. the severity of the pain. If any areas of skin appear suspicious, your provider may examine them with a magnifying instrument or take a biopsy of the area.

Contact us if you have continued vulva pain- Dr. Hall can help.

Contact our office to learn more about our Vulva Dermatology and Vaginal Disorders services or to make an appointment.