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further information orgasm females a vulva with receding labia majora developing clitoral erection engorgement of the labia minora and increased vaginal lubrication the clitoris and the labia minora are both the most erogenous areas of the vulva the labia majora are also somewhat erogenous 57 local stimulation can involve the clitoris vagina and other perineal regions the clitoris especially the glans is the human female s most sensitive erogenous zone and generally the primary anatomical source of human female sexual pleasure 58 sexual stimulation of the clitoris by a number of means can result in widespread sexual arousal and if maintained can result in orgasm stimulation to vulvar orgasm is optimally achieved by a massaging sensation 46 such as oral sex cunnilingus fingering and tribadism two women rubbing vulvas together sexual arousal results in a number of physical changes in the vulva during arousal the bartholin s glands produce more vaginal lubrication vulval tissue is highly vascularised arterioles dilate in response to sexual arousal and the smaller veins will compress after arousal 29 59 so that the clitoris and labia minora increase in size increased vasocongestion in the vagina causes it to swell decreasing the size of the vaginal opening by about 30 clitoral erection takes place which retracts the clitoral hood causing the glans to appear the labia majora have swollen from blood flow 60 and slightly separated revealing a thick and engorged labia minora 61 the labia minora sometimes change considerably in color going from pink to red in lighter skinned women who have not borne a child or red to dark red in those who have during orgasm rhythmic muscle contractions occur in the outer third of the vagina as well as the uterus and anus contractions become less intense and more randomly spaced as the orgasm continues the number of contractions that accompany an orgasm vary depending on its intensity an orgasm may be accompanied by female ejaculation causing liquid from the skene s glands to be expelled through the urethra the pooled blood begins to dissipate although at a much slower rate if an orgasm has not occurred the vagina and its opening return to their normal relaxed state and the rest of the vulva returns to its normal size position and color 62 11 clinical significance main article vulvar disease irritation irritation and itching of the vulva is called pruritus vulvae this can be a symptom of many disorders some of which may be determined by a patch test the most common cause of irritation is thrush a fungal infection vulvovaginal health measures can help to prevent many disorders including thrush 63 infections of the vagina such as vaginosis and of the uterus may produce vaginal discharge which can be an irritant when it comes into contact with the vulvar tissue 64 65 inflammation as vaginitis vulvovaginitis and vulvitis can result from this causing irritation and pain 66 ingrown hairs resulting from pubic hair shaving can cause folliculitis where the hair follicle becomes infected or give rise to an inflammatory response known as pseudofolliculitis pubis 67 a less common cause of irritation is genital lichen planus another inflammatory disorder a severe variant of this is vulvovaginal gingival syndrome which can lead to narrowing of the vagina 68 or vulva destruction 69 many types of infection and other diseases including some cancers may cause irritation 70 71 sexually transmitted infections main article sexually transmitted infection water warts of molluscum contagiosum pubic hair with crab lice vulvar organs and tissues can become affected by different infectious agents such as bacteria and viruses or infested by parasites such as lice and mites over thirty types of pathogen can be sexually transmitted and many of these affect the genitals most stis do not produce symptoms or symptoms may be mild and not be indicative of an sti 72 the practice of safe sex can greatly reduce the risk of infection from many sexually transmitted pathogens 73 the use of condoms either male or female condoms is one of the most effective methods of protection 72 bacterial infections include chancroid characterised by genital ulcers known as chancres granuloma inguinale showing as inflammatory granulomas often described as nodules syphilis the primary stage classically presents with a single chancre a firm painless non itchy ulcer but there may be multiple sores 74 and gonorrhea that very often presents no symptoms but can result in discharge 75 viral infections include human papillomavirus infection hpv this is the most common sti and has many types 76 genital hpv can cause genital warts there have been links made between hpv and vulvar cancer though hpv most often causes cervical cancer 77 genital herpes is mostly asymptomatic but can present with small blisters that break open into ulcers 78 hiv aids is mostly transmitted through sexual activity and the vulva in some cases can be affected by sores 79 a highly contagious viral infection is molluscum contagiosum which is transmissible on close contact and causes water warts 80 81 parasitic infections include trichomoniasis pediculosis pubis and scabies trichomoniasis is transmitted by a parasitic protozoan and is the most common non viral sti 82 most cases are asymptomatic but may present symptoms of irritation and a discharge of unusual odor 83 pediculosis pubis commonly called crabs is a disease caused by the crab louse an ectoparasite 71 when the pubic hair is infested the irritation produced can be intense 71 scabies also known as the seven year itch is caused by another ectoparasite the mite sarcoptes scabiei giving intense irritation 71 cancer main article vulvar cancer malignancies can develop in the glabrous and hair bearing parts of the vulva 29 84 based on the cellular origin and histology vulvar cancers are classified into squamous cell carcinomas melanomas basal cell carcinomas adenocarcinomas sarcomas and invasive extramammary paget s disease 84 squamous cell carcinomas represent the most common variant of vulvar cancers and account for approximately 75 84 these are usually found in the labia particularly the labia majora 85 the second most common vulvar cancer is basal cell carcinoma which rarely spreads to regional lymph nodes or distant organs 84 the third most common subtype is vulvar melanoma studies have shown that vulvar melanomas appear to have a different tumor biology and mutational characteristics compared to skin melanomas which has a direct impact on the medical treatment of vulvar melanomas 86 87 signs and symptoms of vulvar cancer can include itching or bleeding skin changes including rashes sores lumps or ulcers and changes in vulvar skin coloration pelvic pain might also occur especially during urinating and sex 70 however a significant proportion remains asymptomatic in early disease stages often delaying its diagnosis 84 as such 32 of women with vulvar melanoma already have regional involvement or distant metastases at the time of diagnosis which significantly impacts prognosis 86 surgery with or without removal of regional lymph nodes is usually the primary treatment modality typically a wide local excision is performed in which the tumor is excised including a safety margin of healthy tissue to ensure its entire removal which is confirmed by a pathologist 84 in more advanced disease a partial vulvectomy may need to be performed in order to remove some or all of the vulva 88 advanced stage melanomas can be treated with checkpoint inhibitors 89 other labial fusion also called labial adhesion is the fusion of the labia minora this affects a number of young girls and is not considered unduly problematic the condition can usually be treated using creams or it may right itself with the release of hormones at the onset of puberty 43 90 clitoromegaly is an enlarged clitoris caused by either anabolic steroids or an intersex condition vulvodynia is chronic pain in the vulvar region there is no single identifiable cause 91 a subtype of this is vulvar vestibulitis but since this is not thought to be an inflammatory condition it is more usually referred to as vestibulodynia 92 vulvar vestibulitis usually affects pre menopausal women 92 pudendal nerve entrapment can cause sharp pain or numbness in the vulva this condition can be caused by activities such as cycling giving birth or prolonged sitting a number of skin disorders such as lichen sclerosus and lichen simplex chronicus can affect the vulva crohn s disease of the vulva is an uncommon form of metastatic crohn s disease which manifests as a skin condition showing as hypertrophic lesions or vulvar abscesses 93 papillary hidradenomas are nodules that can ulcerate and are mostly found on the skin of the labia or of the interlabial folds another more complex ulcerative condition is hidradenitis suppurativa which is characterised by painful cysts that can ulcerate and recur and can become chronic lasting for many years 94 95 chronic cases can develop into squamous cell carcinomas 95 an asymptomatic skin disorder of the vulval vestibule is vestibular papillomatosis which is characterised by fine pink projections from either the epithelium of the vulva or from the labia minora dermatoscopy can distinguish this condition from genital warts 96 a subtype of psoriasis an autoimmune disease is inverse psoriasis in which red patches can appear in the skin folds of the labia 97 childbirth the vulvar region is at risk for trauma during childbirth 98 during childbirth the vagina and vulva must stretch to accommodate the baby s head approximately 9 5 cm 3 7 in this can result in tears known as perineal tears in the vaginal opening and other structures within the perineum 99 an episiotomy a pre emptive surgical cutting of the perineum is sometimes performed to facilitate delivery and limit tearing a tear takes longer to heal than an incision 100 tears and incisions may be repaired using sutures that may be layered 101 38 among the methods of hair removal evaluated for pre surgeries pubic hair shaving known as prepping was seen to increase the risk of surgical site infections 102 100 no advantages have been demonstrated in the routine shaving of pubic hair prior to childbirth 103 surgery main articles genitoplasty and cosmetic surgery genitoplasties are plastic surgeries that can be carried out to repair restore or alter vulvar tissues 104 particularly following damage caused by injury or cancer treatment these procedures include vaginoplasty and vulvoplasty which can also be performed as a cosmetic surgery other cosmetic surgeries to change the appearance of external structures include labiaplasties 105 some of these procedures vaginoplasties and vulvoplasties are also carried out as gender affirming surgeries 106 107 the use of cosmetic surgeries has been criticized by clinicians 108 109 the american college of obstetricians and gynecologists recommends that women be informed of the risks of these surgeries they refer to the lack of data relevant to their safety and effectiveness and to the potential associated risks such as infection altered sensation dyspareunia adhesions and scarring 110 there is also a percentage of people seeking cosmetic surgery who may be suffering from body dysmorphic disorder and surgery in these cases can be counterproductive 111 society and culture see also vagina society and culture and vulva activism altering the female genitalia further information genital modification and mutilation appearance of an adult vulva after labiaplasty and clitoral hood reduction the labia pride movement opposes the ideals of female cosmetic genital surgeries the muff march in london 2011 in some cultural practices particularly in the african khoikhoi and rwanda cultures the labia minora are purposefully stretched by repeated pulling on them and sometimes by attaching weights 112 113 11 labia stretching is a recognised familial cultural practice in parts of eastern and southern africa 112 114 115 this is a desired and encouraged practice by the women starting at puberty in order to promote better sexual satisfaction for both parties 116 11 the achieved extensions can hang down below the labia majora for up to seven inches 11 children in the african diaspora practise this too so it occurs within immigrant communities in for example britain where a bbc news report labelled it a hidden form of child abuse 117 the girls are subject to familial and social pressure to conform 118 in some cultures including modern western culture women have shaved or otherwise removed the hair from part or all of the vulva when high cut swimsuits became fashionable women who wished to wear them would remove the hair on either side of their pubic triangles to avoid exhibiting pubic hair 119 other women prefer to retain their vulva hair the removal of hair from the vulva is a fairly recent phenomenon in the united states canada and western europe usually in the form of bikini waxing or brazilian waxing but has been prevalent in many eastern european and middle eastern cultures for centuries usually due to the idea that it may be more hygienic or originating in prostitution and pornography 120 121 hair removal may include all most or some of the hair 122 french waxing leaves a small amount of hair on either side of the labia or a strip directly above and in line with the pudendal cleft called a landing strip 122 islam teaching includes muslim hygienical jurisprudence a practice of which is the removal of pubic hair 123 vulva piercings include the clitoral hood piercing above and the labia piercing derived from traditional symbols hanabira scarification is intended to decorate the pubic area several forms of genital piercings can be made in the vulva and include the christina princess albertina isabella nefertiti fourchette and labia piercings piercings are usually performed for aesthetic purposes but some forms like the clitoral hood piercing or rarely glans piercing might also enhance pleasure during sex though they are common in traditional cultures intimate piercings are a fairly recent trend in western society 124 125 126 other forms of permanent modifications of the vulva for cultural decorative or aesthetic reasons are genital tattoos or scarification so called hanabira female genital surgery includes laser resurfacing of the labia to remove wrinkles labiaplasty reducing the size of the labia and vaginoplasty in september 2007 the american college of obstetricians and gynecologists acog issued a committee opinion on these and other female genital surgeries including vaginal rejuvenation designer vaginoplasty revirgination and g spot amplification this opinion states that the safety of these procedures has not been documented the acog and the issvd recommend that women seeking these surgeries need to be informed about the lack of data supporting these procedures and the potential associated risks such as infection ...