Anatomy of the Female External Genitalia:

Vulva:The vulva (Latin: wrapper, covering) consists of the external female sex organs. The vulva includes the mons pubis, labia majora, labia minora, clitoris, bulb of vestibule, vulval vestibule, urinary meatus, greater and lesser vestibular glands, and the vaginal opening.

Vaginal vestibule:The vulval vestibule (or vulvar vestibule) is a part of the vulva between the labia minora into which the urinary meatus (urethral opening) and the vaginal opening open. Its edge is marked by Hart's line. The sides of the vestibule are visible as Hart's line (see white dashed line) on the inside of the inner lips. Hart's line is the outer edge of the area and marks the change from vulvar skin to the smoother transitional skin of the vulva.

Female Sexual Disorders: The Diagnostic and Statistical Manual of Mental Disorders (“DSM”)characterizes female sexual disorders into three categories:Yes it is odd to characterize them as “Mental Disorders”, but this is the state of medicine and reflects the essential element of a woman’s perceived mental distress in experiencing them.

  1. Genitopelvic Pain/Penetration Disorder (GPPD)

Genitopelvic pain and penetration disorder (GPPD) is defined as difficulty in vaginal penetration, marked vulvovaginal or pelvic pain during penetration or attempt at penetration, (dyspareunia),fear or anxiety about pain in anticipation of, during, or after penetration, and tightening or tensing of the pelvic floor muscles during attempted penetration, (vaginismus). GPPD can occur at any time in a woman’s life cycle. Dyspareunia or painful intercourse, or pain on any vaginal penetration affects 50% of postmenopausal women.

Vulvodynia and Vestibulodynia:These two terms are often used interchangeably and therefore a source of confusion when reading articles about pain in the area of the entrance to the vagina, or vaginal vestibule.Vulvodyniais a condition of chronic vulvar pain anywhere in the vulvar area including at the entrance to the vagina (the vagina vestibule).Vestibulodynia, a subset of vulvodynia, is characterized by pain during attempted vaginal entry. Therefore, the pain is often “provoked” by an external stimulus (a finger or penile penetration, a tampon, a vibrator or other foreign object). It is then referred to as “provoked localized vestibulodynia” or the less specific terminology “provoked localized vulvodynia”. The location, constancy, and severity of the pain varies, but it is often described as burning, stinging, irritation, or rawness that is localized to the vulvar vestibule (the ring of tissue surrounding the vaginal opening). Often there is either defined points or diffuse areas of redness circumventing the lateral aspects of the vulvar vestibule. Qtip or cotton swab testing is used to differentiate between generalized and localized pain and delineate the specific areas of pain, their severity and characterize the quality of pain.Frequently the affected area is localized to the posterior forchette or the area located between 4 and 8 o’clock around the posterior hymenal ring.The prevalence of pain at the vulvar vestibule is relatively common. A study by the University of Michigan found that about 28% of women have experienced vulvar vestibular pain in the past, and about 8% had the pain in the last 6 months.[4]Reed, BD; Crawford, S; Couper, M; Cave, C (2004). "Pain at the vulvar vestibule: a web-based survey.". Journal of Lower Genital Tract Disease. 8 (1): 48–57. 15% of all women (pre- and post- menopausal) will experience provokedvestibulodynia at some point in their lifetime. For many women,Provoked vestibulodyniapain may occur outside the context of penetration or sexual intercourse. For example, during masturbation.

Genitourinary Syndrome of Menopause(GSM) is a common cause of GPPD in menopausal women. GSM is defined as a collection of symptoms and signs associated with a decrease in estrogen and other sexsteroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra and bladder. Thesyndrome may include but is not limited to genital symptoms of dryness, burning, and irritation; sexual symptoms of

lack of lubrication, discomfort or pain, and impaired function; and urinary symptoms of urgency, dysuria andrecurrent urinary tract infections. Vulvovaginal Atrophy (VVA)is part of the GSM and describes the clinical Vulvovaginal atrophy refers to the appearance, anatomical and physiological changes of the postmenopausal vulva andvagina secondary to a decrease in estrogen and other sex steroids. This can occur with natural menopause or with surgically induced menopause through the removal of the ovaries. There is thinning of the vulvovaginal epithelium and underlying supporting collagen. The appearance is pale vs pink. There is a loss of rugae or folds within the vagina and a loss of elasticity or stretch ability of the vagina. The skin of the vagina may tear or bleed with penetration. There is a lack of adequate lubrication of the vagina.The genital symptoms of vulvovaginal atrophy include: dryness, burning, and irritation; sexual symptoms oflack of lubrication, discomfort or pain, and impaired sexual function and decrease in quality of life.

In vulvovaginal atrophy, the vaginal pH becomes elevated. A vaginal pH greater than 5, in the absence of other causes such as infection or semenis typically considered an indication of vaginal atrophy. The vaginal maturation indexis a term used to indicate the percentage of surface cells from the upper one third of the vagina. It is typically expressed as percentages of each of three cells types (i.e. parabasal, intermediate and superficial cells). Premenopausal women with adequate estrogen levels have a maturation index of 40% to 70% intermediate cells, 30% to 60% superficial cells,and substantially no parabasal cells (<1%). In vulvovaginal atrophy the vaginal maturation index typically with the majority of cells being basal cells, some intermediate cells and few superficial cells.

  1. Sexual Interest/Arousal Disorder (SIAD)

Sexual Interest and Arousal Disorder(SIAD)is defined in the DSM as “the persistent or recurrent inability to attain or to maintain sufficient sexual excitement which causes personal distress.” In addition to absent or decreased sexual interest, including erotic thoughts or fantasies, there are four criteria that are taken into account to determine whether a woman suffers from SIAD. A woman has SIAD if she experiences personal distress caused by a decrease or lack of at least three of the following four criteria: 1). Initiation of sexual activity or responsiveness to a partner’s attempts to initiate it. 2). Excitement and pleasure. 3). Response to sexual clues and 4). Sensations during sexual activity whether genital or non-genital. It may be expressed generally as lack of subjective excitement or lack of genital lubrication or swelling or other somatic responses.

  1. Female Orgasmic Disorder (FOD) Female Orgasmic Disorder (FOD) is defined in the DSM as the absence (anorgasmia), infrequency or delay of orgasm, and/or reduced intensity of said orgasm. Such orgasmic dysfunction may also occur when a woman has difficulty reaching orgasm, even when sexually aroused with sufficient sexual stimulation. Many women have difficulty reaching orgasm with a partner, or during masturbation, even after ample sexual stimulation. For many women, having unsatisfying orgasms, or taking longer than desirable to reach climax are common symptoms of FOD that lead to emotional distress. Female Orgasmic Disorder affects approximately one in three women.