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Normal vulvar findings
Features of hair-bearing skin on the labia majora are similar to the other non-genital areas of skin. Normal skin is smooth, slightly pigmented, covered by hair and contains skin appendages which are sometimes clearly visible.
Normal mucosa of labia minor and vestibulum is smooth and pink in childhood, whereas extensive or localized micropapillary or villiform pattern is seen in reproductive age. Numerous rugae and papillae are present in the labia minora and near hymenal ring. These occasionally fuse and coalesce and can be misinterpreted as representing human papilloma virus infection. The skin of labia minora may be pigmented, the pigmentation becoming obvious during adolescence. Smooth, white or yellow papules, 1-2 mm in size, may be present especially in upper, inner parts of labia majora as well as in labia minora. These tiny elevations are referred to as Fordyce spots and represent normal sebaceous glands which in this area open directly to surface, while in hair bearing areas they open to hair follicle. Openings of small vestibular glands can also be seen sometimes.
After the menopause, in the absence of estrogen, the vulvar skin becomes pale, thin and dry, resulting in pruritus and general irritation. After the application of acetic acid it whitens. This is associated with a thinning of labial hair due to loss of follicles with increasing age and reduction of pigmentation.
It is important to study the "normal conditions" of the vulva, because mild vulvar changes are a classical example of conditions which are often "over-treated".
Normal colposcopical appearance of vulva include:
1. Aceto-white areas
Following the application of acetic acid, variable extent of aceto-whiteness develops proximally of Heart's line (the border of nonkeratinized vestibular epithelium and thin keratinized epithelium of labia minor). Usually it spreads a few millimeters lateral to vulvo-vaginal line on the medial aspect of labia minora, but does not extend to fourchette. Vulvo-vaginal line is defined by the presence of hymen or its remnants. At that point, going upwards begins glycogen rich, nonkeratinized vaginal epithelium.
The characteristic appearance of this aceto-white area has the shape of a horse-shoe. It is not associable with HPV infection but represents a variant of normal epithelium, possibly caused by constant scratching and rubbing. Usually, it does not have clinical significance. At present time the degree of aceto-whitness in its relationship to vulvar disorders has not been properly determined. In any case, if the intensive aceto-whitness is present, the examination and, if necessary, biopsy should exclude HPV and VIN changes particularly if the lesion extends to vaginal epithelium.
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2. Physiological hyperplasia (Vestibullar papillomatosis)
Vestibullar papillomatosis was first described nearly two decades ago. At that time the condition was thought to be infrequent showing the prevalence of 1%. Today these changes can be seen more often. Other names for this condition include pseudocondylomatosis, pruritic squamous papillomatosis, benign squamous papillomatosis, hirsutes papillares vulvae, vestibular micropapillomatosis and others. There is no general agreement in terms of etiology of vestibular papillomatosis. In the beginning it was considered normal anatomic variant. Later, the changes were ascribed to HPV infection, because of their similarity to HPV infection or even VIN. However, numerous studies did not confirm the relationship between vestibular papilomatosis and the presence of HPV infection. It was shown than HPV DNA was detected in only 6.9% of such cases, which is equal to the prevalence of HPV DNA in women with normal vulvar mucosa. The prevalence of HPV infection in these lesions is too low to be considered causal.
Vestubular papillae are small excrescences, quite regularly and symmetrically distributed over the vestibular mucosa. Sometimes their distribution is linear along the inner surface of labia minora, vestibulum and fourchette. In sexually active women they can be more spread entirely surrounding vestibulum. They are in essence projections of connective tissue covered by a normal epithelium.
In majority of cases they are occasional finding and simptomless, but some patients do complain to pruritus, vulvodynia, superficial dyspareunia or postcoital irritation. More often they are noticed in patients taking oral contraceptives, but they also can be seen in girls who never had sexual intercourse.
Vestibular papillae present as numerous, smooth, white, soft finger-like projections which can be several millimeters long. Therefore the area where they are present looks pearly. Sometimes they can extend to 6-8 mm. These papillae can be distinguished from HPV induced lesions on the basis of its regular shape and distribution, uniform color, soft consistency and lack of tendency to fuse.
Follow up of patients with vestibular papillomatosis, for more than 18 months showed that the distribution and appearance of these papillae remained unchanged, as well as that the male partners did not show HPV related lesions. Despite of the discord concerning the etiology of vestibular papilomatosis, when treatment is concerned all authors agree that patients with symmetrically distributed, vestibular papillae that exist for long time should not be treated, but observed.
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