12 - Labial Concerns in Adolescents

Dr. Vrunda Patel, a PAG physician at Nemours Children's Hospital in Wilmington, Delaware, and Dr. Camille Imbo PGY6 PAG fellow discuss the increasing trend of teenage patients seeking evaluation for labial concerns, often driven by appearance rather than medical issues. Many teens and parents lack understanding about what constitutes normal genital appearance.

Outline

• Normal Vulvar Development in Puberty
• Common Labial Concerns and Influences
• Defining Labial Hypertrophy and Asymmetry
• Psychological Aspects and Assessment
• Treatment Options and Self-Care
• Surgical Considerations and Recovery

Reference

NASPAG Essentials of Pediatric and Adolescent Gynecology: Chapter 16

Labial Anatomy Concerns in the Adolescent - JPAG 

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What is PAG?
Pediatric and Adolescent Gynecology is a subspecialty of OBGYN (2 year fellowship) focusing on reproductive healthcare for children and young adults. It fills the overlap between general gynecologists and pediatricians. It is a multi-disciplinary field involving work with pediatric endocrinology, dermatology, hematology, surgery, ect. Go to NASPAG.org for more PAG educational resources.

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Chapters

• 0:00 Introducing the Case Study
• 2:00 Normal Vulvar Development in Puberty
• 3:44 Common Labial Concerns and Influences
• 5:41 Defining Labial Hypertrophy and Asymmetry
• 9:11 Psychological Aspects and Assessment
• 14:34 Treatment Options and Self-Care
• 19:40 Surgical Considerations and Recovery
• 25:00 Addressing the Case and Conclusion

Transcript

Camille: 0:24

A 14-year-old cis female comes to the clinic with her mom with labial concerns. Her mom is very vocal with concerns that her daughter's genitals do not look like her two sisters' genitals. The patient reports that she thinks her genitals are larger than others, but denies any pain or physical issues and wonders what we can do about it. Hi everyone and welcome to PAG Over Pastries, a 20 to 30 minute review podcast regarding all things pediatric and adolescent gynecology. I'm Dr Camille Imbo, a second year PAG fellow at Phoenix Children's Hospital, and today we have I'm Dr Vrunda Patel.

Vrunda: 0:57

I'm one of the pediatric and adolescent gynecologists at Nemours Children's Hospital in Wilmington, Delaware.

Camille: 1:03

Great, we're so happy to have you here today. We'll be talking about adolescent labial concerns, which is one of those niche things that we do in PAG that's not often talked about in the general OBGYN world. We have two references. Today. We have the chapter 16 from the NASPAC book Essentials of Pediatric and Adolescent Gynecology this chapter written by Drs Lauren Damley and Rachel Casey, and then we also have an article, Labial Anatomy Concerns in the Adolescent, which was released by JPAG in 2023, written by Ashley Lawson and Julie Strickland. All right, so what's your favorite pastry?

Vrunda: 1:42

My favorite pastry is a coffee cake. It has to have the right like crumb to cake ratio. I want almost like 50-50. What about you? What do you like?

Camille: 1:49

My go-to is just always a croissant. I'm pretty basic, just a buttery croissant. Yeah, all right. Well, let's get started. Labial concerns, as I said, is kind of a pretty specific topic. It's one of those. You know. We've talked about puberty a lot on the podcast so far and people know about breast changes and the rest of the body, but the vulva is something people ignore. So what kind of changes do we usually see throughout puberty on the vulva?

Vrunda: 2:21

In terms of changes with puberty. You know, as a child, in terms of labia minora, those aren't well developed at that young age. So if you see a toddler in the office, you're not really seeing the labia minora. You're seeing the labia majora and as they start to enter into puberty later on, those labia minora start to elongate and even darken skin color as well. So those are some of the changes that we like to review that are normal to see as a child is growing and developing, which would look very different if you were to compare a 12 year old to a three year old in the office in terms of their anatomy.

Camille: 2:52

Right One, that's always a big thing. Right Understanding anatomy labia majora versus menorah, because parents be like what's this new thing that's growing? What's this?

Vrunda: 3:01

Yeah, and it's interesting because it's not just teenagers, but you're right, it's also moms bringing in their younger daughters, thinking that something's abnormal as they're starting to develop and because they're like I haven't seen this before, you know, when they were a little bit younger. Now it's all of a sudden seems new to them, but still very normal.

Camille: 3:17

Yeah, what kind of specific concerns do they usually bring up when it comes to the teenagers?

Vrunda: 3:23

I think it often stems from appearance of the labia and not that's abnormal, but it looks different to them, so it's not something that they weren't expecting to see. Sometimes they're also complaining about irritation or chafing, especially with activities or sports. I find the vast majority are kind of a mix between the two of either the appearance of the way that they look or they're coming in specifically with like actual symptoms related to the labia themselves, especially with activities.

Camille: 3:54

Right yeah, I think the biggest complaint is that they're too large. So one is that they identify that it's a labia, because the amount of times they say there's a mass growing or cyst.

Camille: 4:04

If it was the mom saying it, I'll bring her and like, point at it and then like, is this what you're talking about? Or a mirror for the patient? But definitely hypertrophy, and then every now and then it's that one is larger than the other, but then, like you said, sometimes it's just this generic. I don't like the way it looks, but fortunately oftentimes, if I ask enough questions, it's a new boyfriend or they just became sexually active and someone pointed that out to them, which that becomes a kind of a very different conversation.

Vrunda: 4:34

Oh, very, very different, yes, for sure, and I think that also kind of underscores some of the other trends that we've seen in terms like social media and just body appearance and even unfortunate exposure to pornography, where these roles come in kind of having this preconceived notion in their heads as to what their labia should look like, because it doesn't look like the same that they may have seen online. I do think that some of these things aren't just inherently to the patient but I think may be influenced by just the world that we unfortunately live in sometimes.

Camille: 5:04

So with that in mind. So let's start with labial hypertrophy. Is there any like criteria, or you know what numbers do we use to determine if it's actually abnormal?

Vrunda: 5:16

Yeah, so the hard thing with actual hypertrophy is that there's no great consensus guidelines here, and I think that's what's really challenging. When you're counseling a patient, you're seeing them in the office because you can't give them a hard and fast number to relate to. But I think most people tend to err on five centimeters or more. Yeah, but that's the hard thing is that there's no general concessions statement from any societies that I know of at least, that says, hey, this is what the normal anatomy in terms of size should be. And that's hard when we're when we're counseling patients, because they want kind of a number to hold on to and grab on to when they're talking to their gynecologist here.

Camille: 5:54

Yeah, and it's hard too because, as you mentioned earlier, symptoms, if they do have any, come into play as well, because I know with some they're not necessarily larger than five centimeters, but they're twisted on themselves and that causes pain, and so that is something to factor in if it's on the lower side. But yes, we definitely use greater than five centimeters as a harder cutoff to really show to the patient you're within normal range. And then what about asymmetry?

Vrunda: 6:24

In terms of asymmetry, there's definitely a wide, wide variation in terms of the occurrence and the shape as well of the labia, and so I often use a reference book in my office that I like to use, called Petals, by Nick Carris.

Vrunda: 6:37

There's a photographer who was able to take pictures of women's vulva and with their consent, of course and what I like about that book is that there's such a wide variation in terms of age for those women. But you can also tell that there's ethnic differences too, and I like to use that book primarily just to thumb through with my patients and their parent, if they're there with them, just to show them how different everyone's labia look Cause I think that the point of reference here is often very limited until you come into a gynecologist's office, right? So most of these patients have only seen their own, I'm assuming, unless they've been exposed in other ways, like online. But I think having this book of these pictures is helpful in terms of counseling because you can see, even when I flip through them I can say, oh, look like for this patient.

Camille: 7:19

You can see one side is a little bit smaller than the other side and there's never any sort of like what I call cookie cutter labia, like everyone looks very very different there, and I especially love it because I know there's a lot of patients where I'll go through and bookmark a few that look just like hers, so that it's not even just the like.

Camille: 7:37

Oh, generally speaking, there's all these variations there are many people who look exactly like yours, and then sometimes I take a step back of like. Not all the noses in your family look the same. Not everyone has the same ears. There's some parts of their bodies that are going to be slightly different and you know society might tell us oh, what type of nose is too big, too large, whatever, but doesn't mean it's abnormal and that kind of changes that.

Vrunda: 8:01

Right and I think for point of reference there like that's my favorite line to tell them too is that you know the labia are not an external part of your body that you're seeing visibly on every single person, versus if you lined up 10 people, you could point out probably really subtle differences in, like the way your ears are shaped or the way your nose is shaped, and you can point that out pretty easily because that's a very external part of your body versus this is not.

Camille: 8:23

The NASPAG book actually lists two websites there's the great wall of vulva. com and labialibrary. org, which I'll actually have to check out because I've only used the books before, so that'll be a really good resource to give people.

Vrunda: 8:37

I want to say one of those is actually artistic drawings of the vulva, which is also nice if you don't feel like you want to be as graphic as an actual photography book we talk about how much more often we see this in the PAG world compared to adults, I think.

Camille: 8:51

just because it's such a higher frequency, it seems like every other teenager is concerned, but there's actually really no data on this. It is on the rise, which, with social media and everything else, that's definitely expected. The only data we have is on the amount of labial plasties that have been performed. So between 2016 to 2019,. 18.9% of them in the US were performed on patients younger than 18, which we know. You know, performing labial plasties in the first place is something we try to avoid, but even more so, I know, with parents. Even if it is mildly abnormal, they're presenting at 12, 14. Yeah, yeah, what's not going to happen for a few years, right?

Vrunda: 9:37

Oh, yeah, for sure, and I think for that, those ages, I think it's also important to prioritize that the labia will still continue to kind of grow and develop. Now, that doesn't mean that they're going to exponentially continue to grow throughout adolescence, but there's still some remodeling that's going to be happening. And the other point I like to bring up is that we don't even truly know in terms of research how much like sexual function comes from labia as well. So we don't want to have a form surgery at these young ages that could potentially impact sexual function and well-being for the future too.

Camille: 10:07

Part of it. You know we talk a lot about the appearance but there's the symptoms as well. That makes it a little bit harder to argue against. What kind of symptoms have you seen most commonly that kind of pushed you towards okay, maybe they didn't have the labiaplasty I've had one patient who was a horseback rider.

Vrunda: 10:24

It was really hindering her performance. She was saying that her labia felt like they were chafing and she had tried all of the hygiene measures that we always discuss and hers were larger than the hypertrophy side of the, we'd say, of the five centimeters. So I thought that was pretty validated. You know, I think it's hard, though, when we talk to patients and kind of try to tease out what truly is a medical symptom versus is there still a medical symptom? But is there also this component of this like psychological symptom of the actual appearance that may be also factoring, and it's hard to always tease out those two. I think that gets trickier. And so for those patients, I think having an established relationship, so like it's not like you saw them for once and then you're like let's go straight to the OR next week, I think bringing them back and kind of talking it through and making sure it's a well thought out decision and once again you're doing it from a medical standpoint, not a cosmetic or appearance standpoint is really really important here.

Camille: 11:22

And you mentioned that it's psychological to some degree, which is such a good point, because I think of everything else that we do, whether you know things like eating disorders, things like that, where it has that line of, oh, is this medical versus psychological, medical versus psychological? We tend to work with psych. Now that I think about it, this is not one of those situations, at least that we do. Do you ever have psych or therapy involved? You know it's a good question. I don't think.

Vrunda: 11:46

I've ever referred someone specifically for this indication to like a therapist or psychologist, but I do think that brings up a good tool that potentially we could try to do. The review article has a few questions that they actually emphasize in terms of taking a focused history and trying to tease out is there any other symptoms of potentially an underlying body dysmorphia? So they mentioned questions like you know. Are you concerned about how you look, yes or no? And if it's yes, do you think about your appearance problems a lot and do you wish you could actually think about them less? Is your main concern with how you look, that you aren't thin enough or they might get too fat? How has this been a problem with how you look affected your life? Has it upset you a lot? Has it gotten in the way of doing things with friends, dating, your relationships with people? And then also specifically about the labia they mentioned.

Vrunda: 12:32

You know things like when you're questioning a patient saying some patients haven't noticed that their labia until someone else made a comment. Was there someone that has made you feel self-conscious, such as a parent, partner or clinician? Do you fear that someone may make comments about your body? Are there certain scenarios that specifically bring this distress, such as wearing certain clothes like leggings or swimsuits, changing in front of others, such as in a locker room, or intimacy with a partner. So I think those are good questions to sort of think about when we're getting these histories with these patients. In today's day and age, I think that there is some of the psychological components that are getting factored in too for these young women, unfortunately.

Camille: 13:10

Yes, absolutely. Now I would say probably the big two, as if they're experiencing pain. So, whether it's twisting on itself or there's hair getting caught in it, or during activities like you mentioned, especially if they're in an extracurricular where they're always in tight clothes, leotards, things like that, at this point this is one of those where the exam is what's going to tell us the most right, and we on this podcast talk about confidentiality and consent and all that. So much. Is there anything specific for labial concerns that you add to how you go about doing this beyond the usual positioning and mirrors and all of that?

Vrunda: 13:53

I think asking the patient before you even get started with who they feel comfortable having in the room with them. Sometimes I find that there's a discord between the patient's priorities for the visit and the parent, and sometimes it feels like it's a parent driven exam, and so I often will ask the patient if they feel comfortable having their parent in the room and if they want them to step out. I will bring one of our nurse chaperones in with me, of course, to have as a chaperone for the exam. I tend to do this exam in a stirrup position. I just think it's easier to assess the labia. I don't use mirrors as often, but I will often ask the patient if they feel comfortable if we need to take a picture for any reasons for photo documentation.

Camille: 14:43

And I often will have a small tape measure to get some measurements so I can write some of that down in my exam findings, in my chart too afterwards.

Camille: 14:45

And that was something that I had to learn of specifically what we're measuring and how, and so kind of stretching out the labial menorah towards you and we're measuring from the largest width inside to outside, so it's not a length up and down or diagonal or anything like that. So that's very important. Depending on who brought up the issue, I'll ask if kind of them showing me what their concern is right, because I think if I just go in there and look and say, oh, it's normal, that's not going to end that conversation. So I've gone through your exam. So what is the differential diagnosis of medical concerns?

Vrunda: 15:21

For pain. The condition that really sticks out to me would be like vulvodynia right. So for that exam we're likely using a Q-tip and palpating along the vulva and seeing if there's any points that bring up more tenderness for the patient than others. For the other symptoms that patients often bring up in terms like the chafing or the irritation, you may see some erythema or some redness on the exam, but I think that that's more frictional chafing or irritation versus like an actual underlying condition. It's not always based on the size of labia, leading to either. And then of course there's other disorders in which there may be unlikely but there could be masses that are in the labial fold. In younger patients we see KOM syndrome, which is that childhood asymmetric enlargement of the labia majora, but we don't tend to see that with teenagers.

Camille: 16:07

With KOM, because I don't know that I've seen it that much, because I usually have teenagers presenting. What timeline do you give them of it's going to self-resolve?

Vrunda: 16:16

Yeah, I've seen them in younger girls and so it's funny because I feel like I've seen them as a one-time deal and I say, come back when they get to puberty. And I don't know if they've ever ever truly come back, usually because they've gotten better on their own. I mean, that's the assumption.

Camille: 16:38

And I'd venture a guess, say that they're improving on their own by puberty. You know we're focusing on labia, but of course, pointing out that we're also going to look at the clitoris and make sure that the clitoromegaly, going down the road of hyperendocrinism and all of that which we'll talk about in a separate podcast as well. Based on that, if there is some mild abnormality but it's not officially diagnosable, so to speak, what kind of strategies do you use to tell them about management?

Vrunda: 17:05

Yeah, I think some hygiene measures here are really helpful, and the biggest one I'd say is barrier ointments, because, like I said, I think shaving is really one of their biggest concerns, and so any sort of barrier ointment, whether that's Vaseline, eucerin, aquaphor. I've even had patients use coconut oil, applying that often, even twice in a day, or at least before any sports that they're engaging in. I think that's really helpful. Some patients may also choose to wear more tighter fitting underwear, like or biker shorts that gives them a little bit of a breathing room as well to help kind of keep the labia in place, to prevent that from happening, can help as well. And then in terms of menstrual disorders, you know, if they're having issues in terms of using, like pads, even tampons, I think that brings up another opportunity to discuss menstrual management with hormonal medications to potentially alleviate the need for some of those products too actually alleviate the need for some of those products too.

Camille: 17:56

Hygiene, especially because on one hand, we make it very clear to patients you don't clean the vagina. Nothing in there, self-cleaning, but then I think some don't well, a lot actually don't understand the difference between the vagina and the vulva. Yes, that area still needs to be cleaned, and especially if it's slightly larger that you kind of need to get in between the folds and all that, because then you could be at higher risk of developing infections, and then that adds to the shaping combined with a barrier method.

Vrunda: 18:20

Even like hair removal as well, because I like to often talk to our teenagers about hair removal and like safe practices for hair removal too. So if they're going to use a razor blade, to always use a fresh razor blade. I'm more of an advocate for like electric trimmers that are used in that area just to help prevent the risk for infections.

Camille: 18:41

Yeah, and I'm glad you bring that up, because I don't really feel like there's any other topic where that'll come up, and I've had to have that conversation more with teenagers than with adults. But yes, the new razor. And then I tell them about shaving in the direction of the hair and opposite, like you typically do.

Camille: 18:52

Yeah, electric shavers, because trying to avoid the cuts on the skin, which is the risk, and then trying to do it, whether like in the shower or after using warm water to soften the hair, are a few little things that I think are helpful yeah, I've seen some pretty nasty labial abscesses after unfortunate shaving incident. And so we try to avoid surgery at all costs, but of course some do need it. So A, what makes you officially call it? And then, what are your methods?

Vrunda: 19:21

It's hard to say a true number, but if you were going to put me to like a peg and ask for what, that number would be probably around five centimeters or larger. For technique there's a couple of described techniques in the literature. You know. There's the wedge technique in which you're actually taking a wedge of tissue out of the labia and then suturing those two free edges back together. I don't tend to perform that technique just because I'm worried more about skin breakdown and wound healing there and so I am more likely to do a trimming of that excess tissue and I like to just clamp that tissue, to kind of devascularize the tissue, then cut along that devascularized edge and then over-sew with interrupted sutures and usually for those patients we will obviously tell them to when they go home to really have nothing in that area in terms of like tampon use or intercourse, obviously just because we are worried about potential wound breakdown.

Camille: 20:16

Do you only use absorbable sutures or do you ever put non-absorbable on the outside to remove later?

Vrunda: 20:22

No, I only use absorbable yeah.

Camille: 20:25

Yeah, I'd say 99% of the time we do. But then we've had some labia that are so thin that don't seem to want to ever stay together, and so we've had to very rarely put. Are so thin that don't seem to want to ever stay together, and so we've had to very rarely put in like one or two sits on the outside. It's definitely a painstaking surgery. The suturing it back up takes a lot longer than anything else, especially because you're putting an interrupted right.

Vrunda: 20:48

You're not running that stitch just in case that there is wound breakdown. You want to be able to kind of save the rest of that tissue.

Camille: 20:54

Especially for those gals who genuinely had abnormalities. We had one patient greater than 10 centimeters where her quality of life was night and day healing. And when you looked at it after, it looked like nothing had happened, which was incredible. So definitely it's something we try to avoid, but for the ones who really need it, it's absolutely wonderful.

Vrunda: 21:17

I'm sure she was very grateful to you and your team.

Camille: 21:21

Poor thing, absolutely. What do you tell them about recovery and long-term expectations, complications?

Vrunda: 21:28

So I think in the immediate post-op period there is a higher risk for infections, for bleeding, for hematoma formations, wound breakdowns.

Vrunda: 21:37

So you really want to emphasize pelvic rest, Of course, avoid any sports activities if they've been doing, if they've been participating in those. For the pain management, we can give them some topical lidocaine to go home with. So we often will use some topical lidocaine at the end of the case but then save that for the patient to go home with. So we often will use some topical lidocaine at the end of the case but then save that for the patient to go home with. But for long-term management, you know we'd like to see these kids back in a couple of weeks, first for their post-op appointment and see how that wound is, looking at that point, but still knowing that there'll be still some remodeling that takes place over the next few weeks as those sutures start to dissolve and that tissue heals further. And I think it's important to emphasize that doing this, although we're not doing it for cosmetic reasons, it may still look very different than what they were looking at before and so not expecting to come back again for another surgery.

Camille: 22:24

That way. Pain is another big one, which is part of the warnings I get before even doing the surgery, of realizing you're trying to heal a place that has a lot of friction. You sit, you walk, all of that and then the risk of dehiscence and everything. It's just the healing. In general, when putting it together, we try to stay in that middle of enough blood flow so that it heals and not so tight that it dehisses. But then you don't want so much blood flow that it bleeds so easily.

Vrunda: 22:53

Exactly, and that's a very vascular area. So it's got the potential for a hematoma formation, which is the last thing you want to see after a surgery like this, which knock on wood. I haven't seen that from this type of surgery, but you know, hopefully not.

Camille: 23:08

Between ACOG and the Society of OBGYNs in Canada. Both discourage surgery in adolescents, unless one that it's mature, so that there's not that risk of, like you said, it grows more and they come back wanting more surgery and that there's a persistent functional impairment documented. So again same thing, where it's usually not going to be the first visit unless, like that one patient we had that had greater than 10 centimeters, where it's like okay, we can all very clearly see how this is affecting your life.

Vrunda: 23:37

I think sometimes parents come in really expecting that you're just going to say, oh yeah, great, let's, let's set you up for the OR next week and let's get going. And so I think it's really important to emphasize that this can be considered even like a form of general mutilation in some states, and there's some pretty strict state laws that are out there, especially for surgery and minors that could be easily seen as cosmetic, and so I think that's a really fine line that we need to balance, and so I often will even use that article to show parents like how of a overwhelming statement that ECOG has made about this in the past.

Camille: 24:11

Absolutely. And I line I use if someone just can't be reasoned with is even if I wanted to, I ethically, legally can't. So at this point it's not a me problem, it's not a second opinion problem. This is the law, all right? Well, I think that about covers everything regarding legal concerns, right? You think we're good to go back to our case?

Vrunda: 24:35

Sure, let's do it.

Camille: 24:36

We had a 14-year-old cis female who came to the clinic with her mom with labial concerns, and her mom was the one who was very vocal about her daughter's genitals not looking like her other two sisters' genitals and reporting that they thought they were larger than others, but not experiencing any pain or physical issues. So how would we approach this patient?

Vrunda: 25:00

For this mom specifically, I think bringing up that perspective again right. So her comparison right now is her two other daughters, but I think, emphasizing to the parent and to the child that everyone looks very different in this region and, just like I said, this is an internal part of your body that not everyone sees, so you don't have much of perspective on how different everyone looks by using some of the tools that we mentioned. You know, the pedals book, the online websites that are up there too, to help bring perspective to the patient and her parent, to show the wide variation in anatomy, is really helpful, and the fact that she's not having any pains or any sort of irritation is great. So I think reassurance here is the biggest takeaway for them and for the most part, I think that most of those patients leave feeling empowered. I always emphasize that they can always come back at any point right, even as they get older, if they feel like there's things are changing or if there's any continued persistence of symptomatology here.

Camille: 25:54

Tag in general. Sometimes the patient will just be there and you know mom or dad is running the conversation. So in something like this, where the patient themselves had no concerns but they're being told there's a concern, it's really nice to be able to give them a voice of if you're okay, there's no way anyone's going to be operating on you against your consent. Like, right, you can't sign consent, you can still ascend to say it Exactly and then, especially at 14, explaining that they'll grow and how things change Awesome. Well, this was a really great conversation about a niche but important topic, especially with it on the rise.

Camille: 26:34

So thank you for listening to Packover Pastries. This podcast will be posted on our website, which you can access through NASPAC. There will be a transcript as well as links to both references where you can then go and see any tables that we referred to. If you don't mind, we also are doing a survey to see who our listeners are for research purposes and see how we can continue to grow our podcast. If you have any questions, concerns or feedback, you can email us at pagorapastries at gmailcom, but otherwise, that is it for today. Thank you, dr Patel. Great Thanks for having me.