E34: 7 Domains of the Vulva

Before we get going, this women's health podcast is a discussion about female genital anatomy from the view of the "7 Domains of Women's Health." It may not be appropriate for all listeners. And if this is not your cup of tea, come back and join us for another podcast or another topic in women's health on the "7 Domains of Women's Health."

Some years ago, the play "The Vagina Monologues" swept city stages and college campuses across the country. "The Vagina Monologues" was really about the personal and cultural issues around the vulva and people who have one. But they couldn't even use that word. They used the word vagina, and it wasn't really about the vagina at all.

I admit, as a gynecologist sitting in the audience with my husband and my son, that all that frank, painful, and joyful, and funny discussion about the joys and pains of the vulva made me a little uneasy. Well, it made me a lot uneasy.

Now, men give cute names to their body parts that are the male equivalent of vulvar tissue, as if their men's body parts had their own personalities. Well, maybe they do. I don't know. But men also have given disgusting slang words for women's body parts.

We women need to have our own name for our vulva, like vulva. But women can be uncomfortable using the proper word for this body area, and maybe they call it their lady bits. But it's hard to talk about, and that means women with problems are less likely to seek care.

So, today, we're going to talk about the vulva through the lenses of the "7 Domains of Women's Health." And Dr. Camille Moreno is in our virtual Scope studio to help us talk about this personal place. See, I didn't use the word vulva.

Dr. Moreno received broad training in family medicine when she discovered a deep interest in women's midlife health. And so she pursued a women's health fellowship that focused on midlife health issues. She's an assistant professor in the department of OB-GYN and is medical director of the Menopause and Midlife Women's Health Clinic program here at the University of Utah.

Dr. Jones: So welcome to the "7 Domains," Camille. We're going to talk about the vulva.

Dr. Moreno: Ready.

Dr. Jones: So tell me, tell us all, where is it? Where is this body part?

Dr. Moreno: Yes. So that is the number one question here. The vulva is the external female genital area. It is the outside, so the skin outside of the vagina. And the vulva holds several, actually, structures, including our inner and outer lips that are also found outside the vagina. We call that the labia minora and labia majora. So minora being the inner lips or the folds, and majora being the outer lips and the folds.

And we also know that the clitoris is not located inside the vagina. It's located outside. This is at the front part of the vulva. And this is sitting right at the top of the vaginal opening, which is also in the vulva.

Dr. Jones: Right. And so the skin that covers this area is delicate. I mean, it's not quite exactly like skin that's on our arms, but it is kind of like that skin. Well, the labia majora has hair like our arms, but the inner parts is delicate.

Dr. Moreno: Absolutely. You are right. There are different types of cells that make up the vulva, so on the outside skin as well as the vagina, so the inside. And these are made of what we call keratinized and non-keratinized cells. Really, all that means is that these cells contain a specific type of protein called keratin.

And you may actually have seen this on shampoo labeling and shampoo bottles. What it is for the vulva, keratin provides the structural support for the vulva as well as the structures that it contains.

Dr. Jones: Compared to the skin that's on our face or on our arms, the inner skin, and that includes the clitoris and the labia minora, the smaller lips, they actually respond to hormones to some degree.

Dr. Moreno: That is correct. There are what we call receptors all over that vulva, so on the outside skin as well as on the clitoris, and believe it or not, even the bladder, specifically the base of the bladder and the urethra where urine comes from. The receptors are targeted receptors for estrogen and testosterone, what we call androgen receptors. And these are your female hormones that are produced by your ovaries.

Dr. Jones: So that means when little girls are born . . . So when we're developing in utero, I've always reminded women, which is not exactly true, but that women are the default mode. You have to take tissue and do something to it to make it look like a boy. And if you don't do that, then you have tissue that looks like a girl.

But that little girl vulva, it changes from the time a baby is born, because a baby's had all the mom's hormones, right? And so a baby's vulva looks different than a 3-year-old's vulva.

Dr. Moreno: Exactly. Yep. And it starts at birth, really, where the vulva exhibits the effects of residual maternal estrogen. And so that is how the vulva is formed eventually as time goes on and as the child goes through adolescence and puberty, which is really that time of maturation.

The time of maturation really is in response to the production of your sex steroid hormones, like what I mentioned earlier, estrogen and testosterone, which are not only produced by your ovaries, but your adrenal glands also play a significant role. These are your glands and organs specifically that sit on top of the kidneys.

And so what estrogen does is that as we go through puberty well into our adolescent years, estrogen increases and maintains blood flow to the vagina and the vulva tissues. It also increases collagen production, and this provides the support as well.

We also need to moisturize these areas. We don't want them to be dry. And so there's also a role of estrogen in increasing hyaluronic acid production. And also most importantly is that estrogen maintains a healthy environment for the good bacteria that live in the vagina. And so it keeps that vaginal pH nice and acidic.

Dr. Jones: Well, going back to development, if you take these tissues that are going to grow up to be a little girl's vulva and her clitoris, and you then give it testosterone because you're going to make a boy baby, it turns out that the vulvar folds that are the labia become scrotum, which is subsequently where the testicles will land, and the clitoris grows to be longer and it becomes a penis. So we have these tissues that are just waiting for the signal from either an ovary or a testis to do their thing.

And at puberty, when women start growing a little bit more male hormones in their adrenal glands and their ovaries, that makes the hair because there's a little bit of hair on the labia majora, and that requires testosterone to have that.

We've got these hormones. So it's skin tissue, but it's uniquely special skin tissue that does some really amazing things. But sometimes, it's the center many people believe . . . or a center, we should say a center, for women's sexual response. So it can be engorged with blood during sexual pleasure. So it's a pretty active place.

So this is all going on without us paying much attention to it as we go through puberty. We grow some hair and we decide we're going to keep it or not keep it. That's a topic for another domain.

But things happen sometimes in terms of problems, meaning sometimes people have a problem with their vulva, and they don't know what it is, and it's kind of hard to see. I mean, you can try squatting and looking in a mirror. But all they know is something doesn't feel right. So what kind of problems can you have down there at the vulva?

Dr. Moreno: Yes. And so, these problems, I tend to categorize into different buckets, and one being there can be infectious causes causing issues of the skin of the vulva. It can also be related to an allergen or an exposure to that causing an irritation of the skin of the vulva. It could also be related to inflammation, whether it's related to an autoimmune disease or if it runs in families. That could also cause problems, especially in menopausal and midlife women.

And also, since we mentioned there are different hormone receptors that are located in the vulva, there are also deficiencies in hormones that affect the vulva, which is also predominantly in menopause.

The badness that we don't ever want to think about, but we do, is related to, you know, issues with cancer or malignancy of the vulva, which can also happen in rare cases.

Dr. Jones: So we have lumps and bumps and itches, and if you can actually see, there might be rashes or hurts. So you can have lumps and bumps that hurt or don't hurt. You can have bumps that hurt like a follicle or an infection down in your vulva in the hair follicles, or there are some glands that kind of open at the opening of the vagina that can get infected.

Dr. Moreno: Yeah, the lumps or bumps that are related to a bacterial infection could be an infection of the hair follicle, so those hairs that grow on the labia majora and the labia minora, so the folds outside the vagina. And these can be red and they can also increase and grow in size, and really mostly due to shaving, waxing, or from any type of friction down there.

Dr. Jones: Bicycle riding.

Dr. Moreno: Exactly.

Dr. Jones: Being on the bike.

Dr. Moreno: Yes. And for long periods of time, like long distance biking. And if these bumps don't go away, then they could get bigger. Unfortunately, you would have to see your primary care physician or gynecologist to evaluate, to get this treated in the office.

Dr. Jones: And then there are infections. Yeast infections actually arise more in the vagina, although it can be on the vulva. But it's the vulva that gets your attention, right?

Dr. Moreno: Absolutely.

Dr. Jones: The vagina doesn't have much sensation, really. And so the vulva can be very uncomfortable with itching and burning, and it brings your attention.

Dr. Moreno: That's correct. And unfortunately, about 75% of women will have a yeast infection at least once in their lives, and they present with very debilitating symptoms. There's a lot of redness, there's a lot of scratching going on, and just wearing of the skin of the vulva.

Dr. Jones: And then there's herpes, herpes simplex, which is a viral infection that can cause an ulcer that can be very painful. We've talked a little bit about dermatitis, meaning it's skin, and it's delicate skin. So if you're putting lotions or potions or things that cause an irritation of that skin, that can also cause a problem.

Dr. Moreno: That's correct. Yeah. And this can cause not just extreme itching, but also stinging, burning on that skin. Women describe it as just feeling very raw down there. And whether it's because of an exposure to scented toilet paper that they accidentally use or maybe perfumed soap or detergent, that's typically a culprit. Or if they're truly allergic to it, that can present with similar symptoms as well.

Dr. Jones: When I think about all the kinds of lotions, potions that people have in their shower for their hair, they have three different kinds of products. And you put it on your hair, but who knows where else it can go? Or you think, "I'm just going to put it on all my hairs," and you find that you've provided an irritant to your vulva.

Dr. Moreno: And that is why I do let women know that the vagina and the vulva are really self-cleansing organs. They don't really need to be cleaned. You can just run water over the vulva and not use anything inside to clean it out because it does clean itself.

Dr. Jones: Yeah. We were taught that soaps really can be a problem for women's vulva, and just use water. And gentle, not too hot, not too cold.

Well, we talked a little bit about irritations and infections, but there also can be cancers in this area as well.

Dr. Moreno: Yes. And we refer to that as vulvar cancer, which is the fourth most common gynecological cancer in the U.S. And women have about a 0.3% chance of getting vulvar cancers in their lifetime. So these are issues where you have perhaps a painful sore down there that is not healing or getting any better, and it doesn't look good or doesn't look like your normal skin when you're actually looking.

Dr. Jones: If you can see it.

Dr. Moreno: Exactly. Yeah, that's correct.

Dr. Jones: Or if somebody's looking for you. For a lot of ladies, no one is looking down there, and they can't see very well. Or they're just too embarrassed to look.

Dr. Moreno: That is true. And really the only way we can tell if it's cancer or not, cancer or normal skin, is with a biopsy that's done typically in the clinic setting where we take a sample of tissue and that will confirm the diagnosis.

Dr. Jones: Well, I've had a number of women who come from rural communities who maybe their primary care doc is somebody that they know, maybe it's their neighbor, and they have an area that's itching and burning. They think it's a yeast infection, and they call in and the doctor just gives them a yeast medicine without looking.

And this goes on for some time, months, years, and then it was really a cancer. But they were just too modest to say, "You need to look at this."

And it always makes me sad because if it had been somewhere on their face or their arm, it would've had attention early and would've been fixed. That's always difficult.

And then there are people who have vulvar pain. It's not itching or burning, or it could be, but for no particularly good reasons, they just have pain.

Dr. Moreno: Yeah, and this is pain that is typically felt over the vulva itself or in certain areas of the vulva, such as the opening to the vagina. We call that the vestibule. And there could be lots of different causes of this pain. But how women typically describe it is the pain is provoked by touch, such as inserting a tampon or with intercourse, with initial penetration, or even wearing tight clothing or snug underwear.

Dr. Jones: Well, this problem of having something happen down there and not being able to see it, being afraid to ask someone else to look, wanting the privacy that may not be afforded in your clinical care because everybody knows your business in your town, this leads to really emotional consequences.

This is a part of our body that gives both joy and sorrow and pleasure. And then should we be having pleasure? It's a private place and we barely ever use the words. And women may feel hesitant to bring the issues to the clinician because just talking about it builds up feelings of fear or shame.

When you think about the women who've come to see you, tell me a little bit about the emotional and sexual concerns of vulvar disorders that you see in the emotional domain.

Dr. Moreno: Yeah, and this is the tough part of my job, because I do hear these really sad stories about relationships that are not going well because of these disorders. Women develop negative feelings and distress about their bodies, and that may be because when they are looking, they're seeing that there might be scarring or tissues joining together in areas where they shouldn't be joining together.

It could look a little more pale than their tissues on other areas of the body. And when they do attempt to become intimate with their partner or significant other, they are not as sexually stimulated, and they feel more dry down there.

And how actually a patient has described it to me before is, "I just feel dead down there. I'm turning into a prune and I don't know why."

And so that is very hard for me to listen to, to be able to hear these stories. I do want to let them know that they are not alone. Unfortunately, because of the hormonal fluctuations and then the deficiencies that do occur in menopause, estrogen plays a major role and causes some thinning and paleness of the tissues, causing sex to not be as comfortable as before.

Dr. Jones: And I think that areas of the body that we're used to looking at and showing in public, we can have problems there, but almost anything that has to do with our vulva has some emotional overtone. It takes a truly emancipated and self-confident woman to have a vulvar issue, whether it's pain or sorrow or joy or not, and not have some overtone of emotional overlay with it.

For a lot of women, they were abused emotionally or physically as children, and so any kind of problem with their vulva or touching just brings up all the fear and the shame of what happened when they were little kidlets.

I think it's hard and we just don't know exactly what we should be doing. And I think there's also a fair amount of stuff that's sold to women there, that vulvas are supposed to look a certain way. And then women who like to have tattoos.

So we're going to move to the social domain, because I think when it comes to cosmetic stuff or things that you might do to your vulva, I think there are some social pressures there. I'm not sure that women, if they grew up in the wild, would really just have to have a tattoo down there or a piercing or surgery on their vulva.

But I think there are social norms about what people think their vulva should look like. And they look at theirs and they say, "Gosh, it doesn't look like what I saw on the internet and I want mine changed." Have you had people request that?

Dr. Moreno: So, in my practice, I have seen cases where they've noticed that part of the vulva or the outer lip is hanging or may not look the same size as the other flap of skin on the other side of the vulva, and they want to learn more about repairs and surgeries that could make them smaller or trim them and make them look a little bit more symmetric. So I have had those questions asked.

How I look at this and how I go through this conversation with them is there are reconstructive surgeries where you would do the surgery or you would do the repair to improve the function of the body part because it is a debilitating issue. Or it could also be more for cosmetic reasons where you're doing the surgery because of the aesthetics or the appearance of it, when really essentially the anatomy looks normal and it's not really causing any issues. There's a big difference between the two.

Dr. Jones: Well, the idea of normal in terms of the labia majora and minora, there's a huge range of normal. But certainly I've had adolescents who had very large labia minora, but they were being athletes, or if they were bicycling or inserting tampons, there would be enough that it would get caught up. And for those adolescents, it's certainly a reason to think about a labial reduction.

And then there are people who say, "I just don't like that my labia minora, the small lips, are hanging out beyond my large lips. I don't want that because that's not what I've seen." Gosh knows where they've seen it. So there are lots of cultural norms.

We've done the 7 Domains of Personal Grooming, and certainly shaving has been part of many cultures for thousands of years. It's become part of this culture here in the last 30, I think. So shaving is quite common. Tattooing.

And then there are some cultures where the labia have to look a certain way, meaning you're not supposed to have them. The bottom is supposed to be smooth. And female genital cutting is part of a culture . . . less and less, I think, part of a culture in North Africa and parts of the Middle East.

Has that been part of your practice, or would you see people? I certainly see people from these cultures who come in to give birth, and we have to open up their vaginas so they can actually give birth.

Dr. Moreno: Yeah, I have seen a few cases over the last few years, and by the time they see me, they've had some type of complication from getting that surgery or from the female genital cutting. And that would include problems with urination, sometimes chafing or bleeding down there because there's just not enough skin to protect and serve as a barrier.

Women, if they're also shaving their pubic hair with already thin skin, they're increasing their risk of infections that could potentially also travel inside the vagina.

And so there are a lot of concerns and complications that I've seen just from that practice.

Dr. Jones: Yeah. I mean, the part of me that is a biologist says we should just leave it the way it is. Don't shave it, cut it, tattoo it, pierce it. But I have pierced ears, and so I have not left my ears the way they were meant to be. And I can see why people might want to adorn themselves or change that.

And then, of course, there are people who have dysphoria, have sexual dysphoria or gender dysphoria, and they really feel like their female body parts or their male body parts aren't really what they were meant to have and they want to have surgery to change that. And that's a big surgery both to go from male to female or female to male.

Doing that kind of surgery, I always want to say to some teenager, some adolescent, "I think you might want to wait a little bit. I know you'd like to do this now at 13, but you might want to wait until that area is fully developed and you can make that decision a little bit later in life."

I think that's the same thing for labial reduction or whatever you might say. It might be better if you do that a little bit later in life.

And in the financial domain, all this grooming and stuff, it takes a little bit of money. I was glad I grew up where you just didn't do anything, so it didn't cost anything. Life was so cheap 50 years ago. It was cheap. No fancy phones, no fancy shavers. It was pretty easy.

Dr. Moreno: I have a story about really shaving, right? So I was raised in a generation where you have to shave down there because that is the social norm, and it's become standard for women to shave down there. So I didn't know how to ask my mom how to shave down there. It just wasn't comfortable for me to do that when I was 13, 14, however old I was.

So it was hard for me to pick out a razor at the store and choose between . . . Should I choose the three-blade razor that's offered in the men's aisle, or should I use the one that's pink in color in the female aisle and has some moisture that comes with it so it doesn't cut me? And so that was hard for me to ask my mom at the time and even my sisters.

Dr. Jones: So I'm a generation older where, God forbid, you would never do that, at least in the United States. Certainly people all over the world did. But in my generation, you would never do that. And in fact, it was even just considered a little anti-feminist if you shaved your armpits.

I did shave my legs and my armpits, and I used my dad's razor. And when he found out his razors kept getting blunted, he was wondering why his razors weren't in the condition he thought. And I didn't want to tell him that I was shaving my armpits and my legs. But I wasn't shaving my pubic hair.

That thought is just terrifying to me to take a blade to my body down there. It's like, "Oh my god, I would never." I can't even think about doing that without freaking out. I might cut myself. And then how do you get a Band-Aid down there? Oh my gosh, Band-Aids? I could put a Band-Aid on my leg, but I can't get a Band-Aid down there.

So I was very happy to grow up in a generation where that kind of grooming was not only considered not necessary, but it meant that you weren't a totally secure female if you shaved your armpits and your body hairs.

But anyway, yeah, I can't imagine. What would I do if I had a daughter? Would I say, "I know all of your friends are doing this, and I would be happy to go to the store with you, but I am totally clueless. Is this what you want?" "Yeah, Mom, I have to do this."

Dr. Moreno: Yeah. And that is what we see on the internet and social media.

Dr. Jones: Well, in our 7 Domains of Personal Grooming, we talked about how in many cultures all over the world this has been . . . the shaving of pubic hair has been an issue as part of a cultural norm for thousands of year.

And certainly when you look at artwork from the Middle Ages, the Botticelli Venuses, they certainly had very long head hair, but none of them had any pubic hair. I thought, "Well, where did their pubic hair go?" And what, for God's sake, were they shaving with? Can you imagine not having a contemporary razor, having to use a knife?

Dr. Moreno: I think a blade is what they used back then, and maybe toothpaste as that barrier cream.

Dr. Jones: Yeah, this is 1,000 years ago when ladies were doing that. Maybe not quite 1,000, but anyway, there you go.

Well, how about in the intellectual domain? How do you know how you should be taking care of yourself? There are influencers on TikTok, or you name it, who recommend this kind of goop to go here or there or wherever. How do you know what's right to put on that part of your body, if anything?

Dr. Moreno: So that is where social media and a lot of these TikTok influencers really have expressed other ways of personal female hygiene and ways to take care of your vulva.

ut really asking your medical provider, your healthcare professional that you do trust and have established with would be a great resource, especially if you are weary of what they are presenting on TikTok and you're really unsure if this is the right thing, since we know that we shouldn't really clean the vagina or vulva per se to minimize the irritation that goes on.

And the basic rule is really just to clean the vulva with water only. That is as simple as it gets. We don't really need any expensive and fancy products to put on down there because, again, it can change the appearance, the flora is what we call it, so the bacteria that should be living there that's healthy. And also, we want to minimize the skin irritation that goes on when we introduce these products.

Dr. Jones: So there's a lot of myth about the vulva, and maybe it's what you see if you are looking at videos, that maybe you want to look at women's bodies on videos on the internet. But there are myths about the vulva.

Dr. Moreno, if you were going to debunk the myth, give me your top three myths that you'd like to kind of debunk. When women are coming, you wish that they knew this about their vulva.

Dr. Moreno: I think the anatomy and where the vulva is located, people get confused about. And as far as symptoms that are coming from the vagina, they are really coming from the vulva. And so it's important to be able to differentiate between those two areas, because symptoms that you may experience can be the same for both.

Dr. Jones: So how can a woman tell? This is actually a big deal, because all you know is you feel damp or itchy or maybe there's even bleeding on your tissue or on your panties, and you don't know whether it's coming from inside you in the vagina or your vulva.

It is really hard to look down there. I mean, I'm an old lady. And I can get down into a squat, but getting back up is not a joke. So how do you get a look?

Dr. Moreno: So that is something an exam in a clinic setting, a provider doing a pelvic exam, would be able to better tell you whether it is coming from inside or pretty much just found locally on the outside of the vagina or the skin of the vulva, and getting that confirmation and getting an exam.

And that's why I don't like calling in and also messaging as well, because it's hard to be able to tell and diagnose a condition when you are not doing an exam. And so that is really key in differentiating between the two and where these symptoms are really coming from.

Dr. Jones: Well, I will tell you that's one of my number one myths to debunk. And that is there are women . . . No one wants to come into the doctor and take off your clothes and get up in stirrups to be examined. So they say, "Well, I'm having itching and burning, and won't you call in a prescription for some yeast medicine?"

They type in a message for me or they would call my secretary and I would call them back and say, "Itching and burning is just what the vulva does for a living. It just does that. And it could be anything from cancer to whatever. It may not be a yeast infection. And I can't tell over the phone or on the internet what your problem is. I really have to look." I get that they don't want to look. I totally get it. I say, "I cannot make this diagnosis over the phone. This is an in-person thing."

Dr. Moreno: Yeah, absolutely. And also, another fact that actually women do not know is that most vulva owners climax through clitoral and vulva stimulation versus vaginal penetration. So that's why there are women who get vulva piercings because the vulva piercing may rub against the clitoris. And this way, it can be really incredibly pleasurable since the clitoris has over 10,000 nerve endings that can be stimulated.

And if we were to go back to Biology 101, these are where your Pacinian and Meissner's corpuscles are located. So they can be stimulated by firm touch, or vibration, or even just light touch.

Dr. Jones: So number two is . . . would you call it the myth of the vaginal orgasm? That's a Freudian thing. Freud said that only the mature sexual response in women would be that you have an orgasm during penetration sex, and that's the only way you can have an orgasm.

Some women can, and the good news is that usually vulvar tissues are stimulated during intercourse. But most of the work is coming from the vulva and the clitoris and not from the vagina, most of this pleasure work. Would you say that?

Dr. Moreno: Yes. Absolutely.

Dr. Jones: So women who say, "I just don't have orgasm with intercourse." And I say, "Do you have orgasm any other times?" And they say, "Yeah, when we do this and this, but there must be something wrong with me because I can't do it when we do regular intercourse." I say, "There's nothing wrong with you. In fact, you can combine them all together." But this thought that there's something wrong with them if they can't have intercourse with penetration alone, I wish that myth would go away.

One more myth, Dr. Moreno.

Dr. Moreno: I guess this is a myth for the midlife women's health population or the menopausal population who are listening. There are options to help with low sex drive and libido. And even if your ovaries are no longer producing your sex hormones, there are ways to increase sexual sensation and stimulation down there.

So it may take longer to orgasm now, or you may not be able to orgasm now, but that is something we would want our patients to be asking about and be able to feel comfortable bringing up during a visit.

Dr. Jones: Well, that's the big point, is being comfortable to bring it up during the visit, because we do have some options for people who have decreased sensation in their vulva and clitoris just because their hormones have gone away. There are ways to increase blood flow, which can be very helpful.

Well, in the environmental domain, I think of kiddies playing in the sand, kiddies who may not have diapers on and they're playing in their swimsuits or whatever, and then they get sand in their panties. Or should people have a romantic relationship in the sand, that always can be a challenge sometimes in the following days. Or people who are on their bicycles.

I mean, living in the world with these really delicate tissues, it could be hard. Add sand, add a bicycle seat, and you've got some tough stuff out there.

Dr. Moreno: Yeah, absolutely. And in these cases, I would recommend to use a protective barrier such as an emollient. So if you are a Vaseline user on other parts of your body, you can safely also use that on the vulva or outside the vagina. So if you are going to be going for a 30-, 50-, 60-mile bike ride that day, that can help also protect that skin from chafing.

Dr. Jones: That skin is the same skin in babies. They get so irritated when they wear diapers. And so the very same thing that you use on an infant for diaper rash, so something like Desitin or A+D ointment or something, which ends up being a protectant, it also keeps things from . . . It's antibacterial. When I think of all the little babies with sore bottoms, it's just their little sore bottom, and they just need a little something to protect them from urine or whatever.

So if you're going on a lot of bike rides, grease up. Or even long distance runners. We have some athletes in our own department who run hundreds of miles. And hundreds of miles with your panties on, that could be a little sore.

Dr. Moreno: Yeah, absolutely. Depending on also the type of underwear that you're using, making sure that it's not too tight when you are going to be going for these prolonged, high-intensity activities. Cotton underwear is also what we like, and wicking underwear so it doesn't retain the moisture when you're doing these hardcore activities.

Dr. Jones: Well, I am a huge fan of the cultural norms of toileting that you find in Southeast Asia and also in the Philippines. And that is you don't wipe. You don't put paper. And many people in this part of the world say, "Why would you put paper down there?" What you do is just wash off with a little bucket. And so you go in places that don't have a flush toilet, but there's a bucket with fresh water.

I'm becoming more and more enamored with the thought of a bidet, which is something which you stick in your toilet. Also becoming much more popular in the United States, where it just squirts some warm water on you, and you don't have to keep wiping hard toilet tissue that's got scents and stuff on it. But many people in the world just use a bucket to wash off.

Dr. Moreno: Just one simple tool like a bucket and water. And that is available, hopefully, in most areas of not just the country, but the world.

Dr. Jones: Well, I'm going to finish with the spiritual domain. And I know people may think, "How can you think about the vulva and the spirituality in the same sentence?" But in fact, the vulva for women can be the center of their pleasure and of their sorrow and of their shame.

I think the body that you're born with, how you come to terms with that. And if you aren't coming to terms with that, you believe that another body was your future and not the body you were born with, coming to some sense of completeness in the body that you've got, comfort in what it's giving you, comfort in its knowledge to be not poked or shaved or whatever, unless you want it, something more beautiful, that's fine.

But some kind of coming to terms with your body, in particular the vulva, is I think important for not having shame about your whole body. Women have enough shame about their body. And this is a part of your body that is important to have a good attitude about, a good spiritual attitude about.

But that's just my two cents on that. I don't know if you have any other ideas. You may not use the words spiritual and vulva in the same sentence in your clinic, but . . .

Dr. Moreno: That is a great point actually that you just made. And it's also good to give yourself grace and compassion to accept and know and be aware that these changes are going to happen throughout your lifetime. They could be also changes that we can adapt to, but also feel excited about, especially if we talk to others about it, including your healthcare professional, or the doctor that you see, or a provider that you see.

But also, this is a good way to take charge and feel in charge and feel comfortable and confident in your own body, and also knowing that you are not alone when it comes to experiencing these changes. And if you are, I'm sure you are reading about it, listening to podcasts like this, and you really are empowering yourself to help yourself transition and deal with these changes.

Dr. Jones: Yeah. I like that. Well, Dr. Moreno, I'm grateful for your expertise in helping us say the vulva a whole bunch of times out loud, and use the word vulva and spirituality in the same sentence with some grace and forgiveness of ourselves if we have other kind of feelings that we can work on.

I'm going to end with the "7 Domains of Vulva" haiku.

Girls should learn the words
For special private places
Their body's flower

So thanks, everyone. We'll be listening in soon. And thanks, Dr. Moreno, for joining us.