Introduction
Puberty is a time of both cognitive and physical change. Pubertal hormones influence the growth and development of breasts and genitalia. The external appearance of the vulva changes significantly; pubic hair begins to grow, the labia minora elongate and protrude compared with the prepubertal state, the clitoris and clitoral hood enlarge, and the labia majora become fuller in appearance. Although breast growth is often expected, many adolescents and their families are unaware of pubertal changes to the labia. The previously small and barely noticeable labia minora become more prominent and may even protrude from outside of the labia majora, prompting a young teen to feel self-conscious and wonder if their body is normal ( Table 16.1 ). Furthermore, if there is evidence of asymmetry or notable vulvar discomfort; this may result in distress or dissatisfaction in both labial appearance and function.
| Labia majora | Fuller in appearance |
| Clitoris and clitoral hood | Enlarge in tandem |
| Labia minora |
|
Adolescents may have concerns about the comfort of their external genitalia related to wearing certain clothing styles, bathing suits, or exercising. 
Most adolescents do not have any frame of reference for the wide range of normal size and appearance of genitalia other than media, family, or in some cases, personal sexual experiences. Similarly, caretakers may have limited experience to appreciate the vast range of normal genital appearances. Media and online representation of genitalia often provide limited examples of genitalia and promote an unrealistic “ideal vulva” that trends toward smaller, less visible labia minora akin to prepubertal labia. Media images may be digitally altered or include images of people who have had cosmetic surgery.
Physicians may also fail to appreciate the diversity in genital appearance, as most medical textbooks use simplified artistic renderings of anatomy rather than photographs to represent the true range of anatomic variation. Sexual maturity rating, known most commonly as Tanner staging, describes pubic hair and stages of breast development but does not include any description of changes and development of the vulva and vagina.
Disease definition
Labial hypertrophy refers to the enlargement of the labia minora, typically beyond the labia majora. However, 
there is no standard diagnostic criteria for labial hypertrophy, and wide ranges of normal sizes for labia are reported in the literature. Labia minora vary greatly in terms of size (length and width), pigmentation, texture, and symmetry. There is no agreed upon measurement of the labia minora that is classified as pathologic. Various labia minora width measurements have been proposed as a cut-off for hypertrophy, ranging between >3 and 5 cm. 
Labial hypertrophy is subjective; labial size that one person considers too large may be considered normal by another.
Labial asymmetry refers to a discrepancy between the width of the labia minora, although the degree of discrepancy is not defined. One study cites a discrepancy of >20 mm as significant.
Genital dissatisfaction is a newer term that refers to distress about the appearance of the vulva in the absence of any known endocrine or anatomic abnormality. Societal influence, through online images of digitally altered or surgically modified vulvas accessed through social media or pornography, may contribute to genital dissatisfaction by promoting an unrealistic standard for “normal” genitalia. ,
Prevalence and epidemiology
Vulvar appearance and labial size are highly variable ( Fig. 16.1 ). The width of the labia minora varies from 1 to 70 mm, and reported average labia minora widths in adolescents range between 20 and 36 mm. , Asymmetry of labia minora width is common among adolescents. Labia minora lengths range from 10 to 100 mm, , , with a reported average of 31 mm in adolescents. The majority of adolescent labia minora demonstrate color variation between the base and the tip of the labia and variation in texture (keratinized versus smooth).
There are no published epidemiologic data about the prevalence of genital dissatisfaction among adolescents. However, adolescent patients seeking care in regard to concerns about labial size, appearance, and function are common in pediatric and adolescent clinics. , Additionally, current trends suggest that requests for vulva and labia surgery are on the rise and are not uncommon among adolescents. Data from 2016 to 2019 indicate that 18.9% of labiaplasties in the United States were performed on patients under age 18.
Etiology and pathophysiology
Labial growth and change begin with puberty. Sex hormone stimulation results in enlargement of the clitoris and labia and changes to the hymen appearance and vaginal epithelium. Androgens promote the development of pubic hair on the mons, labia majora, and inner thighs. Little is known about labia minora development in regard to rate of growth, what degree of asymmetry is normal or will persist into adulthood, and when labial development can be considered complete. Individual genital anatomy is varied in appearance and is independent of sexual maturity rating, race, or exogenous hormone exposure (such as hormonal contraceptives).
Clinical presentation
Patients and their caregivers may present with concerns regarding appearance of the pubertal labia or physical symptoms. Pediatricians, family practitioners, and gynecologists will frequently encounter patients with questions about their genital appearance and function.
Adolescents may have concerns about how their vulva appears either undressed or with certain form-fitting clothing such as bathing suits, leggings, or sportswear (leotards for dance or ballet, for example). Teens or their caregivers may express worry about the appearance or function of their labia during sexual intimacy.
Common physical symptoms include pain, pruritus, skin changes, and vulvar discomfort in tight-fitting clothing or during participation in sports and exercise. Adolescents may report pain or irritation from friction of the labia on their clothing or the labia becoming caught in their clothing. They may report a sensation of the labia twisting or pinching during certain activities. Menstrual hygiene concerns may include irritation of labia during menstruation or difficulty with tampon or menstrual cup placement.
Evaluation
A comprehensive medical history with a focus on puberty and genital symptoms should be obtained. It is important to speak directly to the adolescent when taking the history. This helps decipher if the concern is primarily from the adolescent or their caregiver. Including caregivers during history taking remains important to ensure a supportive and inclusive experience during the evaluation, but a separate confidential discussion is imperative to allow a teen time to share information that is personal or private. Appropriate questions regarding this concern include the following:
- 1.
When did puberty begin?
- 2.
When did you notice the labial changes?
- 3.
Do the labia cause any discomfort? If yes, what are the symptoms (pain, pruritus, skin changes)?
- 4.
When do you notice this discomfort (sports, exercise, wearing certain clothing, tampon placement, intimacy)?
- 5.
Does anything improve or worsen with these symptoms?
- 6.
Do you have challenges with menstrual hygiene related to your labia? Can you use tampons or a menstrual cup if you want to?
- 7.
Are you concerned about the appearance of your genitalia?
- 8.
Consider using the Female Genital Self-Image Scale (FGSIS) as an objective measure of genital self-image ( Fig. 16.2 ).
Fig. 16.2
Female Genital Self Image Scale. This seven-item self-assessment is scored on a 4-point scale (strongly disagree =1, strongly agree = 4) for a total sum score ranging from 7 to 28; higher scores indicate a more positive genital self-image.
(From Herbenick D, Reece M. Development and validation of the female genital self-image scale. J Sex Med . 2010;7[5]:1822-30. doi:10.1111/j.1743-6109.2010.01728.x )
In addition to these questions, it may be helpful to understand hygiene practices, such as bathing, showering, and what type of soap, washcloths, or loofahs are being used. Ask about any over-the-counter products that a patient may have tried. Pubic hair trimming or removal practices and types of clothing/underwear may also be helpful information while formulating a differential diagnosis and plan.
Gender identity and sexuality are important considerations during confidential history taking. If gender identity differs from sex assigned at birth, this may affect a patient’s feelings about their genital appearance and function. Adolescents considering or engaging in sexual intimacy may express concerns regarding both appearance and function. A confidential history, without the parent or caregiver, is necessary to fully explore the patient’s concerns. During the confidential history, it is important to ask about any prior history of abuse or trauma and to take a detailed history about body image, depression, anxiety, and past or current self-harm behaviors.
All patients presenting with genital dissatisfaction related to vulvar appearance and/or function should be screened for body dysmorphic disorder (BDD). The Body Dysmorphic Disorder Questionnaire (BDDQ, https://www.lifespan.org/sites/default/files/lifespan-files/documents/centers/body-dysmorphic/bddq.pdf ) for adolescents is a self-report screening instrument with high sensitivity and specificity for body dysmorphia. Patients suspected of having BDD should be referred to a mental health professional.
Physical examination
Physical examination of the external genitalia requires sensitive preparation. Patients may prefer to be examined without their adult caretaker present or may prefer their company during the examination. Always ask the patient their preference for who they would like to have present in the room (the confidential interview can be a good time to ask this).
When performing the external genital examination, always obtain consent before touching the patient’s body. Use the examination as an opportunity to counsel about personal body safety. The patient should undress waist down and be provided a gown or drape to cover their body. The legs can be positioned in frog-leg (butterfly) position or in typical gynecologic stirrups. Offering the patient a handheld mirror so that they can watch the examination can help alleviate anxiety and aid in active discussion about examination findings. The patient should be prompted to point to or identify areas of personal concern.
The external genitalia is examined and Tanner stage of pubic hair noted along with any evidence of hair removal. The skin is evaluated for erythema, rashes, pigmentation changes, and lesions such as ulcers, condyloma, hemangiomas, or nevi. The labia may be gently separated to fully assess the labia majora and minora and perform measurements. For patients with specific concerns about the size of the labia, measurements are very helpful ( Fig. 16.3 ). The labia length is the measurement of the labia minora from the superior to inferior aspect. The labia width is the measurement from the base of the labia minora at the junction with the labia majora to the farthest projection of the tissue. The labia width can be measured at rest and on stretch and both measurements documented. Measurements of the clitoris may be helpful to include.
