Fig. 4.1
Labia minora hypertrophy
Common symptoms of adolescents presenting with labial hypertrophy include irritation, pain, and interference with personal hygiene (especially during menses) [1, 3, 9]. In many cases adolescents report interference with sports, like running, cycling, horseback riding, and swimming, and interference with sexual activity [3]. Concerns about the appearance of the labia minora can affect their self-esteem and result in significant psychological distress for the adolescent particularly when wearing specific clothing, like a bathing suit or formfitting clothing [3, 9]. In addition, many parents are unaware of the normal variation of the labia minora and might express their concerns about their daughter’s appearance when comparing it to their own [1, 3]. This can add to the psychological and emotional distress of the adolescent.
After obtaining a detailed history about the adolescent’s concerns and symptoms, the provider should proceed with a physical examination [3]. In most cases, especially in the nonsexually active adolescent, an internal pelvic exam with the use of speculum can be avoided, and an external pelvic exam would be sufficient to evaluate her concerns. Other conditions that can present with similar symptoms and need to be excluded on exam are vulvitis, vaginitis, lichen sclerosus, cysts, lipomas, abscesses, and childhood asymmetric labium majus enlargement [3]. Areas to be inspected include the hair distribution, skin, labia majora and minora, clitoris, urethra meatus, introitus, and perineal body. The labia minora can be measured from the midline to the lateral free edge while holding it fully extended.
Patient Education Is Key
Once other conditions have been excluded, the provider should provide reassurance and education to the adolescent about their normal anatomy and pubertal development [1, 3, 7]. The external genitalia continue to grow and change throughout puberty, including enlargement of the labia majora, which may significantly reduce the prominence of the labia minora.
There are excellent resources, such as Petals by Nick Karras and the Labia Library (web based out of Australia) that can be used to educate girls and their families about the wide variety of genital anatomy. In addition, the patient should be educated about how the labia might appear more prominent if the pubic hair is removed.
Conservative Management of Symptoms
The first approach to discomfort with sports or clothing should be conservative. The use of protective emollients, especially those that are silicon based, can provide relief. Some girls find they have less chafing with looser underwear, where others find they do well with tighter underclothes, and experimentation of these options should be encouraged. Improved hygiene and sitz baths are also important measures that can relieve symptoms (Table 4.1) [1, 7].
Table 4.1
Conservative measures for management of labia hypertrophy
Conservative measures |
|---|
Reassurance about normal vulvar anatomy Referral to resources to show the variations of normal |
Proper genital hygiene to avoid irritation Use simple soaps, use of emollients, avoid scented gels |
Use comfortable underwear Avoidance of formfitting clothing |
Surgical correction of labial hypertrophy in adolescence remains very controversial. There are some who view cosmetic surgery akin to female genital mutation, and some countries such as Great Britain have restricted its use under the age of 18 years.
Labioplasty : A Controversial Intervention in Adolescents
If significant bothersome symptoms persist, such as labia becoming entrapped in clothing or intractable inflammation, then surgical correction can be considered [1, 3]. Some authors recommend avoiding surgery in those younger than 15 years old in order to avoid need for second procedure in the future (if the labia continues to grow) [3]. Proceeding with surgery at an older age also allows the adolescent to be more mature and participate in informed consent.
When considering surgical correction of labia hypertrophy, commonly referred as labiaplasty, it is important to review the motivation and goals of the surgery. The provider should assess whether or not the adolescent has realistic goals of the surgical outcomes and benefits [1]. The adolescent should be screened for body dysmorphic disorder and referred to a mental health professional if there is suspicion of it [1, 10]. Labial cosmetic surgery in adolescence in general is discouraged.
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