Objective
The objective of the study was to determine whether reproductive-age women are more likely to perceive their vulva as abnormal compared with older-aged women.
Study Design
Women aged 18-44 years (group 1) and 45-72 years (group 2) completed a survey on demographics, grooming patterns, vulvar perceptions, and source of information about the vulva.
Results
There was no difference between group 1 and group 2 in how often women looked at their vulva or their perception of having a normal vulva (91% vs 93%, P = .76). Both groups were satisfied with the appearance of their vulva (81% vs 82%, P = .71). A higher percentage in group 2 would consider cosmetic surgery if cost were not an issue versus group 1 (15% vs 8%, P = .05).
Conclusion
A woman’s age does not have an impact on her perception of a normal vulva. The majority of women perceived their vulva to be normal and were satisfied with its appearance. However, older women are more interested in cosmetic vulvar surgery.
With the media-driven spotlight on cosmetic procedures, more procedures are being performed on the vulva, such as labioplasties, hymenoplasties, vaginal rejuvenation, revirgination, and G-spot amplification. This increase may been driven by women’s distorted perception of a normal vulva. According to the American Society of Aesthetic Plastic Surgery, 2142 cosmetic vulvar surgical procedures were performed in 2011. This is an increase by 5.5% compared with 2010. The number of procedures performed is based on a survey of board-certified plastic surgeons and dermatologists and likely is significantly underreported because gynecologists were not included.
Previous studies show a wide range of normal measurements for vulvar anatomy. Although the features of a normal vulva can vary widely, there is still considerable interest in cosmetic vulvar surgery. In women undergoing vulvar reconstructive procedures, 1 study estimated 37% of women sought surgery purely for aesthetic reasons.
With the increased media attention placed on the vulva and availability of labia photos and pornography on the Internet, some women question whether their vulva is normal. In a study conducted in The Netherlands, 14% of women considered their labia minora to be abnormal.
Social cultural imagery has created the notion of uniform vulvar anatomy. However, studies have shown that anatomic variation is the norm. With the advent of cosmetic vulvar surgery, we hypothesize that there is a growing number of younger women who believe their vulvas are abnormal, causing them to seek corrective surgery.
The aim of this study was to determine whether age is a factor in women’s perceptions of their vulva and whether this perception has an effect on their desire to seek cosmetic vulvar surgery. Age breakdown was based on generational categories, Baby Boomers and older (birth year 1964 and less) versus Generation X and Y (birth year 1965 and later).
Materials and Methods
This institutional review board–approved, cross-sectional survey was conducted between August and September 2011. Women recruited were between the ages of 18 and 72 years, English speaking, and able to complete a study questionnaire. Participants were approached at Washington Hospital Center, Georgetown University School of Medicine (Washington, DC), and a local community fair. Participants completed a 24-item survey. Individuals were excluded if they had prolapse, identified by the question, “Do you usually have a bulge or something falling out that you can see or feel in the vaginal area?” from the Pelvic Floor Distress Inventory.
The survey collected information on the participant’s demographics, perceptions of their vulva, grooming patterns, interest in cosmetic vulvar surgery, vulvar interference with physical activity or clothing, and sources of educational information on vulvar appearance. Participants were asked to identify which vulva appeared normal from 4 pairs of photographs ( Figure 1 ). The pairs of photographs compared vulvas with the following: no hair versus hair, redundant protruding labia minora versus small labia minora, small clitoris versus large clitoris, asymmetric labia minora versus symmetric labia minora, and nongaping introitus versus gaping introitus. Finally, women were asked to choose the vulva that was most similar to their vulva and the vulva they preferred from 30 photographs ( Figure 2 ). Photographs taken from Petals , a published book on female genitalia, showed an array of ages, grooming patterns, skin tones, and a variety of vulvar shapes.
Women were divided into 2 groups: group 1, aged 18-44 years, and group 2, aged 45-72 years. These groups were chosen to differentiate between reproductive-age women and peri- and postmenopausal women. The average age of menopause in the United States is 51 years. Based on Treolar’s classical longitudinal study, 95% of women became menopausal between the ages of 44 and 56 years, which is captured in group 2. This is approximately the age breakdown between Baby Boomers and Generation X and Y.
Based on prior study, we hypothesized that 15% of group 1 and 5% of group 2 will perceive their vulva as abnormal. Based on a sample size calculation, 145 participants were needed in each group. Statistical analysis was performed using Stata/IC 11 (StataCorp LP, College Station, TX). Statistical comparisons between groups were done using 2 sample t tests for continuous variables and χ 2 tests for categorical variables.
Results
Five hundred sixteen women were approached; 121 declined, leaving 395 women for a response rate of 77% ( Figure 3 ). The most common reason for decline was the personal nature of the survey topic. Based on age, there were 207 women in group 1 (aged 18-44 years) and 147 women in group 2 (aged 45-72 years). More women in group 2 were menopausal (69% vs 2.4%, P < .001) and had higher parity (1.7 vs 0.6, P < .001). A larger percentage in group 1 worked in health care (93% vs 69%, P < .001), were single (47% vs 22%, P < .01), and were sexually active (84% vs 70%, P < .01). There were no statistically significant differences between the groups with respect to ethnicity, education, or sexual preference ( Table 1 ).
| Demographic | Group 1 | Group 2 | P value |
|---|---|---|---|
| Age | 29.64 (SD ± 6.19) | 55.02 (SD ± 6.08) | < .001 |
| Parity | 0.62 (SD ± 0.99) | 1.70 (SD ± 1.28) | < .001 |
| Menopausal | 2.44% (n = 5) | 68.75% (n = 99) | < .001 |
| Ethnicity | .27 | ||
| White | 40.00 % (n = 82) | 32.19% (n = 47) | |
| Black | 43.41% (n = 89) | 54.11% (n = 79) | |
| Asian | 6.83% (n = 14) | 5.48% (n = 8) | |
| Hispanic | 6.83% (n = 14) | 4.11% (n = 6) | |
| Other | 2.93% (n = 6) | 4.11% (n = 6) | |
| Employed/training in health care | 92.72% (n = 191) | 68.53% (n = 98) | < .001 |
| Education | .39 | ||
| High school | 21.95% (n = 45) | 16.20% (n = 23) | |
| College | 46.83% (n = 96) | 48.59% (n = 69) | |
| Graduate | 31.22% (n = 64) | 35.21% (n = 50) | |
| Marital status | < .001 | ||
| Single | 47.34% (n = 98) | 22.45% (n = 33) | |
| Partner (living alone) | 3.38% (n = 7) | 4.76% (n = 7) | |
| Living with partner | 16.43% (n = 34) | 4.08% (n = 6) | |
| Married | 29.95% (n = 62) | 48.98% (n = 72) | |
| Divorced | 2.90% (n = 6) | 19.73% (n = 29) | |
| Sexually active | 84.47% (n = 174) | 69.78% (n = 97) | .001 |
| With men | 96.32% (n = 157) | 96.25% (n = 77) | .98 |
| With women | 3.68% (n = 6) | 3.75% (n = 3) |
More than half of the women in each group look at their vulva at least once a month or more. There was no difference based on age in the perception that women had a normal vulva (group 1: 91% vs group 2: 93%, P = .76). The 2 groups were similarly satisfied with the appearance of their vulva (81% vs 82%, P = .71) and felt the appearance of their vulva was important (65% vs 66%, P = .97). A significantly higher percentage of older women (group 2) would consider cosmetic surgery if cost were not an issue compared with younger women (group 1) (15% vs 8%, P = .05).
More women in the younger age group (group 1) performed some type of vulvar hair grooming (84% vs 36%, P < .001). However when examining types of grooming, more women shaved, waxed, or used hair removal along the bikini line in group 2 (52% vs 30%, P < .01), whereas more women in group 1 removed all of their pubic hair (36% vs 16%, P = .01). Both groups mostly referred to anatomy books and their physician as a source of information to learn about vulvar appearance; however, in the younger age group, significantly more women used pornography (6.4% vs 1%, P = .01) and their friends (12% vs 4%, P < .01) as a source of information ( Table 2 ). The source of information did not have a significant effect on the perception of a normal vulva in either age group.
| Variable | Group 1 | Group 2 | P value |
|---|---|---|---|
| Frequency of looking at your vulva | .68 | ||
| Never | 4.85% (n = 10) | 4.76% (n = 7) | |
| Once or a few times in the past | 22.82% (n = 47) | 28.57% (n = 42) | |
| Once a year | 6.31% (n = 13) | 8.84% (n = 13) | |
| Once a month | 23.79% (n = 49) | 22.45 (n = 33) | |
| Once a week | 21.36% (n = 44) | 19.05% (n = 28) | |
| Daily | 20.87% (n = 43) | 16.33% (n = 24) | |
| In my opinion my vulva looks normal. | .76 | ||
| Agree | 91.30% (n = 189) | 93.1% (n = 135) | |
| Neutral | 8.21% (n = 17) | 6.21% (n = 9) | |
| Disagree | 0.48% (n = 1) | 0.69% (n = 1) | |
| I am satisfied with the appearance of my vulva and would not change it. | .71 | ||
| Agree | 81.16% (n = 168) | 82.31% (n = 121) | |
| Neutral | 14.01% (n = 29) | 11.6% (n = 17) | |
| Disagree | 4.83% (n = 10) | 6.12% (n = 9) | |
| The appearance of my vulva is important to me. | .97 | ||
| Agree | 64.73% (n = 134) | 65.75% (n = 96) | |
| Neutral | 28.50% (n = 59) | 27.40% (n = 40) | |
| Disagree | 6.76% (n = 14) | 6.85% (n = 10) | |
| If cost were not an issue, I would consider cosmetic surgery. | .05 | ||
| Agree | 7.77% (n = 16) | 15.17% (n = 22) | |
| Neutral | 6.31% (n = 13) | 8.97% (n = 13) | |
| Disagree | 85.92% (n = 177) | 75.86% (n = 110) | |
| My vulva gets in the way of sex, physical activity, wearing certain clothes. | .14 | ||
| Agree | 5.80% (n = 12) | 8.28% (n = 12) | |
| Neutral | 7.25% (n = 15) | 2.76% (n = 4) | |
| Disagree | 86.96% (n = 180) | 88.97% (n = 129) | |
| I shave, wax, or use hair removal products. | |||
| Agree | 83.82% (n = 171) | 35.8 (n = 52) | < .001 |
| Disagree | 16.18% (n = 33) | 64.14% (n = 93) | |
| I shave, wax, or use hair removal products on my vulva. | |||
| Along the panty line | 29.63% (n = 48) | 52.27% (n = 23) | .005 |
| Leaving less than 50% of the hair | 38.27% (n = 62) | 25.0% (n = 11%) | .10 |
| Removing 100% of the hair | 36.42% (n = 59) | 15.91% (n = 7) | .01 |
| Establishing a pattern | 5.56% (n = 9) | 6.82% (n = 3) | .75 |
| Color or dying the hair | 1.23% (n = 2) | 0% (n = 0) | .46 |
| Which of the sources of information do you use to learn about normal vulva appearance? | |||
| Women’s magazines | 12.38% (n = 25) | 11.19% (n = 15) | .74 |
| Internet | 14.85% (n = 30) | 10.45% (n = 14) | .24 |
| Pornography | 6.44% (n = 13) | 0.75% (n = 1) | .01 |
| Anatomy books | 36.63% (n = 74) | 31.34% (n = 42) | .32 |
| Friends | 11.88% (n = 24) | 3.73% (n = 5) | .01 |
| My doctor | 37.62% (n = 76) | 38.06% (n = 51) | .94 |
| Have you ever had any cosmetic plastic surgery? | |||
| Agree | 3.86% (n = 8) | 7.53% (n = 11) | .13 |
| Disagree | 96.14% (n = 199) | 92.47% (n = 135) |
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