Vaginal secretions are primarily from the  uterus , cervix, and vaginal epithelium in addition to minuscule  vaginal lubrication  from the  Bartholin's glands  upon sexual arousal. [ 10 ]  It takes little vaginal secretion to make the vagina moist; secretions may increase during sexual arousal, the middle of or a little prior to  menstruation , or during  pregnancy . [ 10 ]  Menstruation (also known as a "period" or "monthly") is the regular discharge of blood and mucosal tissue (known as menses) from the  inner lining of the uterus  through the vagina. [ 49 ]  The vaginal mucous membrane varies in thickness and composition during the  menstrual cycle , [ 50 ]  which is the regular, natural change that occurs in the  female reproductive system  (specifically the uterus and  ovaries ) that makes pregnancy possible. [ 51 ] [ 52 ]  Different  hygiene products  such as  tampons ,  menstrual cups , and  sanitary napkins  are available to absorb or capture menstrual blood. [ 53 ]


The Bartholin's glands, located near the vaginal opening, were originally considered the primary source for vaginal lubrication, but further examination showed that they provide only a few drops of  mucus . [ 54 ]  Vaginal lubrication is mostly provided by plasma seepage known as  transudate  from the vaginal walls. This initially forms as sweat-like droplets, and is caused by increased fluid pressure in the tissue of the vagina ( vasocongestion ), resulting in the release of plasma as transudate from the  capillaries  through the vaginal epithelium. [ 54 ] [ 55 ] [ 56 ]


Before and during  ovulation , the mucous glands within the cervix secrete different variations of mucus, which provides an  alkaline ,  fertile  environment in the vaginal canal that is favorable to the survival of  sperm . [ 57 ]  Following menopause, vaginal lubrication naturally decreases. [ 58 ]


Nerve endings in the vagina can provide pleasurable sensations when the vagina is stimulated during sexual activity. Women may derive pleasure from one part of the vagina, or from a feeling of closeness and fullness during vaginal penetration. [ 59 ]  Because the vagina is not rich in nerve endings, women often do not receive sufficient sexual stimulation, or  orgasm , solely from vaginal penetration. [ 59 ] [ 60 ] [ 61 ]  Although the literature commonly cites a greater concentration of nerve endings and therefore greater sensitivity near the vaginal entrance (the outer one-third or lower third), [ 60 ] [ 61 ] [ 62 ]  some scientific examinations of vaginal wall innervation indicate no single area with a greater density of nerve endings. [ 63 ] [ 64 ]  Other research indicates that only some women have a greater density of nerve endings in the anterior vaginal wall. [ 63 ] [ 65 ]  Because of the fewer nerve endings in the vagina, childbirth pain is significantly more tolerable. [ 61 ] [ 66 ] [ 67 ]


Pleasure can be derived from the vagina in a variety of ways. In addition to  penile  penetration, pleasure can come from  masturbation ,  fingering , or specific  sex positions  (such as the  missionary position  or the  spoons sex position ). [ 68 ]  Heterosexual couples may engage in fingering as a form of  foreplay  to incite sexual arousal or as an accompanying act, [ 69 ] [ 70 ]  or as a type of  birth control , or to  preserve virginity . [ 71 ] [ 72 ]  Less commonly, they may use non penile-vaginal sexual acts as a primary means of sexual pleasure. [ 70 ]  In contrast,  lesbians  and other  women who have sex with women  commonly engage in fingering as a  main form of sexual activity . [ 73 ] [ 74 ]  Some women and couples use  sex toys , such as a  vibrator  or  dildo , for vaginal pleasure. [ 75 ]


Most women require direct stimulation of the  clitoris  to orgasm. [ 60 ] [ 61 ]  The clitoris plays a part in vaginal stimulation. It is a sex organ of multiplanar structure containing an abundance of nerve endings, with a broad attachment to the pubic arch and extensive supporting tissue to the labia. Research indicates that it forms a tissue cluster with the vagina. This tissue is perhaps more extensive in some women than in others, which may contribute to orgasms experienced vaginally. [ 60 ] [ 76 ] [ 77 ]


During sexual arousal, and particularly the stimulation of the clitoris, the walls of the vagina lubricate. This begins after ten to thirty seconds of sexual arousal, and increases in amount the longer the woman is aroused. [ 78 ]  It reduces friction or injury that can be caused by insertion of the penis into the vagina or other penetration of the vagina during sexual activity. The vagina lengthens during the arousal, and can continue to lengthen in response to pressure; as the woman becomes fully aroused, the vagina expands in length and width, while the cervix retracts. [ 78 ] [ 79 ]  With the upper two-thirds of the vagina expanding and lengthening, the uterus rises into the  greater pelvis , and the cervix is elevated above the vaginal floor, resulting in tenting of the mid-vaginal plane. [ 78 ]  This is known as the tenting or ballooning effect. [ 80 ]   As the elastic walls of the vagina  stretch or contract , with support from the pelvic muscles, to wrap around the inserted penis (or other object), [ 62 ]  this creates friction for the penis and helps to cause a man to experience orgasm and  ejaculation , which in turn enables  fertilization . [ 81 ]


An area in the vagina that may be an  erogenous zone  is the  G-spot . It is typically defined as being located at the anterior wall of the vagina, a couple or few inches in from the entrance, and some women experience intense pleasure, and sometimes an orgasm, if this area is stimulated during sexual activity. [ 63 ] [ 65 ]  A G-spot orgasm may be responsible for  female ejaculation , leading some doctors and researchers to believe that G-spot pleasure comes from the  Skene's glands , a female  homologue  of the  prostate , rather than any particular spot on the vaginal wall; other researchers consider the connection between the Skene's glands and the G-spot area to be weak. [ 63 ] [ 64 ] [ 65 ]  The G-spot's existence (and existence as a distinct structure) is still under dispute because reports of its location can vary from woman to woman, it appears to be nonexistent in some women, and it is hypothesized to be an extension of the clitoris and therefore the reason for orgasms experienced vaginally. [ 63 ] [ 66 ] [ 77 ]


The vagina is the birth canal for the  delivery  of a baby. When labor nears, several signs may occur, including vaginal discharge and the  rupture of membranes  (water breaking). The latter results in a gush or small stream of  amniotic fluid  from the vagina. [ 82 ]  Water breaking most commonly happens at the beginning of labor. It happens before labor if there is a  premature rupture of membranes , which occurs in 10% of cases. [ 83 ]  Among women giving birth for the first time,  Braxton Hicks contractions  are mistaken for actual  contractions , [ 84 ]  but they are instead a way for the body to prepare for true labor. They do not signal the beginning of labor, [ 85 ]  but they are usually very strong in the days leading up to labor. [ 84 ] [ 85 ]


As the body prepares for childbirth, the cervix softens,  thins , moves forward to face the front, and begins to open. This allows the fetus to settle into the pelvis, a process known as lightening. [ 86 ]  As the fetus settles into the pelvis, pain from the  sciatic nerves , increased vaginal discharge, and increased urinary frequency can occur. [ 86 ]  While lightening is likelier to happen after labor has begun for women who have given birth before, it may happen ten to fourteen days before labor in women experiencing labor for the first time. [ 87 ]


The fetus begins to lose the support of the cervix when contractions begin. With  cervical dilation  reaching 10 cm to accommodate the head of the fetus, the head moves from the uterus to the vagina. [ 82 ] [ 88 ]  The elasticity of the vagina allows it to stretch to many times its normal diameter in order to deliver the child. [ 89 ]


Vaginal births are more common, but if there is a risk of complications a  caesarean section  (C-section) may be performed. [ 90 ]  The vaginal mucosa has an abnormal accumulation of fluid ( edematous ) and is thin, with few rugae, a little after birth. The mucosa thickens and rugae return in approximately three weeks once the ovaries regain usual function and estrogen flow is restored. The vaginal opening gapes and is relaxed, until it returns to its approximate pre-pregnant state six to eight weeks after delivery, known as the  postpartum period ; however, the vagina will continue to be larger in size than it was previously. [ 91 ]


After giving birth, there is a phase of vaginal discharge called  lochia  that can vary significantly in the amount of loss and its duration but can go on for up to six weeks. [ 92 ]


The  vaginal flora  is a complex  ecosystem  that changes throughout life, from birth to menopause. The vaginal microbiota resides in and on the outermost layer of the vaginal epithelium. [ 44 ]  This microbiome consists of species and genera, which typically do not cause symptoms or infections in women with normal immunity. The vaginal microbiome is dominated by  Lactobacillus  species. [ 93 ]  These species  metabolize  glycogen, breaking it down into sugar.  Lactobacilli  metabolize the sugar into glucose and lactic acid. [ 94 ]  Under the influence of hormones, such as estrogen, progesterone and  follicle-stimulating hormone  (FSH), the vaginal ecosystem undergoes cyclic or periodic changes. [ 94 ]


Vaginal health can be assessed during a  pelvic examination , along with the health of most of the organs of the female reproductive system. [ 95 ] [ 96 ] [ 97 ]  Such exams may include the  Pap test  (or cervical smear). In the United States, Pap test screening is recommended starting around 21 years of age until the age of 65. [ 98 ]   However, other countries do not recommend pap testing in non-sexually active women. [ 99 ]  Guidelines on frequency vary from every three to five years. [ 99 ] [ 100 ] [ 101 ]  Routine pelvic examination on women who are not pregnant and lack symptoms may be more harmful than beneficial. [ 102 ]  A normal finding during the pelvic exam of a pregnant woman is a bluish tinge to the vaginal wall. [ 95 ]


Pelvic exams are most often performed when there are unexplained symptoms of discharge, pain, unexpected bleeding or urinary problems. [ 95 ] [ 103 ] [ 104 ]  During a pelvic exam, the vaginal opening is assessed for position,  symmetry , presence of the hymen, and shape. The vagina is assessed internally by the examiner with gloved fingers, before the speculum is inserted, to note the presence of any weakness, lumps or  nodules . Inflammation and discharge are noted if present. During this time, the Skene's and Bartolin's glands are palpated to identify abnormalities in these structures. After the digital examination of the vagina is complete, the speculum, an instrument to visualize internal structures, is carefully inserted to make the cervix visible. [ 95 ]  Examination of the vagina may also be done during a  cavity search . [ 105 ]


Lacerations or other injuries to the vagina can occur during  sexual assault  or other  sexual abuse . [ 4 ] [ 95 ]  These can be tears, bruises, inflammation and abrasions. Sexual assault with objects can damage the vagina and  X-ray  examination may reveal the presence of foreign objects. [ 4 ]  If consent is given, a pelvic examination is part of the assessment of sexual assault. [ 106 ]  Pelvic exams are also performed during pregnancy, and women with high risk pregnancies have exams more often. [ 95 ] [ 107 ]


Intravaginal administration  is a  route of administration  where the medication is inserted into the vagina as a creme or tablet.  Pharmacologically , this has the potential advantage of promoting  therapeutic effects  primarily in the vagina or nearby structures (such as the  vaginal portion of cervix ) with limited systemic  adverse effects  compared to other routes of administration. [ 108 ] [ 109 ]  Medications used to ripen the cervix and induce labor are commonly administered via this route, as are estrogens, contraceptive agents,  propranolol , and  antifungals .  Vaginal rings  can also be used to deliver medication, including  birth control  in  contraceptive vaginal rings . These are inserted into the vagina and provide continuous, low dose and consistent drug levels in the vagina and throughout the body. [ 110 ] [ 111 ]


Before the baby emerges from the womb, an injection for pain control during childbirth may be administered through the vaginal wall and near the  pudendal nerve . Because the pudendal nerve carries motor and sensory fibers that innervate the pelvic muscles, a  pudendal nerve block  relieves birth pain. The medicine does not harm the child, and is without significant complications. [ 112 ]


Vaginal infections or diseases include  yeast infection ,  vaginitis ,  sexually transmitted infections  (STIs) and  cancer .  Lactobacillus gasseri  and other  Lactobacillus  species in the vaginal flora provide some protection from infections by their secretion of  bacteriocins  and  hydrogen peroxide . [ 113 ]  The healthy vagina of a woman of child-bearing age is  acidic , with a  pH  normally ranging between 3.8 and 4.5. [ 94 ]  The low pH prohibits growth of many strains of  pathogenic  microbes. [ 94 ]  The acidic balance of the vagina may also be affected by semen, [ 114 ] [ 115 ]  pregnancy, menstruation,  diabetes  or other illness,  birth control pills , certain  antibiotics , poor diet, and stress. [ 116 ]  Any of these changes to the acidic balance of the vagina may contribute to yeast infection. [ 117 ]  An elevated pH (greater than 4.5) of the vaginal fluid can be caused by an overgrowth of bacteria as in  bacterial vaginosis , or in the parasitic infection  trichomoniasis , both of which have vaginitis as a symptom. [ 94 ] [ 118 ]  Vaginal flora populated by a number of different bacteria characteristic of bacterial vaginosis increases the risk of adverse pregnancy outcomes. [ 119 ]  During a pelvic exam, samples of vaginal fluids may be taken to screen for sexually transmitted infections or other infections. [ 95 ] [ 120 ]


Because the vagina is self-cleansing, it usually does not need special hygiene. [ 121 ]  Clinicians generally discourage the practice of  douching  for maintaining vulvovaginal health. [ 121 ] [ 122 ]  Since the vaginal flora gives protection against disease, a disturbance of this balance may lead to infection and abnormal discharge. [ 121 ]  Vaginal discharge may indicate a vaginal infection by color and odor, or the resulting symptoms of discharge, such as irritation or burning. [ 123 ] [ 124 ]  Abnormal vaginal discharge may be caused by STIs, diabetes, douches, fragranced soaps, bubble baths, birth control pills, yeast infection (commonly as a result of antibiotic use) or another form of vaginitis. [ 123 ]  While vaginitis is an inflammation of the vagina, and is attributed to infection, hormonal issues, or irritants, [ 125 ] [ 126 ]   vaginismus  is an involuntary tightening of the vagina muscles during vaginal penetration that is caused by a  conditioned reflex  or disease. [ 125 ]  Vaginal discharge due to yeast infection is usually thick, creamy in color and odorless, while discharge due to bacterial vaginosis is gray-white in color, and discharge due to trichomoniasis is usually a gray color, thin in consistency, and has a fishy odor. Discharge in 25% of the trichomoniasis cases is yellow-green. [ 124 ]


HIV/AIDS ,  human papillomavirus  (HPV),  genital herpes  and trichomoniasis are some STIs that may affect the vagina, and health sources recommend  safe sex  (or barrier method) practices to prevent the transmission of these and other STIs. [ 127 ] [ 128 ]  Safe sex commonly involves the use of  condoms , and sometimes  female condoms  (which give women more control). Both types can help avert pregnancy by preventing semen from coming in contact with the vagina. [ 129 ] [ 130 ]  There is, however, little research on whether female condoms are as effective as male condoms at preventing STIs, [ 130 ]  and they are slightly less effective than male condoms at preventing pregnancy, which may be because the female condom fits less tightly than the male condom or because it can slip into the vagina and spill semen. [ 131 ]


The vaginal lymph nodes often trap  cancerous  cells that originate in the vagina. These nodes can be assessed for the presence of disease. Selective surgical removal (rather than total and more invasive removal) of vaginal lymph nodes reduces the risk of complications that can accompany more radical surgeries. These selective nodes act as sentinel lymph nodes. [ 48 ]  Instead of surgery, the lymph nodes of concern are sometimes treated with  radiation therapy  administered to the patient's pelvic, inguinal lymph nodes, or both. [ 132 ]


Vaginal cancer  and  vulvar cancer  are very rare, and primarily affect older women. [ 133 ] [ 134 ]   Cervical cancer  (which is relatively common) increases the risk of vaginal cancer, [ 135 ]  which is why there is a significant chance for vaginal cancer to occur at the same time as, or after, cervical cancer. It may be that their causes are the same. [ 135 ] [ 133 ] [ 136 ]  Cervical cancer may be prevented by pap smear screening and  HPV vaccines , but HPV vaccines only cover HPV types 16 and 18, the cause of 70% of cervical cancers. [ 137 ] [ 138 ]   Some symptoms of cervical and vaginal cancer are  dyspareunia , and abnormal  vaginal bleeding  or vaginal discharge, especially  after sexual intercourse  or menopause. [ 139 ] [ 140 ]  However, most cervical cancers are  asymptomatic  (present no symptoms). [ 139 ]  Vaginal intracavity brachytherapy (VBT) is used to treat  endometrial , vaginal and cervical cancer. An applicator is inserted into the vagina to allow the administration of radiation as close to the site of the cancer as possible. [ 141 ] [ 142 ]  Survival rates increase with VBT when compared to external beam radiation therapy. [ 141 ]  By using the vagina to place the emitter as close to the cancerous growth as possible, the systemic effects of radiation therapy are reduced and cure rates for vaginal cancer are higher. [ 143 ]  Research is unclear on whether treating cervical cancer with radiation therapy increases the risk of vaginal cancer. [ 135 ]


Age and hormone levels significantly correlate with the pH of the vagina. [ 144 ]  Estrogen, glycogen and lactobacilli impact these levels. [ 145 ] [ 146 ]  At birth, the vagina is acidic with a pH of approximately 4.5, [ 144 ]  and ceases to be acidic by three to six weeks of age, [ 147 ]  becoming alkaline. [ 148 ]  Average vaginal pH is 7.0 in pre-pubertal girls. [ 145 ]  Although there is a high degree of variability in timing, girls who are approximately seven to twelve years of age will continue to have labial development as the hymen thickens and the vagina elongates to approximately 8 cm. The vaginal mucosa thickens and the vaginal pH becomes acidic again. Girls may also experience a thin, white vaginal discharge called  leukorrhea . [ 148 ]  The vaginal microbiota of adolescent girls aged 13 to 18 years is similar to women of reproductive age, [ 146 ]  who have an average vaginal pH of 3.8–4.5, [ 94 ]  but research is not as clear on whether this is the same for premenarcheal or perimenarcheal girls. [ 146 ]  The vaginal pH during menopause is 6.5–7.0 (without  hormone replacement therapy ), or 4.5–5.0 with hormone replacement therapy. [ 146 ]


After menopause, the body produces less estrogen. This causes  atrophic vaginitis  (thinning and inflammation of the vaginal walls), [ 38 ] [ 149 ]  which can lead to vaginal itching, burning, bleeding, soreness, or  vaginal dryness  (a decrease in lubrication). [ 150 ]  Vaginal dryness can cause discomfort on its own or discomfort or pain during sexual intercourse. [ 150 ] [ 151 ]   Hot flashes  are also characteristic of menopause. [ 116 ] [ 152 ]  Menopause also affects the composition of vaginal support structures. The vascular structures become fewer with advancing age. [ 153 ]   Specific  collagens  become altered in composition and ratios. It is thought that the weakening of the support structures of the vagina is due to the physiological changes in this connective tissue. [ 154 ]


Menopausal symptoms can be eased by estrogen-containing vaginal creams, [ 152 ]  non-prescription, non-hormonal medications, [ 150 ]  vaginal estrogen rings such as the  Femring , [ 155 ]  or other hormone replacement therapies, [ 152 ]  but there are risks (including adverse effects) associated with hormone replacement therapy. [ 156 ] [ 157 ]  Vaginal creams and vaginal estrogen rings may not have the same risks as other hormone replacement treatments. [ 158 ]  Hormone replacement therapy can treat vaginal dryness, [ 155 ]  but a  personal lubricant  may be used to temporarily remedy vaginal dryness specifically for sexual intercourse. [ 151 ]  Some women have an increase in sexual desire following menopause. [ 150 ]  It may be that menopausal women who continue to engage in sexual activity regularly experience vaginal lubrication similar to levels in women who have not entered menopause, and can enjoy sexual intercourse fully. [ 150 ]  They may have less vaginal atrophy and fewer problems concerning sexual intercourse. [ 159 ]


Vaginal changes that happen with aging and childbirth include mucosal redundancy, rounding of the posterior aspect of the vagina with shortening of the distance from the distal end of the anal canal to the vaginal opening,  diastasis  or disruption of the  pubococcygeus muscles  caused by poor repair of an  episiotomy , and  blebs  that may protrude beyond the area of the vaginal opening. [ 160 ]  Other vaginal changes related to aging and childbirth are  stress urinary incontinence ,  rectocele , and  cystocele . [ 160 ]  Physical changes resulting from pregnancy, childbirth, and menopause often contribute to stress urinary incontinence. If a woman has weak  pelvic floor  muscle support and tissue damage from childbirth or pelvic surgery, a lack of estrogen can further weaken the pelvic muscles and contribute to stress urinary incontinence. [ 161 ]   Pelvic organ prolapse , such as a rectocele or cystocele, is characterized by the descent of pelvic organs from their normal positions to impinge upon the vagina. [ 162 ] [ 163 ]  A reduction in estrogen does not cause rectocele, cystocele or  uterine prolapse , but childbirth and weakness in pelvic support structures can. [ 159 ]  Prolapse may also occur when the pelvic floor becomes injured during a  hysterectomy , gynecological cancer treatment, or heavy lifting. [ 162 ] [ 163 ]  Pelvic floor exercises such as  Kegel exercises  can be used to strengthen the pelvic floor muscles, [ 164 ]  preventing or arresting the progression of prolapse. [ 165 ]  There is no evidence that doing Kegel exercises  isotonically  or with some form of weight is superior; there are greater risks with using weights since a foreign object is introduced into the vagina. [ 166 ]


During the third stage of labor, while the infant is being born, the vagina undergoes significant changes. A gush of blood from the vagina may be seen right before the baby is born. Lacerations to the vagina that can occur during birth vary in depth, severity and the amount of adjacent tissue involvement. [ 4 ] [ 167 ]  The laceration can be so extensive as to involve the rectum and  anus . This event can be especially distressing to a new mother. [ 167 ] [ 168 ]  When this occurs,  fecal incontinence  develops and stool can leave through the vagina. [ 167 ]  Close to 85% of  spontaneous vaginal births  develop some form of tearing. Out of these, 60–70% require  suturing . [ 169 ] [ 170 ]  Lacerations from labor do not always occur. [ 44 ]


The vagina, including the vaginal opening, may be altered as a result of surgeries such as an episiotomy,  vaginectomy ,  vaginoplasty  or  labiaplasty . [ 160 ] [ 171 ]  Those who undergo vaginoplasty are usually older and have given birth. [ 160 ]  A thorough examination of the vagina before a vaginoplasty is standard, as well as a referral to a  urogynecologist  to diagnose possible vaginal disorders. [ 160 ]  With regard to labiaplasty, reduction of the labia minora is quick without hindrance, complications are minor and rare, and can be corrected. Any scarring from the procedure is minimal, and long-term problems have not been identified. [ 160 ]


During an episiotomy, a surgical incision is made during the second stage of labor to enlarge the vaginal opening for the baby to pass through. [ 44 ] [ 141 ]  Although its routine use is no longer recommended, [ 172 ]  and not having an episiotomy is found to have better results than an episiotomy, [ 44 ]  it is one of the most common medical procedures performed on women. The incision is made through the skin, vaginal epithelium, subcutaneous fat, perineal body and superficial transverse perineal muscle and extends from the vagina to the anus. [ 173 ] [ 174 ]  Episiotomies can be painful after delivery. Women often report pain during sexual intercourse up to three months after laceration repair or an episiotomy. [ 169 ] [ 170 ]  Some surgical techniques result in less pain than others. [ 169 ]  The two types of episiotomies performed are the medial incision and the medio-lateral incision. The median incision is a perpendicular cut between the vagina and the anus and is the most common. [ 44 ] [ 175 ]  The medio-lateral incision is made between the vagina at an angle and is not as likely to tear through to the anus. The medio-lateral cut takes more time to heal than the median cut. [ 44 ]


Vaginectomy is surgery to remove all or part of the vagina, and is usually used to treat malignancy. [ 171 ]  Removal of some or all of the sexual organs can result in damage to the nerves and leave behind scarring or  adhesions . [ 176 ]  Sexual function may also be impaired as a result, as in the case of some cervical cancer surgeries. These surgeries can impact pain, elasticity, vaginal lubrication and sexual arousal. This often resolves after one year but may take longer. [ 176 ]


Women, especially those who are older and have had multiple births, may choose to surgically correct vaginal laxity. This surgery has been described as vaginal tightening or rejuvenation. [ 177 ]  While a woman may experience an improvement in  self-image  and sexual pleasure by undergoing vaginal tightening or rejuvenation, [ 177 ]  there are risks associated with the procedures, including infection, narrowing of the vaginal opening, insufficient tightening, decreased sexual function (such as  pain during sexual intercourse ), and  rectovaginal fistula . Women who undergo this procedure may unknowingly have a medical issue, such as a prolapse, and an attempt to correct this is also made during the surgery. [ 178 ]


Surgery on the vagina can be elective or cosmetic. Women who seek cosmetic surgery can have  congenital  conditions, physical discomfort or wish to alter the appearance of their genitals. Concerns over average genital appearance or measurements are largely unavailable and make defining a successful outcome for such surgery difficult. [ 179 ]  A number of  sex reassignment surgeries  are available to  transgender  people. Although not all  intersex  conditions require surgical treatment, some choose genital surgery to correct atypical anatomical conditions. [ 180 ]


Vaginal anomalies  are defects that result in an abnormal or absent vagina. [ 181 ] [ 182 ]  The most common obstructive vaginal anomaly is an  imperforate hymen , a condition in which the hymen obstructs menstrual flow or other vaginal secretions. [ 183 ] [ 184 ]  Another vaginal anomaly is a  transverse vaginal septum , which partially or completely blocks the vaginal canal. [ 183 ]  The precise cause of an obstruction must be determined before it is repaired, since corrective surgery differs depending on the cause. [ 185 ]  In some cases, such as isolated  vaginal agenesis , the external genitalia may appear normal. [ 186 ]


Abnormal openings known as  fistulas  can cause  urine  or  feces  to enter the vagina, resulting in incontinence. [ 187 ] [ 188 ]  The vagina is susceptible to fistula formation because of its proximity to the  urinary  and  gastrointestinal  tracts. [ 189 ]  Specific causes are manifold and include obstructed labor, hysterectomy,  malignancy , radiation,  episiotomy , and bowel disorders. [ 190 ] [ 191 ]  A small number of vaginal fistulas are  congenital . [ 192 ]  Various surgical methods are employed to repair fistulas. [ 193 ] [ 187 ]  Untreated, fistulas can result in significant  disability  and have a profound impact on  quality of life . [ 187 ]


Vaginal evisceration  is a serious complication of a  vaginal hysterectomy  and occurs when the  vaginal cuff   ruptures , allowing the  small intestine  to protrude from the vagina. [ 106 ] [ 194 ]


Cysts  may also affect the vagina. Various types of  vaginal cysts  can develop on the surface of the vaginal epithelium or in deeper layers of the vagina and can grow to be as large as 7 cm. [ 195 ] [ 196 ]  Often, they are an incidental finding during a routine pelvic examination. [ 197 ]  Vaginal cysts can mimic other structures that protrude from the vagina such as a rectocele and cystocele. [ 195 ]  Cysts that can be present include  Müllerian cysts ,  Gartner's duct cysts , and  epidermoid cysts . [ 198 ] [ 199 ]  A vaginal cyst is most likely to develop in women between the ages of 30 and 40. [ 195 ]  It is estimated that 1 out of 200 women has a vaginal cyst. [ 195 ] [ 200 ]  The  Bartholin's cyst  is of vulvar rather than vaginal origin, [ 201 ]  but it presents as a lump at the vaginal opening. [ 202 ]  It is more common in younger women and is usually without symptoms, [ 203 ]  but it can cause pain if an  abscess  forms, [ 203 ]  block the entrance to the  vulval vestibule  if large, [ 204 ]  and impede walking or cause painful sexual intercourse. [ 203 ]


Various perceptions of the vagina have existed throughout history, including the belief it is the center of  sexual desire , a metaphor for life via birth, inferior to the penis, unappealing to sight or smell, or  vulgar . [ 205 ] [ 206 ] [ 207 ]  These views can largely be attributed to  sex differences , and how they are interpreted.  David Buss , an  evolutionary psychologist , stated that because a penis is significantly larger than a clitoris and is readily visible while the vagina is not, and males urinate through the penis, boys are taught from childhood to touch their penises while girls are often taught that they should not touch their own genitalia, which implies that there is harm in doing so. Buss attributed this as the reason many women are not as familiar with their genitalia, and that researchers assume these sex differences explain why boys learn to masturbate before girls and do so more often. [ 208 ]


The word  vagina  is commonly avoided in conversation, [ 209 ]  and many people are confused about the vagina's anatomy and may be unaware that it is not used for urination. [ 210 ] [ 211 ] [ 212 ]  This is exacerbated by phrases such as "boys have a penis, girls have a vagina", which causes children to think that girls have one orifice in the pelvic area. [ 211 ]  Author Hilda Hutcherson stated, "Because many [women] have been conditioned since childhood through verbal and nonverbal cues to think of [their] genitals as ugly, smelly and unclean, [they] aren't able to fully enjoy intimate encounters" because of fear that their partner will dislike the sight, smell, or taste of their genitals. She argued that women, unlike men, did not have locker room experiences in school where they compared each other's genitals, which is one reason so many women wonder if their genitals are normal. [ 206 ]  Scholar  Catherine Blackledge  [ pl ]  stated that having a vagina meant she would typically be treated less well than her vagina-less counterparts and subject to inequalities (such as  job inequality ), which she categorized as being treated like a second-class citizen. [ 209 ]


Negative views of the vagina are simultaneously contrasted by views that it is a powerful symbol of female sexuality, spirituality, or life. Author Denise Linn stated that the vagina "is a powerful symbol of womanliness, openness, acceptance, and receptivity. It is the inner valley spirit". [ 213 ]   Sigmund Freud  placed significant value on the vagina, [ 214 ]  postulating the concept that vaginal orgasm is separate from clitoral orgasm, and that, upon reaching puberty, the proper response of mature women is a changeover to vaginal orgasms (meaning orgasms without any clitoral stimulation). This theory made many women feel inadequate, as the majority of women cannot achieve orgasm via vaginal intercourse alone. [ 215 ] [ 216 ] [ 217 ]  Regarding religion, the womb represents a powerful symbol as the  yoni  in  Hinduism , which represents "the feminine potency", and this may indicate the value that Hindu society has given female sexuality and the vagina's ability to deliver life; [ 218 ]  however,  yoni  as a representation of "womb" is not the primary denotation. [ 219 ]


While, in ancient times, the vagina was often considered equivalent ( homologous ) to the penis, with anatomists  Galen  (129 AD – 200 AD) and  Vesalius  (1514–1564) regarding the organs as structurally the same except for the vagina being inverted, anatomical studies over latter centuries showed the clitoris to be the penile equivalent. [ 76 ] [ 220 ]  Another perception of the vagina was that the release of vaginal fluids would cure or remedy a number of ailments; various methods were used over the centuries to release "female seed" (via vaginal lubrication or female ejaculation) as a treatment for  suffocatio ex semine retento  (suffocation of the womb,  lit.  'suffocation from retained seed'),  green sickness , and possibly for  female hysteria . Reported methods for treatment included a  midwife  rubbing the walls of the vagina or insertion of the penis or penis-shaped objects into the vagina. Symptoms of the female hysteria diagnosis – a concept that is no longer recognized by medical authorities as a medical disorder – included faintness, nervousness, insomnia, fluid retention, heaviness in abdomen, muscle spasm, shortness of breath, irritability, loss of appetite for food or sex, and a propensity for causing trouble. [ 221 ]  It may be that women who were considered suffering from female hysteria condition would sometimes undergo "pelvic massage" – stimulation of the genitals by the doctor until the woman experienced "hysterical paroxysm" (i.e., orgasm). In this case, paroxysm was regarded as a medical treatment, and not a sexual release. [ 221 ]


The vagina has been given many vulgar names, three of which are  pussy ,  twat , and  cunt .   Cunt  is also used as a  derogatory   epithet  referring to people of either sex. This usage is relatively recent, dating from the late nineteenth century. [ 222 ]  Reflecting  different national usages ,  cunt  is described as "an unpleasant or stupid person" in the  Compact Oxford English Dictionary , [ 223 ]  whereas the  Merriam-Webster  has a usage of the term as "usually disparaging and obscene: woman", [ 224 ]  noting that it is used in the United States as "an offensive way to refer to a woman". [ 225 ]   Random House  defines it as "a despicable, contemptible or foolish man". [ 222 ]  Some  feminists  of the 1970s sought to eliminate disparaging terms such as  cunt . [ 226 ]   Twat  is widely used as a derogatory epithet, especially in  British English , referring to a person considered obnoxious or stupid. [ 227 ] [ 228 ]   Pussy  can indicate " cowardice  or  weakness ", and "the human vulva or vagina" or by extension "sexual intercourse with a woman". [ 229 ]  In English, the use of the word  pussy  to refer to women is considered derogatory or demeaning, treating people as sexual objects. [ 230 ]


The  vagina loquens , or "talking vagina", is a significant tradition in literature and art, dating back to the ancient  folklore   motifs  of the "talking cunt". [ 231 ] [ 232 ]  These tales usually involve vaginas talking by the effect of magic or charms, and often admitting to their lack of  chastity . [ 231 ]  Other folk tales relate the vagina as having teeth –  vagina dentata  ( Latin  for "toothed vagina"). These carry the implication that sexual intercourse might result in injury,  emasculation , or  castration  for the man involved. These stories were frequently told as  cautionary tales  warning of the dangers of unknown women and to discourage  rape . [ 233 ]


In 1966, the French artist  Niki de Saint Phalle  collaborated with  Dadaist  artist  Jean Tinguely  and Per Olof Ultvedt on a large sculpture installation entitled  "hon-en katedral"  (also spelled  "Hon-en-Katedrall" , which means "she-a cathedral") for Moderna Museet, in  Stockholm , Sweden. The outer form is a giant, reclining sculpture of a woman which visitors can enter through a door-sized vaginal opening between her spread legs. [ 234 ]


The Vagina Monologues , a 1996 episodic play by  Eve Ensler , has contributed to making female sexuality a topic of public discourse. It is made up of a varying number of monologues read by a number of women. Initially, Ensler performed every monologue herself, with subsequent performances featuring three actresses; latter versions feature a different actress for every role. Each of the monologues deals with an aspect of the  feminine experience , touching on matters such as sexual activity, love, rape, menstruation, female genital mutilation, masturbation, birth, orgasm, the various common names for the vagina, or simply as a physical aspect of the body. A recurring theme throughout the pieces is the vagina as a tool of female empowerment, and the ultimate embodiment of individuality. [ 235 ] [ 236 ]


Societal views, influenced by tradition, a lack of knowledge on anatomy, or  sexism , can significantly impact a person's decision to alter their own or another person's genitalia. [ 178 ] [ 237 ]  Women may want to alter their genitalia (vagina or vulva) because they believe that its appearance, such as the length of the labia minora covering the vaginal opening, is not normal, or because they desire a smaller vaginal opening or tighter vagina. Women may want to remain youthful in appearance and sexual function. These views are often influenced by the media, [ 178 ] [ 238 ]  including  pornography , [ 238 ]  and women can have low self-esteem as a result. [ 178 ]  They may be embarrassed to be naked in front of a sexual partner and may insist on having sex with the lights off. [ 178 ]  When modification surgery is performed purely for cosmetic reasons, it is often viewed poorly, [ 178 ]  and some doctors have compared such surgeries to  female genital mutilation  (FGM). [ 238 ]


Female genital mutilation, also known as female circumcision or female genital cutting, is genital modification with no health benefits. [ 239 ] [ 240 ]  The most severe form is Type III FGM, which is  infibulation  and involves removing all or part of the  labia  and the vagina being closed up. A small hole is left for the passage of urine and menstrual blood, and the vagina is opened up for sexual intercourse and childbirth. [ 240 ]


Significant controversy surrounds female genital mutilation, [ 239 ] [ 240 ]  with the  World Health Organization  (WHO) and other health organizations campaigning against the procedures on behalf of  human rights , stating that it is "a violation of the human rights of girls and women" and "reflects deep-rooted inequality between the sexes". [ 240 ]  Female genital mutilation has existed at one point or another in almost all human civilizations, [ 241 ]  most commonly to exert control over the sexual behavior, including masturbation, of girls and women. [ 240 ] [ 241 ]  It is carried out in several countries, especially in  Africa , and to a lesser extent in other parts of the  Middle East  and  Southeast Asia , on girls from a few days old to mid-adolescent, often to reduce sexual desire in an effort to preserve vaginal virginity. [ 239 ] [ 240 ] [ 241 ]   Comfort Momoh  stated it may be that female genital mutilation was "practiced in ancient Egypt as a sign of distinction among the aristocracy"; there are reports that traces of infibulation are on Egyptian mummies. [ 241 ]


Custom and tradition are the most frequently cited reasons for the practice of female genital mutilation. Some cultures believe that female genital mutilation is part of a girl's initiation into adulthood and that not performing it can disrupt social and political cohesion. [ 240 ] [ 241 ]  In these societies, a girl is often not considered an adult unless she has undergone the procedure. [ 240 ]


The vagina is a structure of animals in which the female is  internally fertilized , rather than by  traumatic insemination  used by some invertebrates. Although research on the vagina is especially lacking for different animals, its location, structure and size are documented as varying among species. In  therian mammals  ( placentals  and  marsupials ), the vagina leads from the uterus to the exterior of the female body. Female placentals have two openings in the vulva; these are the urethral opening for the urinary tract and the vaginal opening for the genital tract. Depending on the species, these openings may be within the internal  urogenital sinus  or on the external vestibule. [ 242 ]  Female marsupials  have two lateral vaginas , which lead to separate uteri, but both open externally through the same orifice; [ 243 ]  a third canal, which is known as the median vagina, and can be transitory or permanent, is used for birth. [ 244 ]  The female  spotted hyena  does not have an external vaginal opening. Instead, the vagina  exits through the clitoris , allowing the females to urinate, copulate and give birth through the clitoris. [ 245 ]  In female  canids , the vagina contracts during copulation, forming a  copulatory tie . [ 246 ]  Female  cetaceans  have vaginal folds that are not found in other mammals. [ 247 ] [ 248 ]


Monotremes ,  birds ,  reptiles  and  amphibians  have a  cloaca  and is the single external opening for the gastrointestinal, urinary, and reproductive tracts. Some of these vertebrates have a part of the  oviduct  that leads to the cloaca. [ 249 ] [ 250 ]  Chickens have a vaginal aperture that opens from the vertical apex of the cloaca. The vagina extends upward from the aperture and becomes the egg gland. [ 250 ]  In some  jawless fish , there is neither oviduct nor vagina and instead the egg travels directly through the body cavity (and is fertilised externally as in most  fish  and amphibians). In insects and other  invertebrates , the vagina can be a part of the oviduct (see  insect reproductive system ). [ 251 ]  Birds have a cloaca into which the urinary, reproductive tract (vagina) and gastrointestinal tract empty. [ 252 ]  Females of some waterfowl species have developed vaginal structures called dead end sacs and clockwise coils to protect themselves from  sexual coercion . [ 253 ]


A lack of research on the vagina and other female genitalia, especially for different animals, has stifled knowledge on female sexual anatomy. [ 254 ] [ 255 ]  One explanation for why male genitalia is studied more includes penises being significantly simpler to analyze than female genital cavities, because male genitals usually protrude and are therefore easier to assess and measure. By contrast, female genitals are more often concealed, and require more dissection, which in turn requires more time. [ 254 ]  Another explanation is that a main function of the penis is to impregnate, while female genitals may alter shape upon interaction with male organs, especially as to benefit or hinder  reproductive success . [ 254 ]


Non-human  primates  are optimal models for human biomedical research because humans and non-human primates share physiological characteristics as a result of  evolution . [ 256 ]  While menstruation is heavily associated with human females, and they have the most pronounced menstruation, it is also typical of  ape  relatives and  monkeys . [ 257 ] [ 258 ]  Female  macaques  menstruate, with a cycle length over the course of a lifetime that is comparable to that of female humans. Estrogens and  progestogens  in the  menstrual cycles  and during premenarche and postmenopause are also similar in female humans and macaques; however, only in macaques does keratinization of the epithelium occur during the  follicular phase . [ 256 ]  The vaginal pH of macaques also differs, with near-neutral to slightly alkaline median values and is widely variable, which may be due to its lack of lactobacilli in the vaginal flora. [ 256 ]  This is one reason why, although macaques are used for studying HIV transmission and testing  microbicides , [ 256 ]  animal models are not often used in the study of sexually transmitted infections, such as trichomoniasis. Another is that such conditions' causes are inextricably bound to humans' genetic makeup, making results from other species difficult to apply to humans. [ 259 ]


Vaginal anomalies  are  abnormal structures  that are formed (or not formed) during the prenatal development of the female reproductive system and are rare congenital defects that result in an abnormal or absent vagina. [ 1 ]


When present, they are often found with uterine, skeletal and urinary abnormalities. [ 2 ] [ 3 ]  This is because these structures, like the vagina, are most susceptible to disruption during crucial times of organ-genesis. Many of these defects are classified under the broader term  Müllerian duct anomalies . [ 2 ] [ 4 ]  Müllerian duct anomalies are caused by a disturbance during the embryonic time of genitourinary development. [ 5 ]


The other isolated incidents of vaginal anomalies can occur with no apparent cause. Oftentimes vaginal anomalies are part of a cluster of defects or syndromes. In addition,  inheritance  can play a part as can prenatal exposure to some  teratogens . [ 2 ] [ 6 ] [ 7 ] [ 8 ]  Many vaginal anomalies are not detected at birth because the external genitalia appear to be normal. [ 2 ]  Other organs of the  reproductive system  may not be affected by an abnormality of the vagina. The uterus,  fallopian tubes  and ovaries can be functional despite the presence of a defect of the vagina and external genitalia. [ 2 ]


A vaginal anomaly may not affect fertility. Though it depends on the extent of the vaginal defect, it is possible for  conception  to occur. In instances where a functional ovary exists,  IVF  may be successful. Functioning ovaries in a woman with a vaginal defect allows the implantation of a fertilized ovum into the uterus of an unaffected gestational carrier, usually another human. A successful conception and can occur. [ 9 ] [ 2 ]  Vaginal length varies from 6.5 to 12.5 cm. Since this is slightly shorter than older descriptions, it may impact the diagnosis of women with vaginal agenesis or hypoplasia who may unnecessarily be encouraged to undergo treatment to increase the size of the vagina. [ 10 ]


Vaginal anomalies may cause difficulties in urination, conception, pregnancy, impair sex. Psychosocial effects can also exist. [ 11 ]


Some anomalies are found upon examination shortly after birth or when the development of sexual characteristics does not progress as expected. Defects that prevent menstrual flow become obvious when amenorrhea occurs. [ citation needed ]


Syndromes may take longer to identify since they are rare and often involve errors in metabolism. Many syndromes share the same signs and symptoms. [ citation needed ]


Uterine defects can accompany vaginal abnormalities:


Women with uterine abnormalities may have associated renal abnormalities including unilateral renal agenesis. [ 14 ]


Some congenital syndromes present with vaginal anomalies in association with other serious conditions. These include  Fraser syndrome ,   WNT4 deficiency , and  Bardet-Biedl  syndrome, [ 15 ] [ 16 ] [ 17 ] [ 18 ]  Isolated incidents of vaginal anomalies can occur with no apparent cause and in other instances these anomalies are part of a  syndrome  or cluster of other abnormalities. The origin of many vaginal anomalies is due to a disturbance during the  embryonic  stage of  genitourinary  development. [ 5 ]  Inheritance can play a part as can prenatal exposure to  hormones  and  teratogens . [ 2 ] [ 7 ]  Though the presence of a vaginal anomaly does not necessarily prevent conception and a successful pregnancy when a functional uterus and ovaries are present, vaginal anomalies increase the risk of miscarriage. [ 19 ] [ 9 ] [ 2 ]


Prenatal exposure to some  hormones  can cause vaginal anomalies as can the lack of necessary hormones needed for normal development. [ 39 ]   Diethylstilbestrol  (DES), also known formerly (and inappropriately) as  stilboestrol , is a  synthetic   nonsteroidal estrogen  and teratogen that can cause vaginal abnormalities in the developing embryo. [ 40 ]


The cause of isolated cases of vaginal anomalies can not always be identified, though disruption of the embryonic development of the vagina likely plays a significant role. [ citation needed ]


Imaging studies are usually the most useful in diagnosing vaginal anomalies including retrograde contrast studies. [ 1 ]  An  anomaly scan  can be helpful, especially detecting the presence of a urogenital syndrome. Genetic and metabolic defects require further testing to support a diagnosis. [ citation needed ]


Vaginal anomalies are treated surgically. [ 41 ]  A 'neo-vagina' can be constructed for those girls and women who do not have a vagina. [ 42 ] [ 43 ]  Vaginal septa are treated surgically. [ 44 ] [ 45 ]


The most common vaginal anomaly is an  imperforate hymen . This anomaly occurs often enough that it can be detected by some pediatricians shortly after birth. It can be corrected through a minor surgery and may be delayed until puberty. [ 46 ]  The hymen can be unusually thick or partially obstructed by the presence of fibrous bands of  tissue . An imperforate hymen can also present with other abnormalities such as septa. An imperforate hymen can be displaced and its location may not be where it is expected. Other abnormalities of the hymen can exist including the presence of septa, displacement and a hymen that consists of microperforations. [ 47 ] [ 19 ]  Uncommonly, a double hymen is present. [ 48 ] [ 49 ] [ 50 ]  The imperforate hymen is treated by excision and drainage. Sometimes a small border of hymenal tissue is left around the opening of the vagina. [ 51 ]


Congenital adrenal hyperplasia  can cause the abnormal development of the vagina. [ 52 ] [ 53 ] [ 54 ]   Vaginal adenosis  is the abnormal presence of cervical and uterine tissue within the wall of the vagina. [ 55 ]  Ten percent of women have this condition and remain unsymptomatic. It rarely develops into a malignancy. [ 56 ]   Cloacal exstrophy  is a condition when two vaginas are present. [ 57 ] [ 58 ] [ 27 ]   Vaginal agenesis  or the complete absence of the vagina affects 1 out of 5,000 women. [ 35 ]  A hemivagina is the abnormal presence of a partial vagina that is attached to the wall of the functioning vagina. The  hemivagina does not open to the normal vagina and is attached to an abnormal, second uterus. [ 59 ]   Vaginal hypoplasia  is the under-development of the vagina and is found in instances of  complete androgen insensitivity syndrome . [ 60 ] [ 61 ] [ 15 ]   Vaginal septa  are structures consisting of fibrous tissue that block the vagina. [ 57 ] [ 62 ]  The tissue extends horizontally, blocking or partially blocking the vaginal canal or transversely essentially creating two vaginas that connect to a normal uterus. [ 63 ] [ 64 ]  Septa can prevent menstrual flow and result in painful intercourse, though some women do not have symptoms. [ 65 ] [ 60 ] [ 63 ]  Many vaginal anomalies are not detected at birth because the external genitalia can appear to be normal. [ 2 ]


The occurrence of vaginal defects varies widely and some are only known from case studies. The prevalence of an imperforate hymen is 1 in 1000. [ 66 ]


Notable is the mention of vaginal anomalies and pelvic organ prolapse in older cultures and locations. [ 78 ]  In 1500 B.C. Egyptians wrote about the "falling of the womb". In 400 B.C. a Greek physician documented his observations and treatments:


"After the patient had been tied to a ladder-like frame, she was tipped upward so that her head was toward the bottom of the frame. The frame was then moved upward and downward more or less rapidly for approximately 3–5 min. As the patient was in an inverted position, it was thought that the prolapsing organs of the genital tract would be returned to their normal position by the force of gravity and the shaking motion." [ 78 ]


Hippocrates  also described the prolapse of other organs out through the vagina. [ 78 ]  In 1521,  Berengario da Carpi  performed the first surgical treatment for prolapse. This was to tie a rope around the prolapse, tighten it for two days until it was no longer viable and cut it off. Wine, aloe, and honey were then applied to the stump. [ 78 ]


References regarding the existence of vaginal anomalies related to müllerian defects have been traced back to 300 BC when a historian described a case of vaginal agenesis. [ 79 ]


In 1823, other physicians proposed that vaginoplasty may provide treatment for pelvic organ prolapse. In 1830, the first dissection of the vagina was performed on a living woman. Other vaginal repairs were described in 1834 and treatment sometimes the suturing the edges of a vaginal defect. In 1859 a solution to vaginal elongation was to remove the cervix. [ 78 ]  In 1866, methods that resembled those used today came into practice. Surgery on the anterior vaginal wall at this time did not have to involve full-thickness repairs to be successful. Sim subsequently developed another procedure that did not require the full-thickness dissection of the vaginal wall. Shortly after this time it was proposed that reattaching the vagina to support structures was more successful and resulted in less recurrence. This same proposal was proposed again in 1976 but further studies indicated that the recurrence rate was not better. Further advances in 1961 began when surgeons started to reattach of the anterior vaginal wall to Cooper's ligament. [ 78 ]


In 1955, surgical mesh began to be used to strengthen pelvic tissue. In 1970, tissue from pigs began to be used to strengthen the anterior vaginal wall in surgery. Beginning in 1976, improvement in suturing began along with the surgical removal of the vagina being used to treat prolapse of the bladder. In 1991, assumptions about the detailed anatomy of the pelvic support structures began to be questioned regarding the existence of some pelvic structures and the non-existence of others. More recently, the use of stem cells, robot-assisted laparoscopic surgery are being used during vaginectomy and vaginoplasty. [ 78 ]


Vaginal contractions  are  contractions  of the  pelvic muscles  surrounding the  vagina , especially the  pubococcygeus muscle . Vaginal contractions are generally an involuntary muscular response to  orgasm . Women can control the muscles of the vagina to perform vaginal contractions at will. Vaginal contractions can enhance the sexual experience and pleasure for both parties during  sexual intercourse .


In a 1982 study, pelvic contractions of 11 women who manually self-stimulated to orgasm were monitored using an anal probe and a vaginal probe simultaneously. Near the perceived start of orgasm, a series of regular contractions began in 9 of the women, with anal and vaginal contractions synchronizing with each other. Three of the women's orgasms consistently included only a series of regular contractions; for six other women, orgasms consistently continued beyond the regular series with additional irregular contractions. Two women had no regular contractions during reported orgasms. The women showed marked differences in orgasm duration and the number of contractions. [ 1 ]  A 1994 study confirmed these results but concluded that some women experience their orgasm regularly without contractions and some report having contractions during orgasm only occasionally. [ 2 ]


Vaginal contractions are caused by both the activity of certain brain regions and the release of the hormone oxytocin. It has been suggested that vaginal contractions during orgasm can increase the chances of pregnancy as they transport sperm up the reproductive tract from the vagina to the oviducts, which decreases the distance it has to travel. Additionally, when the woman is fertile, sperm is only transported to the side of the dominant ovary. [ 3 ]


Involuntary vaginal contractions may arise from non-sexual causes. Involuntary spasm of the muscles around the vagina, usually caused by anxiety, can result in  vaginismus . [ 4 ] [ 5 ]


Vaginal contractions should not be confused with  uterine contractions .


The  vaginal cuff  is the upper portion of the  vagina  that opens up into the  peritoneum  and is sutured shut after the removal of the  cervix  and  uterus  during a  hysterectomy . [ 1 ] [ 2 ]


The vaginal cuff is created by  suturing  together the edges of the surgical site where the cervix was attached to the vagina. This is accomplished by bringing the edges of the vagina together and suturing them together and to the  uterosacral ligaments  to prevent prolapse. The peritoneum is also sewn into the newly created vaginal cuff. [ 1 ]  There may be an advantage to using one method of closure over another. [ 3 ]  The vaginal cuff has a tendency to partially or completely  dehisce  or open up. [ 4 ] [ 5 ]


A further complication that can accompany the dehiscence of the vaginal cuff is  evisceration  or the movement of  intestines  into the vagina. [ 3 ]  Some or all of the vaginal cuff can reopen. [ 6 ]


The risk of vaginal cuff complications is related to the approach to hysterectomy: robotic-assisted total  laparoscopic  hysterectomy, total  laparoscopic hysterectomy , laparoscopic-assisted vaginal hysterectomy, total abdominal hysterectomy, and total vaginal hysterectomy. [ 6 ]


The vaginal cuff can be stressed by sexual intercourse,  chronic constipation ,  asthma ,  COPD , and other actions that increase intra-abdominal pressure. This structure is prone to infection,  hematoma  and other postoperative complications. Factors that are thought to affect wound healing are radiation treatments, age,  pelvic organ prolapse , the use of  corticosteroids , concurrent malignancy. [ 6 ]


Though rare, estimates of the prevalence of vaginal cuff dehiscence after hysterectomy are estimated and reported to be between 0.14 and 4.1% per the  American College of Obstetricians and Gynecologists (ACOG) . [ 7 ]  If the vaginal cuff is compromised, vaginal evisceration can occur with the  small intestine  protruding out through the vagina. [ 3 ]


A  vaginal dilator  (sometimes called a  vaginal trainer ) [ 1 ]  is an instrument used to gently stretch the  vagina . They are used when the vagina has become narrowed ( vaginal stenosis ), such as after  brachytherapy  for gynecologic cancers, [ 2 ]  and as therapy for  vaginismus  and other forms of  dyspareunia . [ 3 ]


There is evidence for dilator use [ 4 ]  across many different diagnoses with fair to good results. This includes following  cancer treatments  and for vaginal  agenesis  conditions. The evidence presents varying approaches and protocols.


Vaginal dilators, also called  vaginal stents  or  vaginal expanders , can be inflatable and are used during surgeries. [ 5 ] [ 6 ]  Vaginal stents are routinely used in postoperative care for transgender patients who have undergone vaginoplasty as part of gender confirmation surgery. They are also used for various conditions, such as  vaginal agenesis . [ 7 ]  The vaginal expander is used immediately after surgery to keep the passage from collapsing, and regularly thereafter to maintain the viability of the  neovagina . Frequency of use requirements decrease over time, but remains obligatory lifelong. [ 8 ] [ 9 ]


With solid vaginal dilators, the patient starts with the smallest dilator size, then gradually increasing until the largest dilator size is reached. This practice can be accompanied by breathing exercises in order to relax the pelvic floor muscles. Dilation acts should not cause pain or bleeding. [ 10 ]  Dilatation with rigid dilators must be done carefully as vaginal perforation and urethral injury may occur. [ 11 ] [ 12 ]  There is no consensus on the frequency and duration of using vaginal dilators. [ 13 ]  In case of vaginal expanders, the therapist or the patient introduces the deflated balloon into the vagina and then inflates it gently until the required diameter is obtained. [ 7 ]


Vaginal dilators appear in the comedy feature film  Lady Parts , as the main character struggles with  vaginismus  after receiving a  vestibulectomy . [ 14 ]


The  vaginal epithelium  is the  inner lining of the  vagina  consisting of multiple layers of ( squamous ) cells. [ 1 ] [ 2 ] [ 3 ]  The basal membrane provides the support for the first layer of the epithelium-the basal layer. The intermediate layers lie upon the basal layer, and the superficial layer is the outermost layer of the epithelium. [ 4 ] [ 5 ]  Anatomists have described the epithelium as consisting of as many as 40 distinct layers of cells. [ 6 ] [ 7 ]  The mucus found on the epithelium is secreted by the cervix and uterus. [ 8 ]  The rugae of the epithelium create an involuted surface and result in a large surface area that covers 360 cm 2 . [ 9 ]  This large surface area allows the trans-epithelial absorption of some medications via the vaginal route.


In the course of the  reproductive cycle , the vaginal epithelium is subject to normal, cyclic changes, that are influenced by  estrogen : with increasing circulating levels of the  hormone , there is proliferation of epithelial cells along with an increase in the number of cell layers. [ 10 ] [ 11 ]  As cells proliferate and mature, they undergo partial cornification. [ 9 ] [ 12 ]  Although hormone induced changes occur in the other tissues and organs of the female reproductive system, the vaginal epithelium is more sensitive and its structure is an indicator of estrogen levels. [ 11 ] [ 12 ] [ 13 ]  Some  Langerhans cells  and  melanocytes  are also present in the epithelium. [ 12 ]   The epithelium of the  ectocervix  is contiguous with that of the vagina, possessing the same properties and function. [ 14 ]   The vaginal epithelium is divided into layers of cells, including the  basal cells , the parabasal cells, the superficial  squamous flat cells , and the intermediate cells. [ 15 ] [ 16 ] [ 8 ]  The superficial cells  exfoliate  continuously, and basal cells replace the superficial cells that die and slough off from the  stratum corneum . [ 17 ] [ 18 ] [ 19 ]  Under the stratus corneum is the  stratum granulosum  and  stratum spinosum . [ 20 ]  The cells of the vaginal epithelium retain a usually high level of glycogen compared to other epithelial tissue in the body. [ 21 ]  The surface patterns on the cells themselves are circular and arranged in longitudinal rows. [ 7 ]  The epithelial cells of the uterus possess some of the same characteristics of the vaginal epithelium. [ 22 ]


Vaginal epithelium forms transverse ridges or  rugae  that are most prominent in the lower third of the vagina. This structure of the epithelium results in an increased surface area that allows for stretching. [ 23 ] [ 24 ] [ 9 ]  This layer of epithelium is protective, and its uppermost surface of cornified (dead) cells are unique in that they are permeable to microorganisms that are part of the vaginal flora.  The lamina propria  of  connective tissue  is under the epithelium. [ 4 ] [ 5 ]


The basal layer of the epithelium is the most mitotically active and reproduces new cells. [ 18 ]  This layer is composed of one layer of cuboidal cells lying on top of the basal membrane. [ 7 ]


The parabasal cells include the stratum granulosum and the stratum spinosum. [ 20 ]  In these two layers, cells from the lower basal layer transition from active metabolic activity to death (apoptosis). In these mid-layers of the epithelia, the cells begin to lose their  mitochondria  and other cell organelles. [ 18 ] [ 25 ]  The multiple layers of parabasal cells are polyhedral in shape with prominent nuclei. [ 7 ]


Intermediate cells make abundant glycogen and store it. [ 26 ] [ 27 ]   Estrogen  induces the intermediate and superficial cells to fill with  glycogen . [ 19 ] [ 28 ]  The intermediate cells contain nuclei and are larger than the parabasal cells and more flattened. Some have identified a transitional layer of cells above the intermediate layer. [ 7 ]


Estrogen  induces the intermediate and superficial cells to fill with  glycogen . [ 19 ] [ 28 ]  Several layers of superficial cells exist that consist of large, flattened cells with indistinct nuclei. The superficial cells are exfoliated continuously. [ 7 ]


The junctions between epithelial cells regulate the passage of molecules, bacteria and viruses by functioning as a physical barrier. [ 14 ] [ 9 ]  The three types of structural adhesions between epithelial cells are: tight junctions,  adherens junctions , and  desmosomes . "Tight junctions ( zonula occludens ) are composed of  transmembrane proteins  that make contact across the intercellular space and create a seal to restrict  transmembrane proteins  difusion. [ 17 ]  of molecules across the epithelial sheet. Tight junctions also have an organizing role in epithelial polarization by limiting the mobility of membrane-bound molecules between the apical and basolateral domains of the plasma membrane of each epithelial cell. Adherens junctions (zonula adherens) connect bundles of  actin filaments  from cell to cell to form a continuous adhesion belt, usually just below the microfilaments." [ 14 ]  Junction integrity changes as the cells move to the upper layers of the epidermis. [ 9 ]


The vagina itself does not contain  mucous glands . [ 29 ] [ 30 ]  Though  mucus  is not produced by the vaginal epithelium, mucus originates from the cervix. [ 8 ]  The cervical mucus that is located inside the vagina can be used to assess fertility in ovulating women. [ 29 ]  The  Bartholin's glands  and  Skene's glands  located at the entrance of the vagina do produce mucus. [ 31 ]


The epithelium of the vagina originates from three different precursors during embryonic and  fetal development . These are the vaginal squamous epithelium of the lower vagina, the columnar epithelium of the  endocervix , and the squamous epithelium of the upper vagina. The distinct origins of vaginal epithelium may impact the understanding of  vaginal anomalies . [ 32 ]   Vaginal adenosis  is a vaginal anomaly traced to displacement of normal vaginal tissue by other reproductive tissue within the muscular layer and epithelium of the vaginal wall. This displaced tissue often contains glandular tissue and appears as a raised, red surface. [ 27 ]


During the luteal and follicular phases of the estrous cycle the structure of the vaginal epithelium varies. The number of cell layers vary during the days of the estrous cycle:


Day 10, 22 layers


Days 12-14, 46 layers


Day 19,  32 layers


Day 24, 24 layers


The glycogen levels in the cells is at its highest immediately before ovulation. [ 7 ]


Without estrogen, the vaginal epithelium is only a few layers thick. Only small round cells are seen that originate directly from the basal layer ( basal cells ) or the cell layers (parabasal cells) above it. The parabasal cells, which are slightly larger than the basal cells, form a five- to ten-layer cell layer.  The parabasal cells can also differentiate into  histiocytes  or glandular cells. Estrogen also influences the changing ratios of nuclear constituents to cytoplasm. As a result of cell aging, cells with shrunken, seemingly foamy cell nuclei (intermediate cells) develop from the parabasal cells. These can be categorized by means of the nuclear-plasma relation into "upper" and "deep" intermediate cells. [ 11 ]  Intermediate cells make abundant glycogen and store it. The further nuclear shrinkage and formation of  mucopolysaccharides  are distinct characteristics of superficial cells. The mucopolysaccharides form a  keratin -like cell scaffold. Fully keratinized cells without a nucleus are called "floes". [ 33 ] [ 26 ]  Intermediate and superficial cells are constantly exfoliated from the epithelium. The glycogen from these cells is converted to sugars and then fermented by the bacteria of the vaginal flora to lactic acid. [ 33 ] [ 28 ]  The cells progress through the cell cycle and then decompose (cytolysis) within a week's time. Cytolysis occurs only in the presence of glycogen-containing cells, that is, when the epithelium is degraded to the upper intermediate cells and superficial cells. In this way, the cytoplasm is dissolved, while the cell nuclei remain. [ 33 ]


Low pH is necessary to control vaginal microbiota. Vaginal epithelial cells have a relatively high concentration of glycogen compared to other epithelial cells of the human body. The metabolism of this complex sugar by the lactobacillus dominated microbiome is responsible for vaginal acidity. [ 34 ] [ 35 ] [ 36 ]


The  cellular junctions  of the vaginal epithelium help prevent pathogenic microorganisms from entering the body though some are still able to penetrate this barrier. Cells of the cervix and vaginal epithelium generate a  mucous  barrier (glycocalyx) in which immune cells reside. In addition,  white blood cells  provide additional immunity and are able to infiltrate and move through the vaginal epithelium. [ 14 ]  The epithelium is permeable to antibodies, other immune system cells, and  macromolecules . The permeability of epithelium thus provides access for these immune system components to prevent the passage of invading pathogens into deeper vaginal tissue. [ 9 ]  The epithelium further provides a barrier to microbes by the synthesis of antimicrobial peptides ( beta-defensins  and  cathelicidins ) and immunoglobulins. [ 14 ]  Terminally differentiated, superficial keratinocytes extrude the contents of  lamellar bodies  out of the cell to form a specialized, intercellular  lipid  envelope that encases the cells of the epidermis and provides a physical barrier to microorganisms. [ 9 ]


Sexually transmitted infections, including HIV are rarely transmitted across intact and healthy epithelium. These protective mechanisms are due to frequent exfoliation of the superficial cells, low pH, and innate and acquired immunity in the tissue. Research into the protective nature of the vaginal epithelium has been recommended as it would help in the design of  topical medication  and microbicides. [ 9 ]


There are very rare malignant growths that can originate in the vaginal epithelium. [ 37 ]  Some are only known through case studies. They are more common in older women. [ 38 ]


The vaginal epithelium changes significantly when estrogen levels decrease at menopause. [ 46 ]   Atrophic vaginitis [ 47 ]  usually causes scant odorless discharge [ 48 ]


The vaginal epithelium has been studied since 1910 by a number of histologists. [ 32 ]


The use of  nanoparticles  that can penetrate the cervical mucus (present in the vagina) and vaginal epithelium has been investigated to determine if medication can be administered in this manner to provide protection from infection of the Herpes simplex virus. [ 49 ]  Nanoparticle drug administration into and through the vaginal epithelium to treat HIV infection is also being investigated. [ 50 ]


Vaginal lubrication  is a naturally produced fluid that lubricates the  vagina . Vaginal lubrication production increases significantly during  sexual arousal  in anticipation of  sexual intercourse . [ 1 ]   Vaginal dryness  is the condition in which this lubrication is insufficient, and sometimes artificial lubricants are used to augment it. Without sufficient lubrication, sexual intercourse can be painful. The vaginal lining has no glands, and therefore the vagina must rely on other methods of lubrication.  Plasma  from the  vaginal walls  due to vascular engorgement is considered to be the chief lubrication source, and the  Bartholin's glands , located slightly below and to the left and right of the introitus (vaginal opening), also secrete  mucus  to augment vaginal wall secretions. Near ovulation,  cervical mucus  provides additional lubrication.


Vaginal lubrication fluid is a  plasma  transudate which diffuses across the vaginal wall. Composition varies with length of arousal. [ 1 ]


During arousal, vaginal lubrication, also sometimes called "arousal fluid", is produced. This is clear, thin, and slippery. It typically only lasts up to an hour. [ 2 ] [ 3 ] [ 4 ]  It can sometimes be confused with  cervical mucus . [ 4 ]


The human  vagina  is serviced by nerves that respond to  vasoactive intestinal polypeptide  (VIP). [ 1 ]  As a result, VIP induces an increase in vaginal blood flow accompanied by an increase in vaginal lubrication. The findings suggest that VIP may participate in the control of the local physiological changes observed during sexual arousal: genital vasodilation and increase in vaginal lubrication. [ 5 ]   Neuropeptide Y  is also involved in producing it. [ 1 ] [ 6 ]


Insufficient lubrication or vaginal dryness can cause  dyspareunia , which is a type of  sexual pain disorder . While vaginal dryness is considered an indicator for  sexual arousal disorder , vaginal dryness may also result from insufficient excitement and stimulation or from hormonal changes caused by  menopause  (potentially causing  atrophic vaginitis ),  pregnancy , or breast-feeding. Irritation from contraceptive creams and foams can also cause dryness, as can fear and anxiety about sexual intimacy. Vaginal dryness can also be a symptom of  Sjögren syndrome  (SS), a  chronic   autoimmune disorder  in which the body destroys moisture-producing  glands .


Certain medications, including some over-the-counter  antihistamines , as well as life events such as pregnancy,  lactation ,  menopause ,  aging  or diseases such as  diabetes , will inhibit lubrication.  Medicines with  anticholinergic  or  sympathomimetic  effects will dry out the mucosal or "wet" tissues of the vagina.  Such medicines include many common drugs for allergenic, cardiovascular, psychiatric, and other medical conditions.  Oral contraceptives  may also increase or decrease vaginal lubrication.


In seemingly rare cases,  selective serotonin reuptake inhibitors (SSRIs)  have been reported to cause a long-lasting  iatrogenic  disorder known as post-SSRI sexual dysfunction, the symptoms of which include reduced vaginal lubrication in females.


Vaginal dryness affects 3-43% of women, and it is more common in after  menopause . [ 1 ]  Post-menopausal women produce less vaginal lubrication and reduced  estrogen  levels may be associated with increased vaginal dryness. [ 7 ]


Hormonal


Estrogen treatments are considered the gold standard for managing vaginal dryness. [ 8 ]  They are available in systemic and vaginal forms, with systemic estrogen addressing multiple issues such as vasomotor symptoms and osteoporosis, albeit with a higher risk profile. [ 9 ]  Vaginal estrogen, which includes creams, pills, rings, and inserts, is more commonly prescribed due to its lower risk. DHEA (prasterone) is a promising alternative that enhances vaginal health with minimal side effects and does not significantly alter hormone levels. [ 8 ]  Testosterone therapy is also an option, though it is off-label and lacks FDA-approved formulations, with limited data on its efficacy and safety.


Non-Hormonal


The treatment of vaginal dryness includes over-the-counter (OTC) options of vaginal lubricants and moisturizers, non-estrogenic prescription treatments, laser and ultrasound devices, as well as lifestyle changes. [ 8 ] [ 10 ]  Non-hormonal vaginal lubricants and moisturizers, which have minimal side effects and are easy to obtain, are the primary recommendation, especially for those contraindicated for hormone treatments. [ 11 ]  They aim to mimic natural vaginal conditions and provide temporary relief during intercourse, while regular use of moisturizers helps maintain moisture. Prescription treatments include non-estrogenic options for women who can't use estrogen. Ospemifene is a notable FDA-approved medication for vaginal dryness and discomfort, although concerns about long-term safety remain.  Vaginal laser therapy and ultrasound devices, are emerging options, particularly for those who do not respond to traditional methods. While initial results appear promising, evidence for their long-term efficacy is still limited. [ 12 ]  Lifestyle modifications can also alleviate vaginal dryness; quitting smoking, reducing alcohol intake, and maintaining a healthy weight are beneficial. [ 8 ]  Additionally, regular sexual activity can enhance tissue health and moisture levels, further aiding in symptom relief.


Some people practice  dry sex , which involves the removal of vaginal lubrication in some way. [ 13 ]  The rationale for the practice seems to be for cleansing purposes and to enhance the sexual pleasure of the penetrating partner. [ 14 ]   However, besides making sexual intercourse painful for the female, [ 15 ]  the practice is believed to increase the risk of transmitting sexually transmitted infections for both partners, [ 15 ]  such as  HIV , with which the risk of transmission is increased by lacerations in the vaginal tissue resulting from the lack of lubrication. [ 16 ]


Vaginal rugae  are structures of the vagina that are transverse ridges formed out of the supporting tissues and  vaginal epithelium  in females. [ 1 ]  Some conditions can cause the disappearance of vaginal rugae and are usually associated with childbirth and prolapse of pelvic structures. The rugae contribute to the resiliency and elasticity of the vagina and its ability to distend and return to its previous state. [ 2 ] [ 3 ] [ 4 ]  These structures not only allow expansions and an increase in surface area of the vaginal epithelium, they provide the space necessary for the vaginal microbiota. The shape and structure of the rugae are supported and maintained by the  lamina propria  of the vagina and the anterior and posterior rugae. [ 5 ]


The anterior and posterior columnae rugae are transverse vaginal support structures between which the transverse rugae exist. The cross section of the vagina normally forms a shape that resembles the letter 'H' due to these structures. [ 6 ]


Vaginal rugae disappear in older women and those with an  estrogen deficiency . [ 7 ]  The rugae can disappear with anterior vaginal wall prolapse which can occur when supports to the portion located between the vagina and bladder are damaged and the bladder bulges into the vaginal lumen. Vaginal self-examination includes visualizing the presence of vaginal rugae. [ 8 ]  Anatomists identified rugae of the vagina as early as 1824. [ 9 ]


The appearance and presence of vaginal rugae change over the life span of females and are associated with hormonal cycles,  estrogens , childbirth, puberty and menopause. During gynecological examination of  prepubescent  girls, rugae can be visualized. [ 10 ]   The vaginal rugae change after  menopause . In some older women the rugae are present but become flattened and difficult to see. [ 11 ]  In others, the rugae tend to disappear. [ 1 ]


Other structures can be present on the vaginal wall though most of the time these can be differentiated from rugae. [ 12 ] [ 13 ]   Vaginal cysts  can be small protrusions into the vagina that can be felt or palpated by a clinician. Vaginal inclusion cysts can appear as small bumps and can develop after childbirth. [ 12 ]  Other small structures or protrusions can be  Gartner's duct cysts , patches of endometrial tissue, and benign tumors. [ 12 ] [ 14 ]  These cystic structures can obliterate the rugae and is a clue to their presence. [ 15 ]  The absence of vaginal rugae seen in the normal vagina of a healthy woman may be an indication of a prolapsed bladder (cystocele) or rectocele. [ 13 ] [ 12 ]  An  enterocele , or bulging of the  bowel  into the vagina can also cause vaginal rugae to disappear. [ 16 ]  The absence of vaginal rugae may also be an indicator of  pelvic organ prolapse . [ 17 ] [ 18 ] [ 19 ]  Vaginal rugae disappear in those with an  estrogen deficiency . [ 7 ] [ 20 ]


Vaginal rugae can disappear during the second stage of labor. [ 21 ]  After a vaginal birth, the rugae are not visible and the walls of the vagina are smooth. By the third week postpartum, the vagina has become much smaller and the rugae begin to reform on the vaginal walls. Six weeks after birth, the rugae have returned to approximately the same size as they were before the birth. The number of rugae after childbirth decreases. [ 22 ]  In women who have not given birth, the rugae are more prominent than in those who have given birth multiple times. [ 6 ]


A  vaginal septum  is a  vaginal anomaly  that is partition within the  vagina ; such a  septum  could be either longitudinal or transverse. In some affected women, the septum is partial or does not extend the length or width of the vagina. [ 1 ]   Pain during intercourse  can be a symptom. A longitudinal vaginal septum develops during  embryogenesis  when there is an incomplete fusion of the lower parts of the two  Müllerian ducts . As a result, there may appear to be two openings to the vagina. There may be associated duplications of the more cranial parts of the Müllerian derivatives, a double  cervix , and either a  uterine septum  or  uterus didelphys  (double uterus). [ 1 ] [ 2 ]  A transverse septum forms during embryogenesis when the Müllerian ducts do not fuse to the  urogenital sinus . A complete transverse septum can occur across the vagina at different levels. Menstrual flow can be blocked, [ 3 ]  and is a cause of primary  amenorrhea . The accumulation of menstrual debris behind the septum is termed  cryptomenorrhea . Some transverse septa are incomplete and may lead to  dyspareunia  or obstruction in  labour . [ 4 ] [ 5 ]


Media related to  Vaginal septum  at Wikimedia Commons


The  vaginal support structures  are those  muscles ,  bones ,  ligaments ,  tendons , membranes and fascia, of the  pelvic floor  that maintain the position of the  vagina  within the pelvic cavity and allow the normal functioning of the vagina and other reproductive structures in the female. Defects or injuries to these support structures in the pelvic floor leads to  pelvic organ prolapse . Anatomical and congenital variations of vaginal support structures can predispose a woman to further dysfunction and prolapse later in life. [ 1 ]  The urethra is part of the anterior wall of the vagina and damage to the support structures there can lead to  incontinence  and  urinary retention . [ 2 ]


The support for the vagina is provided by muscles, membranes, tendons and ligaments. These structures are attached to the  hip bones . These bones are the  pubis ,  ilium  and  ischium . The interior surface of these pelvic bones and their  projections  and contours are used as attachment sites for the fascia, muscles, tendons and ligaments that support the vagina. These bones are then fuse and attach to the  sacrum  behind the vagina and anteriorly at the  pubic symphysis . [ 3 ]  Supporting ligaments include the  sacrospinous  and  sacrotuberous ligaments . The sacrospinous ligament is unusual in that it is thin and triangular. [ 3 ] [ 4 ]


The muscular pelvic diaphragm is composed of the bilateral  levator ani  and coccygeus muscles and these attach to the inner pelvic surface. The iliococcygeus and pubococcygeus make up the levator ani muscle. The muscles pass behind the rectum. The levator ani surrounds the opening which the urethra, rectum and vagina pass. The pubococcygeus muscle is subdivided into the pubourethralis,  pubovaginal muscle  and the puborectalis muscle. The names describe the attachments of the muscles to the urethra, vagina, anus, and rectum. The names are also called the pubourethralis, pubovaginalis, puboanalis, and puborectalis muscles and sometimes the pubovisceralis since it attaches to  the viscera. [ 3 ]


The urogenital diaphragm, or  perineal membrane , is present over the anterior pelvic outlet below the pelvic diaphragm. [ 5 ]  The exact structure description is controversial. Despite the controversy, MRI imaging studies support the existence of the structure. [ 3 ] [ 6 ]


Superficial and inferior muscles of the perineum (urogenital diaphragm):


The perineum attaches across the gap between the inferior pubic rami bilaterally and the perineal body. This grouping of muscles constricts to close the urogenital openings. The perineum supports and functions as a sphincter at the opening of the vagina. Other structures exist below the perineum that support the anus. [ 3 ] [ 6 ]


The  perineal body  is a pyramidal structure of muscle and connective tissue and part of it is located between the anus and vagina. It is a tendon that is formed at the point where the  bulbospongiosus muscle ,  superficial transverse perineal muscle , [ 7 ]  and external anal sphincter muscle converge to form this major supportive structure of the pelvis and vagina. [ 8 ] [ 9 ] [ 10 ]   Below this, muscles and their fascia converge and become part of the perineal body. The lower vagina is attached to the perineal body by attachments from the pubococcygeus, perineal muscles, and the  anal sphincter . The perineal body is made up of  smooth muscle , elastic  connective tissue  fibers, and nerve endings. Above the perineal body are the vagina and the uterus. Damage and resulting weakness of the perineal body changes the length of the vagina and predisposes it to rectocele and enterocele. [ 3 ] [ 6 ]


The vagina is attached to the pelvic walls by endopelvic fascia. The peritoneum is the external layer of skin that covers the fascia. This tissue provides additional support to the pelvic floor. The endopelvic fascia is one continuous sheet of tissue and varies in thickness. It permits some shifting of the pelvic structures. The fascia contains elastic collagen fibers in a 'mesh-like' structure. The fascia also contains fibroblasts, smooth muscle, and vascular vessels. The cardinal ligament supports the apex of the vagina and derives some of its strength from vascular tissue. The endopelvic fascia attaches to the lateral pelvic wall via the arcus tendineus. [ 3 ]


Not all agree to the amount of supportive tissue or fascia exists in the anterior vaginal wall. The major point of contention is whether the vaginal fascial layer exists. Some texts do not describe a fascial layer. Other sources state that the fascia is present under the urethra which is embedded in the anterior vaginal wall. [ 3 ]  Despite disagreement, the urethra is embedded in the anterior vaginal wall. [ 3 ]


The midsection of the vagina is supported by its lateral attachments to the  arcus tendineus . Some describe the pubocervical fascia as extending from the pubic symphysis to  the anterior vaginal wall and cervix. Anatomists do not agree on its existence. [ 3 ] [ 11 ]


Vaginal support structures can be damaged or weakened during childbirth or pelvic surgery. Other conditions that repeatedly strain or increase pressure in the pelvic area can also compromise support. Examples are: [ 12 ]


This article incorporates text in the  public domain  from the 20th edition of   Gray's Anatomy   (1918)


The term  Vaginitis emphysematosa  is related to Women's Reproductive Health and  coined by Zweifel in 1877. The cases of Vaginitis emphysematosa are rare. The most important thing is that women never consult with the doctors for particularly Vaginitis emphysematosa but when they visit a doctor for some other reproductive health issue, they diagnose with the Vaginitis emphysematosa fortunately. Vaginitis emphysematosa is not common and Gynaecologists rarely know about it. Basically, this is characterised by gas-filled cysts in the mucosa of the vagina. [ 1 ]  Vaginitis emphysematosa is usually a self limited cystic disorder of the vagina. It is a very rare condition and has not much specific features to arouse clinical suspicion. [ 2 ]


The term ''Vaginitis emphysematosa'' has 'vaginitis' in it but it has been observed that inflammation is generally mild and absent. [ 2 ]  This is characterised by gas-filled cysts in the vaginal wall and does not imply life-threatening infection. [ 3 ]


Vaginitis emphysematosa occurs primarily in pregnant women, but there are some cases of non-pregnant women too. [ 4 ]   It  is a rare, benign  vaginal cyst  identified in 173 cases. [ 5 ] [ 6 ] [ 7 ] [ 8 ]  Women that have been affected were 42 to 65 years old. [ 6 ]  The cysts appear grouped but defined from one another, smooth, and can be as large as 2 cm. [ 5 ]  Symptoms included:  vaginal discharge , itching, sensation of pressure, appearance of nodules, and sometimes a "popping sound". [ 5 ] [ 9 ]


The cause is unknown. Histological examination showed the cysts contained pink hyaline-like material, foreign body-type giant cells in the cyst's wall, with chronic inflammatory cell fluid. The gas-filled cysts are identified with CT imaging. The gas contained in the cysts has been analysed and consists of nitrogen, oxygen, argon, carbon dioxide, and sulphur dioxide. [ 5 ]  Treatment may not be required and no complications follow the resolution of the cysts. [ 6 ]  It may be associated with  immunosuppression ,  trichomonas , or  Haemophilus vaginalis   infection . [ 5 ] [ 10 ]  Vaginitis emphysematous is characterized by gas-filled cysts in the vaginal wall. [ 5 ] [ 8 ]


A  vaginogram  is a  medical imaging  method in which a  radiocontrast agent  is injected while  X-ray pictures  are taken, to visualize structures of the  vagina . [ 1 ]  It has been used to visualize  ureterovaginal fistulas . [ 2 ] [ 3 ]


This article related to  medical imaging  is a  stub . You can help Wikipedia by  expanding it .


Veillonella parvula  is a strictly anaerobic, Gram-negative, coccus-shaped bacterium in the genus  Veillonella . [ 2 ]  It is a normal part of the oral flora but can be associated with diseases such as  periodontitis  and  dental caries  as well as various systemic infections, including meningitis and osteomyelitis. [ 3 ]  It has also been isolated from women with  bacterial vaginosis  and has been associated with  hypertension  together with  Campylobacter rectus  and  Prevotella melaninogenica . [ 4 ]


V. parvula  is unable to feed on carbohydrates, but can feed on lactate provided by  Streptococcus  species also found in the oral cavity. [ 5 ]  Specifically,  Streptococcus mutans  and  V. parvula  can form multispecies  biofilms  that lead to a lower susceptibility to antimicrobial treatments, resulting in periodontitis and dental caries. [ 6 ]


V. parvula  bacteria are susceptible to and typically treated with  metronidazole  and  penicillin  in clinical reports. [ 7 ] [ 8 ] [ 9 ] [ 10 ]  Other antibiotics that have been shown to be active against  V. parvula  include  cephalosporin ,  clindamycin , and  chloramphenicol . [ 7 ]


There have been several reports of  antibiotic resistance  in  V. parvula  isolates in different countries. [ 11 ] [ 12 ] [ 13 ]  In Greece,  V. parvula  isolates were found to be somewhat resistant to penicillin,  ampicillin ,  piperacillin/tazobactam , clindamycin, and  moxifloxacin , with no reported resistance to metronidazole. [ 13 ] [ 14 ]  In Taiwan,  V. parvula  isolates were found to be resistant against metronidazole. [ 15 ]  These findings represent the growing issue of antibiotic resistance worldwide. [ citation needed ]


Mashima I, Nakazawa F (August 2014). "The influence of oral Veillonella species on biofilms formed by Streptococcus species".  Anaerobe .  28 :  54– 61.  doi : 10.1016/j.anaerobe.2014.05.003 .  PMID   24862495 .


A  vulvar disease  is a particular abnormal, pathological condition that affects part or all of the  vulva . Several  pathologies  are defined. Some can be prevented by  vulvovaginal health maintenance .


Vulvar  cancer  accounts for about 5% of all gynecological cancers and typically affects women in later life.  Five-year survival rates  in the United States are around 70%. [ 1 ]


Symptoms of vulvar cancer include itching, a lump or sore on the vulva which does not heal and/or grows larger, and sometimes discomfort/pain/swelling in the vulval area. Treatments include  vulvectomy  – removal of all or part of the vulva.


Systemic disorders may be localized in the vulvo-perineal region. [ 2 ]


Walthard cell rests , sometimes called  Walthard cell nests , are a benign cluster of  epithelial  cells most commonly found in the  connective tissue  of the  fallopian tubes , but also seen in the  mesovarium ,  mesosalpinx  and  ovarian   hilus .


They appear as white/yellow cysts or nodules that can reach a size of 2 millimeters.  They typically have elliptical nuclei with a long groove (along the major axis) – so-called "coffee bean" nuclei.


It has been suggested that these cell rests are the  histogenetic  origins of  Brenner tumors , due to the  histological  similarity of the  epithelium  of Walthard cell rests and Brenner tumors to the  urothelium  of the lower  urinary tract . Also, it has been proposed that Brenner tumors and Walthard cell rests signify urothelial differentiation within the female genital tract.


They are named after Swiss  gynecologist   Max Walthard  (1867–1933), who provided a comprehensive description of them in 1903.


This  oncology  article is a  stub . You can help Wikipedia by  expanding it .


Wandering womb  was the belief that a displaced  uterus  was the cause of many medical  pathologies  in women. [ 1 ]  The belief is first attested in the medical texts of ancient Greece, [ 2 ]  but it persisted in European academic medicine and popular thought for centuries. The wandering womb as a concept was popularized by doctor  Edward Jorden , [ 3 ]  who published  The Suffocation of the Mother  in 1603.  Suffocation of the Mother  was the first text on the subjects of the wandering womb and hysteria that was written in English.


The belief in the "wandering womb" was found in ancient Greece. Some scholars have argued that it originated in Egypt, but this has now been disproved. [ 2 ]  One description of the theory of a "wandering womb" comes from  Aretaeus , a physician from Cappadocia, who was a contemporary of  Galen  in the 2nd century AD. He wrote that the uterus could move out of place, and float within the body. In the translation of  Francis Adams  (1856) [ 4 ]  this reads:


In the middle of the flanks of women lies the womb, a female  viscus , closely resembling an animal; for it is moved of itself hither and thither in the flanks, also upwards in a direct line to below the cartilage of the thorax, and also obliquely to the right or to the left, either to the liver or the spleen, and it likewise is subject to prolapsus downwards, and in a word, it is altogether erratic. It delights also in fragrant smells, and advances towards them; and it has an aversion to fetid smells, and flees from them; and, on the whole, the womb is like an animal within an animal.


The Greek translated here as "like an animal within an animal" would be better translated as "like a living thing inside another living thing". [ 5 ]  The belief that the uterus could move freely, which this imagery evokes, was linked to the use of scent therapy to entice it up or down within the body. This may have been part of ancient cultural beliefs in Greece, [ 6 ]  but the earliest known written accounts of it are in the fifth- and fourth-century BCE texts associated with the name of  Hippocrates . The movement of the uterus was believed to cause symptoms throughout the body, depending on the destination to which the uterus moved in search of fluid. [ 7 ]


Soranus  of Ephesus, another second century CE physician, opposed the theory of the "wandering womb". In a description of what he labelled "hysterical suffocation" – suffocation arising in the uterus – Soranus wrote, "the uterus does not issue forth like a wild animal from the lair, delighted by fragrant odors and fleeing bad odors, rather it is drawn together because of stricture caused by inflammation". [ 8 ]  Where  Aretaeus  used the more neutral "living thing", Soranus used the term for "wild beast",  therion .  Galen  also insisted that the uterus was stationary and that symptoms were due to substances being retained inside it. [ 9 ]  This suggests that Aretaeus was unusual among physicians of his period in believing in a mobile and animate womb. Despite the fact that Soranus was an influential writer on gynecology, and that Galen was the  Greco-Roman  medical writer with the greatest overall influence on Medieval and  Renaissance medicine  in Europe, the belief in the "wandering womb" continued for centuries, for example in  Edward Jorden 's influential 1603 treatise on the supposed bewitching of 14 year-old Mary Glover. [ 10 ]


The idea of a condition called  hysteria  caused by "wandering womb" developed from the "hysterical suffocation" of ancient Greek writers. Medical researchers developed a better understanding of anatomy after the invention of microscopes in the 17th century and cellular research in the 19th century.  Sigmund Freud 's theory of the free-floating unconscious, the "mind within the mind", was similar to the ancient belief in the "animal within the animal". [ 11 ]


Edward Jorden , author of  The Suffocation of the Mother,  used hysteria as an explanation for mysterious medical occurrences in young women. He supposed that the hysteria caused by the "wandering" of the womb around the body was the source of witchcraft, and often presided in witchcraft-related trials as an expert on the subject.  The Suffocation of the Mother  connected the phenomenon of hysteria with actions like singing, laughing, crying, and choking.


Both "wandering womb" and "hysteria" are unused in medical theories of today.


Childbirth  and  obstetrics  in  classical antiquity  (here meaning the ancient  Greco-Roman world ) were studied by the physicians of ancient Greece and Rome. Their ideas and practices during this time endured in Western medicine for centuries and many themes are seen in modern women's health. Classical gynecology and obstetrics were originally studied and taught mainly by midwives in the ancient world, but eventually scholarly physicians of both sexes became involved as well. Obstetrics is traditionally defined as the  surgical  specialty dealing with the care of a woman and her offspring during pregnancy, childbirth and the  puerperium  (recovery).  Gynecology  involves the medical practices dealing with the health of women's reproductive organs (vagina, uterus, ovaries) and breasts.