Many studies have been conducted to determine the criteria for normality of the female external genitalia. The measurements made in most of these studies span a wide range, varying according to ethnicity, age, weight, hormonal status, and skin type (13). Regardless, surgeons dealing with genital aesthetics need a definition of the ideal vulva.
However, our medical definition of normal and self-perceptions of normality do not always coincide, especially with the external genitalia. Criteria for the aesthetic ideal can be defined simply as symmetrical labia minora that do not extend beyond the labia majora (16).
On physical examination, labia minora protrusion was detected in 45.1% and asymmetry in 42.5% of the participants in our study. However, despite this high rate, only 10.6% of them defined their genital area as abnormal. Normal is defined in dictionary as conforming to a standard; usual, typical, or expected whereas ideal is defined as existing only in the imagination or perfection but not likely to become a reality (17). Considering these rates, asymmetry and protrusion could be considered normal. In the literature, protusion rates are reported above 50% (9, 21). The values defined as normal in the literature actually seem to be ideal vulva criteria.
Labia minora hypertrophy can be most simply defined as labia minora that protrude beyond the labia majora. It can affect only one side or both labia (18). Classification systems to describe labia minora hypertrophy have been published (19, 20). These classification systems are generally based on width measurements of the labia minora. Although useful for surgical algorithms, their role in defining hypertrophy is controversial. A study evaluating perceptions of genital appearance in women indicated that the normal labial appearance was highly variable and the extent of physical and psychological complaints was not associated with objective measurements of the labia minora. Therefore, the term “labial hypertrophy” and the use of terms such as “normal” and “pathological” labial size were not recommended. The authors emphasized that it was not possible to define specific threshold values for these terms that could be associated with complaints (9). In our study, we observed that labia minora protrusion was not associated with base and width measurements of labia minora, the differences in these measurements between the two labia minora, or asymmetry. To accept the genitalia as ideal or within aesthetic limits, it would not be right to define certain criteria for the labia minora alone while ignoring the other structures. The genital region is a whole and its evaluation should include all relevant anatomical structures. Hypertrophy or ptosis of the labia major may cause them to completely cover the labia minora. However, to what degree can the resulting genital configuration be considered ideal or aesthetically pleasing? The main person who evaluates these ideals and aesthetic concepts is the individual themselves. Considering that aesthetic surgery is a personal desire, it seems that self-perception is the most important factor. In one study it was reported that 54% of women had labia minora protrusion, but only 17.3% of these women regarded their labia minora as abnormal. In contrast, 7.3% of the women without protrusion evaluated their labia minor as abnormal (21). In another study, when asked for their subjective perceptions, 65% of the women said they considered their labia minora to be normal, while approximately one-third considered them too large. In the same study, the prevalence of labia minora protrusion was 56%, and objective labia size was significantly associated with the women’s subjective perceptions of labia size but not with self-reported complaints (9). Lykkebo et al. also reported that women who considered their genitalia abnormal had a higher frequency of visible labia minora and larger labia sizes, but the differences were not statistically significant (21). In our study, the prevalence of labial minora protrusion on examination was 45.1%, yet only 15.7% of the participants with protrusion considered their genitalia to be abnormal. The other 84.3% said they perceived it as normal. Overall, 10.6% of the participants reported self-perceived abnormality and 27.4% were dissatisfied with the appearance of their genitalia. The difference between these two percentages suggests that there is a population of women who perceive their genitalia as normal but are not satisfied for some reason. In our study, we observed that self-perception of the genitalia being normal in appearance and size was associated with asymmetry of the labia minora and hyperpigmentation, but not with labia minora measurements or protrusion.
Lykkebo et al. also emphasized that although age difference did not have a significant effect on perception, most women who considered their genitals abnormal were younger (21). In the present study, self-perceived abnormality and dissatisfaction were more common in participants under the age of 40 than in participants over the age of 40. In addition, we determined that satisfaction was not associated with measurements, asymmetry, or protrusion. A reason for this difference observed in our series could be that the under-40 population in our society has greater interest in the online and social media environment and has easier access to information there. In addition, cultural and social differences may influence the relationship between age and genital perception. However, education level had no effect on self-perception or satisfaction in our study.
In the literature there is another series in which percentages of complaints of their labia minora were relatively higher (%27), and the reported rate of labial protrusion in that study was 56% (9). The prevalence of labia minora protrusion in our study was 45%, while the proportion of women reporting physiological, functional, or psychological problems associated with their genitalia was low. These studies were conducted in different populations, and differences between these populations in lifestyle, sports habits, and clothing preferences may lead to different physiological, functional, and psychological problems despite the similar prevalence of labial protrusion.
Labia minora hypertrophy is most often idiopathic in etiology (22). However, it may also be congenital. Enlargement may be present from birth, but usually becomes most apparent when the woman enters adolescence (23). In our study, 82.3% of the participants stated that their genitalia had not changed and appeared the same for as long as they could remember, while 17.7% reported that their genitalia had changed over time. An individual’s awareness of the genitals varies according to the value judgments and views of sexuality of the society in which they live. The genitalia change and mature during puberty, and particularly in traditionalist societies, it may not be possible for people to become aware of and visually examine their genitalia and recognize these developmental changes. Therefore, this distinction between congenital and acquired may not be accurate.
The size of the labia minora has been reported to be independent of the woman’s age, parity, ethnicity, hormone use, and history of sexual activity. The size of the labia changes over time, with the most significant increase during puberty, and can reportedly be increased with external stimuli such as stretching with weights (24–26). It has been reported that in some African countries, the labia minora can reach 20 cm in size with direct manipulation (24). Other causes of hypertrophy include androgenic hormone exposure in infancy, sensitivity to topical estrogen, dermatitis secondary to urinary incontinence, vulvar lymphedema, and myelodysplastic diseases. Some also believe that the recurrent stretching that can occur with multiple pregnancies may also contribute to labial hypertrophy (27).
However, in our study, we observed that protrusion was more common among nulligravida women compared to gravid women. The prevalence of protrusion was also lower among women who had normal vaginal delivery than in those who had delivered by cesarean section. Again, protrusion was more common in nulliparous and uniparous women, and asymmetry was more common among multiparous women. If factors such as stretching and trauma caused labial hypertrophy, labial protrusion would be expected in participants with a history of vaginal delivery and multiple births. However, the opposite was observed in our study. Our finding that labial asymmetry was more common among multiparous women but was not associated with mode of delivery suggests that this may be a result of hormonal effects.
Lykkebo et al. found no statistical relationship between labia minora measurements and age or parity but detect a significant relationship with BMI. They found that women with high BMI had smaller labia minora (21). In our study, asymmetry was more frequent among participants with a BMI of 30 or higher, while labia minora protrusion was less frequent. As labia minora measurements are not affected by BMI, the low level of protrusion is likely due to fat accumulation in the labia majora increasing their length and resulting in better coverage of the labia minora. However, this does not explain why these women appear to have more asymmetry.
In addition, despite claims that excessive sexual activity cause labia minora hypertrophy, this has not been proven (23, 28). In our study, we asked the participants about their age at first sexual intercourse. Although participants with a first sexual experience before the age of 20 were expected to have a higher rate of labial hypertrophy due to the early onset of sexual intercourse trauma, we actually found that asymmetry was more common in this age group, while contrary to expectation, protrusion was more common in participants who were over 20 years of age at first sexual intercourse. There was no difference between participants with and without a history of sexual intercourse in terms of anatomical measurements or aesthetic perceptions. These results indicate that labia minora hypertrophy is not significantly associated with sexual intercourse. In our society, women in particular are assumed to be monogamous, or those with more than one partner avoid expressing this. Therefore, the concepts of multi-partner women or excessive sexual activity were not examined in this study.
Participants whose reported duration of menstruation was 6 days or more showed greater labial asymmetry and differences in width between the labia when compared with individuals with a menstrual period of less than 5 days. The same relationship was observed in the group with total pad use of 20 or less compared to the group using over 20 pads. This may be due to moisture in the genital area during menstruation or irritation caused by the pads used, or it may be related to hormonal effects.
In our study, we determined that participants with more than 31 years of estrogen exposure had greater differences in base length and widths between the labia minora but less protrusion. The lack of protrusion may be because the labia majora undergo hypertrophy in response to estrogen, thereby providing better coverage of the labia minora. Labia majora asymmetry in adolescents is thought to result from asymmetric physiological enlargement as a hormonal response, and it can reportedly regress (29).
However, these two complementary structures develop from the same embryonic structures and are expected to be symmetrical, and it does not seem possible to attribute their asymmetry in adults to a single cause. It is likely a multifactorial condition.
When we evaluated anatomical relationships, we found that labia minora base and width measurements were larger in participants with perineal body measurements greater than 1 cm, while protrusion was more common in participants whose perineal body measured 1 cm or smaller. We believe that genital anatomy is a structure with certain proportions between its components, as well as a region that shows individual differences, like the face. For this reason, the appearance of the genitalia is as personal as the face, and an individual’s self-perception is more important than our ideal.
In addition, we observed that both base and width measurements and the differences between the two labia were found to be greater in participants with labia minora asymmetry than in those with symmetrical labia minora. Asymmetry arises not only from one labium being larger than the other, but is also due to the general size of the labium. This information should be considered In conclusion, although there is a tendency in the field of aesthetic surgery to define ideals and aesthetic standards for all parts of the body, our definitions of normality do not always coincide with those of the individual. Although the aesthetic criteria we define and our efforts to classify the abnormal are indispensable for the surgical literature and correct surgical approaches to the genital area, they seem meaningless in defining what is abnormal. The results of our study indicate that a woman being satisfied with her body and receiving no negative feedback from their male partner creates her perception of normal. Moreover, the high satisfaction rate of 72% in our study may be related to the fact that only 4 of the participants received negative feedback from their male partner. Like the face, the genitals also seem to be a region of individuality. As in all other aesthetic approaches, there should be certain definitions in genital aesthetics. The criterias defined by the professionals are different from the non-professional individual.